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Review
. 2013 Jul 11;2013(7):CD004074.
doi: 10.1002/14651858.CD004074.pub3.

Effect of Timing of Umbilical Cord Clamping of Term Infants on Maternal and Neonatal Outcomes

Affiliations
Free PMC article
Review

Effect of Timing of Umbilical Cord Clamping of Term Infants on Maternal and Neonatal Outcomes

Susan J McDonald et al. Cochrane Database Syst Rev. .
Free PMC article

Abstract

Background: Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord more than one minute after the birth or when cord pulsation has ceased. The benefits and potential harms of each policy are debated.

Objectives: To determine the effects of early cord clamping compared with late cord clamping after birth on maternal and neonatal outcomes

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013).

Selection criteria: Randomised controlled trials comparing early and late cord clamping.

Data collection and analysis: Two review authors independently assessed trial eligibility and quality and extracted data.

Main results: We included 15 trials involving a total of 3911 women and infant pairs. We judged the trials to have an overall moderate risk of bias. Maternal outcomes: No studies in this review reported on maternal death or on severe maternal morbidity. There were no significant differences between early versus late cord clamping groups for the primary outcome of severe postpartum haemorrhage (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.65 to 1.65; five trials with data for 2066 women with a late clamping event rate (LCER) of ~3.5%, I(2) 0%) or for postpartum haemorrhage of 500 mL or more (RR 1.17 95% CI 0.94 to 1.44; five trials, 2260 women with a LCER of ~12%, I(2) 0%). There were no significant differences between subgroups depending on the use of uterotonic drugs. Mean blood loss was reported in only two trials with data for 1345 women, with no significant differences seen between groups; or for maternal haemoglobin values (mean difference (MD) -0.12 g/dL; 95% CI -0.30 to 0.06, I(2) 0%) at 24 to 72 hours after the birth in three trials. Neonatal outcomes: There were no significant differences between early and late clamping for the primary outcome of neonatal mortality (RR 0.37, 95% CI 0.04 to 3.41, two trials, 381 infants with a LCER of ~1%), or for most other neonatal morbidity outcomes, such as Apgar score less than seven at five minutes or admission to the special care nursery or neonatal intensive care unit. Mean birthweight was significantly higher in the late, compared with early, cord clamping (101 g increase 95% CI 45 to 157, random-effects model, 12 trials, 3139 infants, I(2) 62%). Fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group (RR 0.62, 95% CI 0.41 to 0.96, data from seven trials, 2324 infants with a LCER of 4.36%, I(2) 0%). Haemoglobin concentration in infants at 24 to 48 hours was significantly lower in the early cord clamping group (MD -1.49 g/dL, 95% CI -1.78 to -1.21; 884 infants, I(2) 59%). This difference in haemoglobin concentration was not seen at subsequent assessments. However, improvement in iron stores appeared to persist, with infants in the early cord clamping over twice as likely to be iron deficient at three to six months compared with infants whose cord clamping was delayed (RR 2.65 95% CI 1.04 to 6.73, five trials, 1152 infants, I(2) 82%). In the only trial to report longer-term neurodevelopmental outcomes so far, no overall differences between early and late clamping were seen for Ages and Stages Questionnaire scores.

Authors' conclusions: A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.

Conflict of interest statement

The contact review author (S McDonald) is the author of one of the included studies. The other review authors assessed this trial for potential inclusion and data extraction.

Figures

Figure 1
Figure 1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 2
Figure 2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Early versus late cord clamping, Outcome 1 Severe PPH/blood loss 1000 mL or more.
Analysis 1.2
Analysis 1.2
Comparison 1 Early versus late cord clamping, Outcome 2 Neonatal death.
Analysis 1.3
Analysis 1.3
Comparison 1 Early versus late cord clamping, Outcome 3 PPH/blood loss 500 mL or more.
Analysis 1.4
Analysis 1.4
Comparison 1 Early versus late cord clamping, Outcome 4 Mean blood loss (mL).
Analysis 1.5
Analysis 1.5
Comparison 1 Early versus late cord clamping, Outcome 5 Maternal haemoglobin (g/dL) 24 to 72 hours postpartum.
Analysis 1.6
Analysis 1.6
Comparison 1 Early versus late cord clamping, Outcome 6 Need for blood transfusion.
Analysis 1.7
Analysis 1.7
Comparison 1 Early versus late cord clamping, Outcome 7 Need for manual removal of placenta.
Analysis 1.8
Analysis 1.8
Comparison 1 Early versus late cord clamping, Outcome 8 Length of third stage > 30 mins.
Analysis 1.9
Analysis 1.9
Comparison 1 Early versus late cord clamping, Outcome 9 Length of third stage > 60 mins.
Analysis 1.10
Analysis 1.10
Comparison 1 Early versus late cord clamping, Outcome 10 Need for therapeutic uterotonics.
Analysis 1.11
Analysis 1.11
Comparison 1 Early versus late cord clamping, Outcome 11 Apgar score < 7 at 5 mins.
Analysis 1.12
Analysis 1.12
Comparison 1 Early versus late cord clamping, Outcome 12 Any admission to SCN or NICU.
Analysis 1.13
Analysis 1.13
Comparison 1 Early versus late cord clamping, Outcome 13 Respiratory distress.
Analysis 1.14
Analysis 1.14
Comparison 1 Early versus late cord clamping, Outcome 14 Jaundice requiring phototherapy.
Analysis 1.15
Analysis 1.15
Comparison 1 Early versus late cord clamping, Outcome 15 Clinical jaundice.
Analysis 1.16
Analysis 1.16
Comparison 1 Early versus late cord clamping, Outcome 16 Polycythaemia.
Analysis 1.17
Analysis 1.17
Comparison 1 Early versus late cord clamping, Outcome 17 Cord haemoglobin (g/dL).
Analysis 1.18
Analysis 1.18
Comparison 1 Early versus late cord clamping, Outcome 18 Newborn haemoglobin (g/dL).
Analysis 1.19
Analysis 1.19
Comparison 1 Early versus late cord clamping, Outcome 19 Infant haemoglobin at 24‐48 hours (g/dL).
Analysis 1.20
Analysis 1.20
Comparison 1 Early versus late cord clamping, Outcome 20 Infant haemoglobin at 3‐6 months (g/dL).
Analysis 1.21
Analysis 1.21
Comparison 1 Early versus late cord clamping, Outcome 21 Low infant haemoglobin at 3‐6 months.
Analysis 1.22
Analysis 1.22
Comparison 1 Early versus late cord clamping, Outcome 22 Infant haematocrit (%).
Analysis 1.23
Analysis 1.23
Comparison 1 Early versus late cord clamping, Outcome 23 Low infant haematocrit (< 45% at 6 hours).
Analysis 1.24
Analysis 1.24
Comparison 1 Early versus late cord clamping, Outcome 24 Low infant haematocrit (< 45% at 24‐48 hours).
Analysis 1.25
Analysis 1.25
Comparison 1 Early versus late cord clamping, Outcome 25 Infant iron deficiency at 3‐6 months.
Analysis 1.26
Analysis 1.26
Comparison 1 Early versus late cord clamping, Outcome 26 Birthweight (g).
Analysis 1.27
Analysis 1.27
Comparison 1 Early versus late cord clamping, Outcome 27 Not breastfeeding on discharge (or later).
Analysis 1.28
Analysis 1.28
Comparison 1 Early versus late cord clamping, Outcome 28 Neurodevelopment at 4 months.
Analysis 1.29
Analysis 1.29
Comparison 1 Early versus late cord clamping, Outcome 29 Symptoms of infection during first 4 months.

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