Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 34  |  Issue : 1  |  Page : 216--220

Study of short-term outcome of early and late cord clamping in full-term newborns


Maha A Tawfik1, Dalia M Ellahony1, Aymen M Abdel-Qader2,  
1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Pediatrics, Ministry of Health, El Giza Pediatrics Hospital, Giza, Egypt

Correspondence Address:
Aymen M Abdel-Qader
Department of Pediatrics, Ministry of Health, El Giza Pediatrics Hospital, Giza
Egypt

Abstract

Objective The aim was to assess short-term outcome of both early and late cord clamping in full-term newborns. Background Delaying clamping of the umbilical cord for at least 2 min after birth consistently improved both the short-term and long-term hematologic and iron status of full-term infants. Participants and methods This is a case–control study that was conducted on 100 Egyptian full-term neonates (47 males and 53 females), involving 50 newborns with early clamping of the cord less than or equal to 1 min as group I and 50 newborns with late clamping of the cord more than 1 min without milking of the cord, matched for age and sex, as group II. All of them were subjected to full history, physical examination, Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (APGAR) score, and blood samples taking at birth and after 24 h. Complete blood count including hemoglobin (Hb), packed cell volume, hematocrit, mean corpuscular volume, reticulocyte count, and total serum bilirubin (TBS) was done. Results Hb, hematocrit, packed cell volume, and TBS (P < 0.05) were significantly higher after 24 h of cord clamping in the delayed clamping group than early clamping. APGAR score had no significant difference. Conclusion In term infants, delayed umbilical cord clamping increases Hb levels at birth. There is a small increase in TBS, requiring follow-up after 24 h, in term infants undergoing delayed umbilical cord clamping.



How to cite this article:
Tawfik MA, Ellahony DM, Abdel-Qader AM. Study of short-term outcome of early and late cord clamping in full-term newborns.Menoufia Med J 2021;34:216-220


How to cite this URL:
Tawfik MA, Ellahony DM, Abdel-Qader AM. Study of short-term outcome of early and late cord clamping in full-term newborns. Menoufia Med J [serial online] 2021 [cited 2021 Dec 5 ];34:216-220
Available from: http://www.mmj.eg.net/text.asp?2021/34/1/216/312026


Full Text



 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 clamping of the cord more than 5 min after birth. In a series of small studies of blood volume changes after birth, it was reported that 80–100 ml of blood was transmitted from the placenta to the newborn in the first 3 min after birth and up to 90% of that blood volume transfer was received within the first few breaths in healthy term infants [1]. Delayed umbilical cord clamping appears to be beneficial for term and preterm infants. In term infants, delayed umbilical cord clamping increases hemoglobin (Hb) levels at birth while improving iron stores in the first several months of life, which may have a favorable effect on developmental outcomes. In preterm infants, rates of intraventricular hemorrhage and necrotizing enterocolitis are lower, and fewer newborns require transfusion when delayed umbilical cord clamping is employed [2]. This growing body of evidence has led a number of professional organizations to recommend delayed cord clamping in term and preterm infants. For example, the World Health Organization recommends that the umbilical cord not be clamped earlier than 1 min after birth in term or preterm infants who do not require positive pressure ventilation. Recent Neonatal Resuscitation Program guidelines from the American Academy of Pediatrics recommend delayed umbilical cord clamping for at least 30–60 s for most vigorous term and preterm infants. The Royal College of Obstetricians and Gynecologists also recommends deferring umbilical cord clamping for healthy term and preterm infants for at least 2 min after birth. Additionally, the American College of Nurse–Midwives recommends delayed umbilical cord clamping for term and preterm infants for 2–5 min after birth [3]. The universal implementation of delayed umbilical cord clamping has raised concern. Delay in umbilical cord clamping may delay timely resuscitation efforts, if needed, especially in preterm infants. However, because the placenta continues to perform gas exchange after delivery, sick and preterm infants are likely to benefit most from additional blood volume derived from continued placental transfusion. Another concern is that a delay in umbilical cord clamping could increase the potential for excessive placental transfusion. To date, the literature does not show evidence of an increased risk of polycythemia or jaundice; however, in some studies, there is a slightly higher rate of jaundice that meets criteria for phototherapy in term infants. Given the benefits to most newborns and concordant with other professional organizations, the American College of Obstetricians and Gynecologists now recommends a delay in umbilical cord clamping for at least 30–60 s after birth in vigorous term and preterm infants [4]. The benefits of umbilical cord clamping not earlier than 2–3 min after birth are the result of physiological mechanisms; for this reason, it may not be considered an actual treatment but a practice that respects natural physiological mechanisms. Such benefits are mainly the product of allowing the infant to receive the blood volume that ought to have been in the child. That is to say, that placental transfusion is an unavoidable physiological outcome occurring in the first minutes of life and resulting from the redistribution of blood between the placenta and the infant [5]. The aim of the present study was to assess the benefits with later cord clamping between 1 and 3 min after the birth and its effects on the mother and the infant.

 Participants and methods



After approval of the Local Institutional Ethical Committee of Menoufia University Hospital and after taking a written consent from parents of studied neonates to share in the study, our study was conducted as a case–control study. It was conducted on 50 Egyptian term neonates (47 males and 53 females) who were sporadically selected from those delivered and resuscitations in Algalaa Hospitals in the period from April 2017 to November 2018. All newborn were divided into two groups: group I (50 newborns with early clamping of the cord ≤1 min) and group II (50 newborns with late clamping of the cord >1 min). Inclusion criteria were infants delivered with gestational age greater than or equal to 37 weeks, birth weight greater than or equal to 2000 g (≥2 kg), all delivered vaginally, and with cephalic presentation. Family history, antenatal history, natal history, postnatal history were recorded. Full clinical examination included gestational age (weeks) by new Ballard score, APGAR score, body length (cm) (the average length at birth for a full-term baby is 50 cm, but the range for most newborns is between 45.7 and 60 cm), and birth weight (normal range 2500 up to 4000 g), and laboratory investigations included complete blood count, with the values of Hb level (g/dl), hematocrit (HCT) (%), mean cell volume (pg), mean cell Hb (g/dl), reticulocyte count, done by blood film and detected by microscopic examination, and total serum bilirubin (TBS) (mg/dl) by BioSystemA15 analyzer C/ Costa Brava 30 08030 Barcelona (Spain). Blood samples were cord sample at birth and serum sample after 24 h. The samples were used for complete blood count, an Adevia 2012 (Siemens Corporation, Erlangen, Germany) automated hematology analyzer.

Statistical analysis

Data were collected and entered to the computer using SPSS 18 (statistical package for the social sciences; SPSS Inc., Chicago, Illinois, USA), program for statistical analysis. Data were entered as numerical or categorical, as appropriate. Two types of statistics were done: first, descriptive statistics in which quantitative data were expressed in mean, SD, and SE and second, qualitative data, which were expressed in number (frequency) and percentage. Analytical statistics were done by using χ2-test and Fisher's exact test to measure association between qualitative variables as appropriate. Moreover, Student t-test, which is a test of significance, was used for comparison between two groups having quantitative variables. Mann–Whitney test (nonparametric test), which is a test of significance, was used for comparison between two groups not normally distributed having quantitative variables. The level of significance used was 95%, so P value of greater than 0.05 was considered statistically nonsignificant, P value of less than 0.05 was considered statistically significant, and P value of less than 0.001 was considered statistically highly significant.

 Results



A total of 100 Egyptian full-term neonates (47 males and 53 females) were classified into two groups: group I (50 newborns with early clamping of the cord ≤1 min) and group II (50 newborns with late clamping of the cord >1 min). Weight for group I was 2.65–4 kg and weight for group II was 2.65–4 kg, body length (cm) for group I was 46–54 and body length for group II was 46.5–54, and head circumference was 33.5–38 and 32.5–38 for groups I and II, respectively, which showed no significant difference between the two groups. Moreover, regarding the percentage of females versus males with early and late clamping of the cord, there was a greater percentage of females than males in late clamping, but with no statically significant difference (P = 0.218) [Table 1]. Regarding the laboratory findings for group I and group II at birth with respect to the levels of Hb, HCT %, mean corpuscular volume (MCV), mean corpuscular hemoglobin, packed cell volume (PCV), reticulocyte count %, TBS, there was no statistically significant difference between groups [Table 2]. Regarding APGAR scoring in first and fifth minute in the early and late groups, there were no statistically significant differences on APGAR score at first minute and 5 min, as shown in [Table 3]. Moreover, when comparing laboratory finding after 24 h between group I and group II, there was a statically significantly higher score in group II regarding Hb level (P = 0.009), HCT (P = 0.019), PCV (P = 0.055), and TSB (P = 0.048) [Table 4].{Table 1}{Table 2}{Table 3}{Table 4}

 Discussion



Delayed cord clamping has been practiced in obstetrics based on recommendations made by scientific societies and in systematic reviews, which have provided solid evidence to support this practice in term infants [6]. After delivery, the infant should be placed skin-to-skin on the mother's abdomen or in her arms, dried and covered with a warm blanket, and the umbilical cord should be leaved intact until it becomes pale or white, flat and look obviously emptied [7]. Delayed cord clamping and early cord clamping as well as the selection criteria of studies based on the guidelines developed by WHO and International Confederation of Midwives [8]. Our study showed that in group I male patients represented 48% and female patients represented 52.0%, and in group II, males represented 58% and females represented 42%. Both groups were sex and age matched. Mean gestational age (weeks) of both groups was 34, and mean birth weight (kg) in group I was 3.15 ± 0.28 and of group II was 3.13 ± 0.33. Moreover, head circumference (cm) and length (cm) were comparable in group I and group II, with no statistically significant difference. This is in accordance with Rincón et al. [9], who reported that there was no significance difference between sex and age, and the median weight, length, and head circumference at birth were similar in all groups. In our study, regarding the percentage of females versus males with early and late clamping of the cord, there was a larger percentage of females than males on late clamping, but with no statistically significant difference. Indraccolo et al. [10] found that each second of delay in cord clamping resulted in a reduction in the percentage of weight loss at the first day (P = 0.024), at the second day (P = 0.007), and at the third day (P = 0.028) after birth. On the contrary, Rincón et al. [9] noted the difference in the number of newborns included in each group. The late clamping group included over half of the sample, with no sex determination. Our study associated with no statically difference regarding all hematological laboratory between group I and group II at birth with respect to Hb, HCT, MCV, mean corpuscular hemoglobin, reticulocytic count, PCV, and TBS. McAdams [11] found that newborns in the early umbilical cord clamping group had significantly lower Hb concentrations at birth (weighted mean difference: –2.17 g/dl; 95% CI: –4.06 to –0.280) as well as at 24–48 h after birth (mean difference: –1.49 g/dl; 95% CI: –1.78 to –1.21). Moreover, there was no difference in the rate of polycythemia between the two groups nor were overall rates of jaundice different, but jaundice requiring phototherapy was less common among those newborns who had early umbilical cord clamping (2.74% of infants in the early cord clamping group compared with 4.36% in the late cord clamping group; relative risk (RR): 0.62; 95% CI: 0.41–0.96). In contrast with our study, Backes et al. [12] reported that initial HCT at birth was higher in term neonates in the delayed cord clamping group compared with early cord clamping. McDonald et al. [13] in a meta-analysis of trials in term infants confirmed that measures of blood volume and HCT generally improved among infants with delayed clamping. In our study, we found that there was a significant difference in Hb, HCT, PCV, and MCV regarding difference (between cord and after 24 h) for both groups. DCC difference mean value is lower for all parameters, which means more improvement of hematological values. We did not find statistically significant difference between the groups regarding reticulocytic count. In agreement with us, Mercer et al. [14] reported that infants randomized to DCC compared with ICC had significantly higher Hb levels at 24–48 h, with no difference in bilirubin levels. Al-Tawil et al. [15] reported that term infants had early hematological advantage of DCC without increases in hyperbilirubinemia or symptomatic polycythemia. Rincón et al. [9] noted that the analysis performed at 48 h after birth showed higher levels of Hb and HCT, and significant differences in ferritin were observed starting at minute 2. In contrast, according to Zhao et al. [16], Hb is normally not affected until iron stores are depleted, but MCV increased before 6 months of age for DCC. Andersson et al. [17] found that reticulocyte and Hb were higher for those allocated to delayed cord clamping. Our study showing that there is no statistically significance regarding APGAR and no significant difference between both groups at 5 min. Altaf et al. [18] reported that there was no significantly difference in infants receiving ECC vs. DCC with respect to APGAR scores. Salari et al. [19] reported that late cord clamping leads to a significant increase in the HCT of the neonate but it does not affect APGAR score and duration of the third stage of labor. In our study, there was a statistically significant increase on TSB for DCC (after 24 h and for the regarding difference between samples of both group), with no difference for phototherapy needing cases. Rincón et al. [9] reported that the bilirubin levels at 48 h showed no significant differences between the groups. Mercer et al. [14] reported that bilirubin levels are elevated but within a normal range (associated with normal physiologic jaundice), which may provide a unique protective antioxidant effect, especially for the developing brain.

 Conclusion



The results obtained in our study support that delayed umbilical cord clamping in term infants increases Hb levels in the first several months of life. There is a small increase in TSB and needs follow-up of term infants every 24 h undergoing delayed umbilical cord clamping. We recommend delayed cord clamping to avoid anemia for the baby in the first months of life. Further studies are required to establish this finding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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