International Journal of

Pediatrics, Neonatology and Primary Care

Research Article Open Access

The role of Delayed Cord Clamping in improving the

Outcome in Preterm Babies
Dina Kamal Sayed Ali1* and Hamdy Mohamed Talkhan2
1
Assistant Professor of Pediatrics, Faculty of Medicine, Cairo University, Egypt
2
Department of Obstetrics and Gynecology, El Sahel Teaching Hospital, Cairo, Egypt

Article Info Abstract

*Corresponding author: Objective: Despite significant proposed benefits, delayed umbilical cord clamping
Dina Kamal Sayed Ali (DCC) is not practiced widely in preterm infants largely because of the question of
Assistant professor of pediatrics
Cairo University feasibility of the procedure and uncertainty regarding the magnitude of the reported
Eygpt benefits, especially intraventricular hemorrhage (IVH) vs the adverse consequences of
E-mail: dinakamal_2009@yahoo.com delaying the neonatal resuscitation. The objective of this study was to determine
whether implementation of the protocol-driven DCC process in Elsahel teaching hospital
Received: January 1, 2019 would improve the outcome in preterm infants without adverse consequences.
Accepted: February 18, 2019
Published: February 22, 2019 Study design: We implemented a quality improvement process for DCC for 13 months
started in August 2014 in infants born at less than 37 weeks’ gestational age. Eligible
Citation: Sayed Ali DK, Talkhan HM. The role
infants were left attached to the placenta for 45 seconds after birth. Neonatal process
of Delayed Cord Clamping in improving the
Outcome in Preterm Babies. Int J Pediatr and outcome data were collected until discharge. We compared infants who received
Neonatal Prim Care. 2019; 1(1): 6-10. DCC with infants who were born for 13 months started at February 2014, but whose
doi: 10.18689/ijpn-1000103 cord was clamped immediately after birth, because they were born before the protocol
implementation.
Copyright: © 2019 The Author(s). This work
is licensed under a Creative Commons Results: DCC was performed on 79 infants; and 81 infants were identified as control.
Attribution 4.0 International License, which Gestational age, birth weight, and other demographic variables were similar between
permits unrestricted use, distribution, and
reproduction in any medium, provided the both groups. There were no differences in Apgar scores or admission temperature, but
original work is properly cited. significantly fewer infants in the DCC group were intubated in delivery room, had
Published by Madridge Publishers respiratory distress syndrome, or received red blood cell transfusions in the first week of
life compared with the control group. A significant reduction was noted in the incidence
of IVH in the DCC compared with the historic control group, after adjustment for
gestational age, an association was found between the incidence of IVH and DCC. IVH
was significantly lower in the DCC compared with control group. There were no
significant differences in deaths and other major morbidities.
Conclusion: DCC, as performed in our institution, was associated with significant
reduction in IVH and early red blood cell transfusions. DCC in preterm infants appears
to be safe, feasible, and effective with no adverse consequences.
Keywords: Delaying Umbilical Cord Clamping; Intra Ventricular Hemorrhage; Preterm
Infant.

Introduction
Before the mid-1950s, the term early clamping was defined as umbilical cord clamping
within 1 min of birth, and late clamping was defined as cord clamping more than 5 minutes
after birth [1,2]. Because of the several studies done on blood volume change after birth,
which reported that 80-100 ml of blood transfer from the placenta to the newborn in the

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first 3 minutes after birth, and up to 90% of that blood volume The total number of babies included in the study was 160
transfer was achieved within the first few breaths in healthy preterm, where the protocol of DCC was applied on 79
term infants, the time between birth and cord clamping was preterm. With approval by the institutional review board,
shortened to be 15-20 seconds after birth [3-5]. prospective and retrospective data were extracted from
But recently several systematic reviews have suggested maternal and neonatal electronic medical records. The
that clamping the umbilical cord in all births should be prospective study period was 13 months, from Aug 2014. The
delayed for atleast 30–60 seconds, with the infant maintained study period for the historic cohort was also 13 months, from
at or below the level of the placenta because of the associated February 2014. Collected data included maternal demographics,
neonatal benefits, including increased blood volume, reduced obstetric complications, any antenatal steroid and magnesium
need for blood transfusion, decreased incidence of intracranial use, and other labor and delivery variables. Neonatal data
hemorrhage in preterm infants, and lower frequency of iron included gestational age, birth weight, sex, post-delivery data
deficiency anemia in term infants [2,4,6,7]. variables such as Apgar scores, resuscitation data, and the
infant’s temperature upon admission to the neonatal intensive
WHO recommendations 2012, based on several randomized
care unit. Other clinical variables included treatment with
controlled studies, for basic newborn resuscitation are, in newly
phototherapy, (intensive phototherapy defined as irradiance
born babies who do not require positive-pressure ventilation,
in the blue-green spectrum of at least 30 µW/cm2 per nm).
the cord should not be clamped earlier than 1 min after birth [6].
For all tests of significance, p-values less than 0.05 were
The aim of our study is to compare between immediate
considered statistically significant and were used as evidence
and delayed cord clamping in preterm infants less than 37
against the null hypothesis of no difference between DCC and
weeks, and its effect on the outcomes of such babies.
ICC participants. All statistical methods were performed using
the SAS software system (Release 8.2, SAS Institute, Inc., Cary,
Aim of the Study NC, USA).
To study the effect of delayed cord clamping on premature
infants. Results
During the prospective study period, after implementation
Patients and Methods of DCC protocol 79 infants were born at less than 37 weeks’
On average, our level III Neonatal Intensive Care Unit gestation. After excluding multiple gestation infants, DCC was
cares for approximately 200 preterm inborn infants every performed on all of the 79 eligible infants per pre specified
year. The previous routine clinical practice was to clamp the protocol (DCC). During the retrospective study period, 81
umbilical cord immediately after the birth. The DCC process infants were born at less than 37 weeks’ gestation, all of these
was implemented starting August 2014. All infants born at infants received immediate umbilical cord clamping (ICC)
less than 37 weeks’ gestation were eligible for DCC, unless after birth. There were no significant differences in maternal
they met the following exclusion criteria: severe maternal characteristics. Artificial reproductive therapy and cesarean
illness that prompted immediate delivery, placental causes delivery numbers were not different between the groups.
(abruption or previa) or fetal causes (multiple gestation, major Similarly, there were no differences in other maternal variables
congenital anomalies, severe growth restriction, or hydrops such as chorioamnionitis, gestational hypertension or
fetalis). After birth, the infant was left unstimulated, attached diabetes mellitus, preeclampsia, or poly- or oligohydramnios.
at or slightly below the level of placenta for 45 seconds. The Overall antenatal steroid administration and maternal
cord was then clamped and cut, and the neonatal team magnesium exposure were similar between the groups. There
initiated resuscitation efforts. Apgar timing was initiated at were no significant differences in baseline neonatal
the time of birth when the infant was delivered completely. characteristics between the two groups. Mean gestational
We placed the baby at or below the level of the placenta as age was 34 weeks in the ICC group compared with 34.1 weeks
feasible. Because most of the preterm deliveries in our in the DCC group; mean birth weight was 2250 g in the ICC
institution were cesarean sections, it was a challenge getting cohort compared with 2325 g in the DCC cohort. Male infants
the baby truly below the level of the placenta. Because good represented 35% in DCC group, compared to 38% in the ICC
evidence is emerging in more mature infants, the optimal group. There were no significant differences in 1- and
timing and positioning in a very preterm infant still must be 5-minute Apgar scores, admission temperature or Ph, PCO2,
explored. A large percentage of deliveries did not receive PO2 done at birth from the umbilical cord. However,
DCC because of our predefined narrow eligibility criteria. The significantly fewer infants in the DCC cohort were intubated in
question of DCC being beneficial or harmful in these higher the delivery room compared with the ICC cohort. Significant
risk excluded infants (such as multiple gestations, growth differences in glucose levels with those in the DCC group
restricted, and other vulnerable preterm groups) must be having higher initial glucose levels than those in the ICC
explored carefully in the future. We were aware of the different group. Red blood cell transfusion need in the first week of life
approaches reported in the literature like umbilical cord was significantly lower in the DCC cohort compared with the
milking and mobile trolley use that may minimize delay in ICC, although the use of pressor support or corticosteroids
resuscitation. was not different. Phototherapy in first week of life was

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significantly higher in the DCC, but none of the infants in Discussion

either groups received intensive phototherapy or exchange
transfusion. Incidence of RDS and surfactant administration There are several factors that contributed to the high rate
was significantly lower in the DCC cohort. A significant of compliance with DCC in our institution. First, the process
reduction was noted in the incidence of IVH in the DCC group was developed with substantial inter professional coordination
compared with the ICC group. After adjustment for gestational between the departments of obstetrics and neonatology that
age, an association was found between the incidence of IVH resulted in standardized protocol and narrow eligibility
and DCC, with IVH significantly lower in the DCC group criteria to overcome perceived barriers. In addition, the
compared with the ICC group. Also we found that, despite extensive implementation plan included staff education,
delaying resuscitation briefly, Apgar scores, other resuscitation simulation exercises, and interim monitoring. Finally, this
variables, and mean admission temperature were not different intervention was incorporated into our Golden Hour protocol
between the DCC and ICC control groups. Additionally, a that has objectives and processes for preterm infant care in
significantly lower number of infants in the DCC group were the delivery room that we have used successfully in our
intubated in the delivery room. More infants were breathing practice. Our study agreed with other studies about delayed
spontaneously after DCC, which contributes to the success of cord clamping in preterm infants. Many obstetricians and
non-mechanical ventilation. This supports the general neonatologists share the same concern regarding DCC in
hypothesis that DCC at birth decreases the need for preterm infants, which are adverse outcomes that result from
resuscitation by promoting a more physiologic transition to delaying the resuscitation in these infants [8-12]. We found
extrauterine life. Number of preterm with suspected NEC that, despite delaying resuscitation briefly, Apgar scores,
(necrotizing enterocolitis) or feeding intolerance were, other resuscitation parameters, and mean admission
significantly lower in the DCC compared to ICC group. temperature were not different between the DCC and control
group. Additionally, a significantly lower number of infants in
Table 1. Maternal demographic and clinical data.
the DCC were intubated in the delivery room. More infants
DCC ICC
Maternal Data
n=79 n=81
P value were breathing spontaneously after DCC, which contributes
Maternal age, mean (SD) 26.3(6.7) 26.2(5.4) .8 to the success of non-mechanical ventilation. This supports
Artificial reproductive therapy, n (%) 2 (2.5) 1 (1.2) .8 the general hypotheses that DCC at birth decrease the need
Number of CS, n (%) 48 (60.7) 53 (65%) .9 for resuscitation by promoting a more physiologic transition
Chorioamnionitis, n (%) 1 (1.2) 1 (1.2) .8 to extra uterine life [13,14]. Our observed reduction in the
Gestational DM, n (%) 3 (3.8) 5 (6%) .66
incidence of RDS and surfactant administration adds evidence
Pre-eclampsia, n (%) 1 (1.2) 3 (3.7) .7
to the recommendation of DCC for decreased incidence of
Poly or oligohydramnios, n (%) 5 (6.3) 7 (8.6) .9
Ante-natal steroid, n (%) 68 (86) 74 (91) .5 RDS [15,16].
Mg sulfate 1 (1.2) 2 (2.4) .8 In our study, preterm babies who needed blood
transfusion were lower in the DCC group compared to ICC
Table 2. Infants’ Demographic and Clinical Characteristics after delivery.
group, this was in agreement with physiologic studies in
Infants Data DCC 79 ICC 81 P value
preterm infants, which have shown that a transfer from the
Gestational age wk, mean (SD) 34.2(2.2) 34.6(2) 0.3
Birth Weight,g, mean (SD) 1325(365) 1250(429) 0.4
placenta of approximately 80 mL of blood occurs by 1 minute
Sex after birth, reaching approximately 100 mL at 3 minutes after
Male, n (%) 35 (44%) 38 (47%) 0.5 birth. This additional blood can supply extra iron, amounting
Female, n (%) 44(56%) 43(53%) 0.7 to 40–50 mg/kg of body weight. This extra iron, combined
Apgar Score at 1min,median (range) 8 (3-9) 8 (3-9) 0.7 with body iron (approximately 75 mg/kg of body weight)
Apgar Score at 5min, median(range) 9 (4-9) 9 (5-9) 0.7 present at birth in a preterm newborn, may help prevent iron
Admission Temperature, mean (SD) 36.8 (2.3) 36.7 (2.2) 0.5
deficiency during the first year of life [17,18].
Initial blood glucose, mean (SD) 73 (28.1) 51s(18) 0.03
Initial mean blood pressure, mean (SD) 29(4.8) 33(6) 0.1 According to Mark Sloan, M.D., whether a baby “is
Intubation in the delivery room, n (%) 3 (3.8%) 9 (8.6%) 0.03 premature or full term, approximately one-third of its total
PH, mean (SD) 7.3 (0.06) 7.3 (0.07) 0.6 blood volume resides in the placenta. This is equal to the
PCO2 mmHg, mean (SD) 47 (13.2) 46.3 (11.6) 0.7 volume of blood that will be needed to fully perfuse the fetal
PO2 mm Hg, mean (SD) 55 (28) 60.3(20.4) 0.8 lungs, liver, and kidneys at birth. In addition to the benefits
Table 3. Infant morbidity during NICU stay.
that come with adequate iron stores. . .babies whose cords
Infants Morbidity DCC 79 ICC 81 P value
are clamped at 2 to 3 minutes—and thus, who have an
Blood transfusion after 1 wk of birth, n (%) 23(33) 35(49) 0.02 increased total blood volume compared with their
Pressor Support or Corticosteroid, n (%) 41(60) 45 (61) 0.9 immediately-clamped peers—have a smoother
Phototherapy, n (%) 53 (70) 39 (49) 0.03 cardiopulmonary transition at birth [19,20]. Another potential
RDS-use of surfactant n (%) 41 (60) 63 (80) 0.02 benefit of delayed cord clamping is to ensure that the baby
Assisted Ventilation, n (%) 49 (62) 65 (82) 0.03 can receive the complete retinue of clotting factors.” In other
Days on oxygen, mean ± SD 45 (14.3) 49 (16.7) 0.3
words, the increased volume of blood will naturally increase
IVH, n(%) 9 (20) 24 (30) 0.01
blood platelet levels, which are needed for normal blood
Suspected NEC, n (%) 9 (7.9) 14(20) 0.01
clotting [21,22].
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In our study, the number of babies who needed improved outcomes. In conclusion, we have implemented
phototherapy in the DCC group were significantly higher than DCC process successfully in a large delivery hospital. DCC, as
ICC group. One analysis found a very slight (2%) increase in performed in our hospital, was associated with a significant
jaundice among babies who received delayed cord clamping. reduction in IVH and early red blood cell transfusion. Further
However, according to the Thinking Midwife, “The only clinical studies are needed to optimize the timing and
studies available involve the administration of an artificial technique of DCC and to report the impact of this potentially
oxytocic (syntocinon or syntometrine) in the ‘delayed valuable procedure on long term neuro developmental
clamping’ group IV syntocinon is associated with jaundice. outcomes of the preterm infants.
Therefore, it could be the oxytocic making a difference here–
not the clamping. Other studies, found “that the difference References
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