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Delayed Cord Clamping
Placental transfusion: Umbilical Cord Clamping and Preterm Infants. Ibrahim HM, Krouskop RW, Lewis DF, et al. J Perinatol 2000; 20:351-354.
This study investigated the clinical effects of early vs late cord clamping in preterm infants. 32 preterm infants, 24-28 weeks gestation, were randomized to receive either early (immediately after delivery) or delayed (20 seconds after body delivered) umbilical cord clamping. The delayed cord clamping (DCC) group exhibited a decrease in the frequency of blood transfusions (p < .001), and also a decrease in albumin transfusions over the first 24 hours (p < .03). The mean blood pressure in the first 4 hours was higher in the DCC group (p < .01), and there were statistically significant increases in Hct (21%), Hgb (23%), and RBC count (21%) vs the early cord clamping group. The incidence of PDA, hyperbilirubinemia and IVH was similar in both groups.
Comment. Delayed cord clamping seems like a simple therapeutic maneuver with several beneficial effects in small premature babies. In addition to the benefits mentioned in the abstract, it is useful to note that the DCC group also had significantly higher 5-minute Apgar scores. The reduction in the number of blood transfusions needed in the DCC group was impressive (1.2 transfusions vs 3.6 in the control group). This is much greater than the effect on this variable seen in the Epogen studies. Also the hemodynamic benefits of DCC were significant, as these babies had higher mean blood pressures and required fewer volume boluses. While potential adverse side effects of DCC (ie IVH, polycythemia, jaundice) were not increased in the study group, a much larger sample size will be needed to draw any conclusions about the safety of this practice. Please note that the delay in cord clamping in this study was only 20 seconds, and that the infant was held at the level of the introitus during this period. Just because a little placental transfusion may be good, it doesn’t mean that a lot is better. More aggressive efforts to increase placental transfusion into premature infants (such as a longer delay in cord clamping, "stripping" the cord toward the baby, or holding the infant at a lower level than the mother) will probably result in a higher incidence in these adverse side effects.
Andrew B. Kairalla MD
Sent: 21 Oct 2001 at 09:23:58
This study lacks a physiological control group and comment is based on two fallacies: 1. That placental transfusion is pathological 2. That the cord clamp is physiological. During physiological birth, (no cord clamp) placental oxygenation and transfusion continue until pulmonary oxgenation and an optimal blood volume are established; the child then reflexively closes the umbilical vessels permanently. This physiology has been honed to perfection over millions of years by natural selection for optimal newborn survival and avoids neonatal asphyxa. Premature cord clamping interrupts placental oxygenation and transfusion, producing hypoxia/asphyxia and hypovolemia/ischemia which result in HIE, IVH & NEC (hemorrhagic infarcts of the germinal matrix and gut from hypovolemic vasospasm,) RDS (hypovolemic shock lung,) pallor, hypotension, hypothermia, oliguria, metaboic acidosis and anemia. Physiological cord closure produces a physiological (healthy) newborn, term or preterm. Cord clamps disrupt physiology and produce iatrogenic pathology. The rational way to treat extreme immaturity is to deliver the intact cord and placenta into a warmed, oxygenated, isobaric nutrient solution in the attempt to maintain some placental function and to allow some maturing of the immature lungs. Amputation of a normally functioning placenta at any gestational age is not rational care.
UserName: G. M. Morley, MB ChB, FACOG
Institution: retired obstetrician
telephone: 1(231) 386 9655
email: gmmorley@webtv.net