Delayed Cord Clamping vs. Immediate Cord Clamping: Independent Study on Human Birthing

Introduction

Throughout the students practical placements they have witnessed midwives having conflicting views on the practice of delayed cord clamping which then allowed the student to research the topic in depth. After reviewing all the evidence the student will make recommendations for practice. They should discuss the implications of both delayed cord clamping and immediate cord clamping to improve patient safety and reduce harm to both the neonate and the mother. For the student to show their ability to be an independent learner they must undertake a study on a subject of their choice. The student has chosen to discuss whether delayed cord clamping or immediate cord clamping is more beneficial for a positive outcome for neonates and mothers. The student will relate this subject to The World Health Organisations (WHO) documentation relating to patient safety and also how delaying cord clamping could reduce harm to the neonate and mother.
Previous to this study the student will have presented their plan and learning outcomes to a small audience and has also provided a rationale, stating the aim, learning outcomes and also outlining their reasoning on choosing this particular topic for their Independent study (appendix 1).

Literature Review

The most historically practiced protocol has been delayed cord clamping, with work dating back to 1773, when Charles While published his famous work, A Treatise on the Management of Pregnant and Lying in Women, which taught delayed cord clamping as common practice except in the case of a nuchal cord (Cook, 2007). Erasmus Darwin in 1801 suggested that it was injurious to an infant if the umbilical cord was cut too soon. He advised it should always be left until the child has repeatedly breathed and the cord had stopped pulsating, otherwise the baby would be left much weaker than it should be as the blood which should have been transfer to the baby would have been left in the placenta (Bluff, 2006).
Immediate cord clamping started becoming more common practice in the 1960s due to two reasons. Firstly, mismanaged jaundice provoked a great deal of lawsuits against paediatricians who then urged obstetricians to minimise placental transfusion. Secondly, due to the increase use of analgesia and active management of the third stage of labour Eastman (1950) stated that by the widespread use of analgesic drugs in labour, it has resulted in a number of infants who had sluggish respiratory effects at birth causing the need for immediate cord clamping to take place. In 1997 the World Health Organisation suggested the primary reason for early clamping being practiced is to protect the neonate from the large infusion of blood that occurs from the Syntocinon induced contraction immediately after delivery. More recent studies have shown the opposite from this and that delayed cord clamping is more beneficial to the mother and baby.
The NICE Clinical Guidelines (2007) on intra-partum care carried out a review to ascertain whether interfering with placental transfusion had any benefits to the mother or the baby. Their findings was that there was insufficient evidence to support delayed cord clamping in high income countries but it did support that delayed cord clamping reduced anaemia in low to middle income countries. They suggest this is due to anaemia being more prevalent in those countries over all and that more research needs to be done to suggest delayed cord clamping is beneficial to mother and baby.
The student has chosen three studies to consider and review. The first is a study by Anderson et al, (2011). Their aim was to determine the effects of delayed cord clamping versus early cord clamping on neonatal outcomes and iron status at four month. Their reasoning behind this was that previous studies have found that as much as 26% of children suffer from anaemia and in India 70% of children between six-eleven months were found to be anaemic (Jaleel, Deeba, Khan, 2009). It has been suggested that iron deficiency has been associated with impaired neurological development; therefore Anderson et al (2011) decided to carry out a randomised control trial to try and decided what would be the best practice. They state their main focus is haemoglobin and iron status at four months of age and they have a secondary focus of neonatal anaemia, early respiratory symptoms and polycythaemia. Their aim was clear from the outset that they would show delayed cord clamping reduces iron deficiency in neonates. The second study is an article by Bluff (2006) discussing early versus delayed cord clamping. Bluffs objective is to prove that by delaying cord clamping it can reduce the incidences of Respiratory Distress Syndrome, Intravatricular Haemorrhage, Necrotizing Enterocolostic and brain damage. Bluff (2006) provides sufficient evidence to back up their claim agreeing with Anderson et al (2011) that delayed cord clamping is more beneficial to the mother and baby than early cord clamping. The third study the student has chosen to discuss is one of midwives views on delayed cord clamping. Airey et al (2008) states that although there is evidence to associate delayed cord clamping with benefits to mother and baby midwives still practice early clamping. The author claims there is an uncertainty of alternative strategies with cord clamping. Falcao (2012) agrees suggesting this may be due to the lack of knowledge and clear guidelines of what delayed cord clamping is. Therefore Airey et al (2008) conducted a survey, their aim was to interview a number of delivery suite midwives and record the results, stating there is conflicting knowledge of the timing of delayed cord clamping.
Anderson et al (2011) states that young children are at risk of iron deficiency due to low iron intake and the need for iron for rapid growth. Iron is essential for cognitive development (Mitra, 2009) therefore it is important that we understand the best practice possible to reduce these risk associated with iron deficiency and achieve optimal brain development. Bluff (2006) states that iron stores are crucial for optimal neurological development. Anderson et al (2011) obtained their results from 400 full term infants in low risk pregnancy which makes it one of the largest randomised controlled studies comparing delayed and early clamping. By using a larger group it gives more accurate and widespread results (NIH,2012). Their results showed, that at four months of age infants had no significant differences in haemoglobin concentration, but 45% of infants that had delayed cord clamping had higher ferritin levels and lower prevalence of iron deficiency. Mitra et al (2009) also carried out a similar study, although only using 130 participants the same results were found that delayed cord clamping reduces the risk of iron deficiency. Many studies have shown that by clamping the umbilical cord immediately after birth it reduces the blood the neonate receives therefore it may increase the risk of that infant becoming iron deficient or anaemic. The blood circulating the placenta and umbilical vessels is 25-40% of the babies total blood volume (Yao & Lind,1974). A healthy neonate’s blood volume is around 80-115ml/kg of birth weight therefore a neonate weighing 3.6kg has a blood volume of 209- 290mls of blood, which 75-125mls may have been transfused. By delaying cord clamping and allowing the extra blood to be transfused this could provide the neonate with an additional 50 mg of additional iron which may prevent or delay low iron levels as an infant ( Bluff, 2006).
Bluff (2006) also discusses the other benefits to delayed cord clamping, such as reducing the risks of Respiratory Distress Syndrome (RDS) which is the major cause of neonatal morbidity, mortality, Necrotising Enterocolitis (NEC) and Intraventricular Haemorrhages (IVH). This is due to immediate clamping of the cord preventing additional blood being transfused to the neonate which is the equivalent to the amount transferred to a baby with profound shock Morley (1998). This describes immediate cord clamping as the equivalent of subjecting an infant to a massive haemorrhage. Mercer and Skovgaard (2002) state that if we lost this much blood at any other point in our lives it would cause serves morbidity or death. . By clamping the cord immediate after delivery this would result in blood being sacrificed from other organs in order to establish pulmonary perfusion, which may increase the risk of the neonate suffering from RDS, NEC or IVH.
The use of Delayed Cord Clamping should also be used with preterm neonates. Strauss et al (2008) also carried out a randomised controlled trial comparing delayed versus immediate cord clamping but specifically relating to preterm neonates. The outcomes are the same as the previous trials that delayed cord clamping is more beneficial to the neonate than immediate cord clamping. The author states that the neonates whole blood volume was increased after delayed cord clamping. Bluff (2006) also agrees that delayed cord clamping should be used with preterm infants if possible as it increases red blood cells and stabilises blood pressure therefore decreasing the need for transfusions and also decreases the risk of bleeding in the brain.
Although there is a great deal of evidence showing benefits to the neonate from delayed cord clamping, there is also benefits to the mother. Bluff (2006) suggests that by delaying the clamping of the cord it reduces the risk of the mothers experiencing a post-partum haemorrhage or a retained placenta. By immediately clamping the cord it increases the placentas blood supply by as much as 100mls therefore increasing the bulk of the placenta and decreasing the efficiency of uterine contractions which are necessary for the expulsion (Bluff, 2006). In 1968 Walsh found that Delayed Cord clamping reduces post-partum haemorrhages and retained placentas. She states that with the placenta being less bulky when it has been drained blood by the neonate, the uterus can contract easier and more effectively on a less engorged placenta therefore reducing maternal blood loss. This is helping to improve patient safety to the mothers by preventing PPHs and retained placentas. It was thought that early cord clamping should be performed if the mother is anaemic, so in 2004 a study conducted by the Liverpool school of tropical medicine assessed mothers with a mean haemoglobin level of 10g/dl. The results showed it was still beneficial to the neonatal to delay the cord clamping and caused no adverse effects to the mother.
The adverse effects of delayed cord clamping which are outlined in the studies are that it may cause polycythaemia and hyperbilirubinemia. There have been studies to show that polycythaemia and jaundice is an increased risk of delayed cord clamping. Polycythaemia means that more red cells are transfused delivering more oxygen to the tissues which Bluff (2006) suggests could be beneficial. Some, use the reasoning that there is a risk that by having more red blood cells may cause the blood to become too thick as an argument against delayed cord clamping, which seems to be negligible in healthy babies. (Morley 1998). A study carried out by Hutton and Hussian (2007) showed that the infants who had delayed cord clamping had a slight increase in polycythaemia but where not symptomatic and did not need any treatment. Morley(1998) suggest that if a baby receives their full quota of blood, then the baby is almost certain to suffer from slight jaundice as its caused by the normal breakdown of the normal excess blood to produce bilirubin, but there is no evidence of adverse effects from this. Mercer et al (2003) also carried out randomised and nonrandomised studies on delayed cord clamping. From the five hundred and thirty one term infants and nine trials she conducted, there were no significant symptoms of either polycythaemia or hyperbilirubinemia noted. Hutton and Hussians study also showed a slight increase in bilirubin levels within the first 24 hours of live but no infants had to be treated. There were insignificant differences in bilirubin levels from three to fourteen days. The trial Anderson et al (2011) carried out also found no differences in these outcomes. The Cochrane review (2008) was one which reported significant differences in bilirubin levels between immediate cord clamping and delayed cord clamping and suggested a number of infants needed phototherapy for jaundice, although it was conducted using unpublished data. Therefore given no reason to ensure the cord is clamped immediately to prevent any harm to the infant.
One of the problems the student observed while working in a clinical area was the midwives different views and practices on cord clamping. Airey et al (2008) carried out a study to gather the general senses of midwives views on the subject. They interviewed 63 delivery suit midwives of which 42 described delayed cord clamping as when the pulsation stops, but 48 of the midwives admitted to clamping the cord within one minute of the baby being delivered. The author states that within the UK 87% of units give Sytocinon and clamps the cord early applying controlled cord traction. Falcao (2012) agrees in which a higher percentage of midwives will practice early cord clamping rather than delayed. She suggests this may be due to the lack of knowledge and clear guidelines of what delayed cord clamping is. Falcao (2012) states all midwives should have a clear understanding of the timing and benefits of delayed cord clamping to have the safest up to date practice.

Discussion

Patient safety is a worldwide public health problem, but the issues around patient safety differ. In 2002, The World Health Organisation recognises patient safety as ‘the need to reduce harm and suffering of patients and their families’. They state that any producers carried out should be evidence based to help prevent harm. Anderson et al (2011) randomised controlled trial refers to reducing harm to the neonate. They suggest that by delaying the cord clamping it is improving iron stores. As previously discussed by increasing iron stores it is likely to reduce the risk of impaired cognitive function, Respiratory Distress Syndrome, Intraventricular Haemorrhage and Necrotising Enterocolitis (Bluff, 2006). This is giving us evidence that delayed cord clamping is beneficial to the neonate.
The Royal College of Midwives have produced a document ‘Evidence Based Guidelines for midwifery-led care in labour; third stage of labour’ which outlines the ‘pros and cons’ for delaying cord clamping, stating communication is important. They suggest by informing the women of her choices and explaining to her the benefits she should be able to make a decision which midwifes will support. According to the joint commission on Accreditations of HealthCare Organization, communication was the worst category in 2005. They state the reason for ineffective communication is varied from stressful environments causing staff to forget information, to the culture of autonomy and hierarchy of staff. Poor communications between health care professionals, patients and their carers has shown to be the most common reason for lawsuits against health care providers (WHO,2011). It is important that information about delayed cord clamping is shared with the women herself so she is able to make an informed choice about the care of her and her baby. Another problem highlighted in communication is the ability to handover correct information to staff taken over their care. The SBAR communication tool has been implement for staff to be able to communicate effectively with one another (NHS, 2006). Communication is essential to good team work, and team work is essential to patient safety (NHS, 2007). Staff should use the tool in the clinical area where it enables the communication to be clear and allows the midwife looking after the women to write down their care plan for the staff to take over without the worry of missing essential information.
Communication is also very important in delayed cord clamping as Airey et al (2008) highlighted the midwives have different views on cord clamping and the timing that defines delayed clamping. Their results showed a variance in understanding of delayed clamping times whether it should be after one minute, five minutes or after pulsation has stopped. Each unit should be able to communicate with their staff to make sure that all midwives have the same understanding of cord clamping to promote the best possible practice to reduce harm.
NHS Scotland (2007) state that clinical descions about treatments should be made on the basis of the best possible evidence to ensure care is safe and effective. Midwives should have the ability to be able to assess information which would help them make decisions about the best possible care for that women. They should be able to understand where delayed cord clamping is not appropriate by identifying a problem such as an obstetric emergencies, and use appropriate interventions to care for that women and her baby to reduce the risk of any harm (WHO 2011). WHO (2007) state that evidence does not always need to be the most up to date to be the most accurate. Bluff (2006) discusses article written as far back as 1773 which are relevant to practice today and still adhere to patient safety guidelines discussing how delayed cord clamping reduces harm to the neonate by increasing blood supply.
As Bluff (2006) discusses, there is some evidence that shows immediate cord clamping contributes to post-partum haemorrhage (PPH). The rate of PPH continues to rise although most other causes of severe maternal morbidity declines. International data suggest that post-partum haemorrhage is increasing worldwide with 385 women in Scotland experienced PPH in 2011, one in every 170 births. PPH accounted for 73% of all the reported incidents of severe maternal morbidity. (Healthcare Improvement Scotland, 2013). As Bluff (2006) states by simply practicing delayed cord clamping causing the placenta to be drained of blood by the neonate it will help reduce the number of women experiencing Post-partum haemorrhages improving Patient safety.
By gathering all the information and research studies carried out it is clear that by delaying cord clamping at deliveries it can reduce harm to neonates and prevent unnecessary illnesses and diseases. WHO state that’s when solutions have been shown to work effectively in controlled research settings, it is important that we can assess and evaluate the impact, accessibility and affordability of these solutions and implement then accordingly. It has been proven that by practicing delayed cord clamping cost is reduced as it is less likely for the neonate to need a blood transfusion. (Kinmond, 1993) . It is very accessible as we would not be changing practice just delaying it therefore we should implement delayed cord clamping to reduce harm and improve on patient safety for both mothers and neonates.

Conclusion and Recommendations
To conclude, the student has shown that all the evidences suggest that delayed cord clamping is beneficial to the mother and baby. Anderson et al (2011) study shoes that it increases iron stores reducing the risk of iron deficient anaemia which is associated with reduced neurological development. It is a simple and cost free intervention for reducing anaemia (Jaleel,2009). Bluff also shows through using an ample of evidence that delayed cord clamping reduces the risk to the neonate and mother by stating that the extra blood transfused from the placenta reduces the risk of Respiratory Distress Syndrome, Necrotising Enterocolitis and Intraventricular Haemorrhages. She also explains that by draining the placenta of the extra blood improves patient safety with the mother as it reduces the risk of Post-partum haemorrhaging.
There have now been guidelines enforced in NHS Lanarkshire for delayed cord clamping. The guidelines state that all babes should have delayed cord clamping unless there are contraindications such as need for immediate resuscitation or post-partum haemorrhage. They suggest the time for delayed cord clamping should be after thirty seconds to one minute, preferably one minute if the baby is stable.
Although these guidelines have now been implanted, the student has still witnessed the majority of midwives practice immediate cord clamping. Aireys survey showed that 92% of the midwives clamped the cord before one minute. This is due to lack of knowledge and conflicting reports of the benefits of delayed clamping. NHS (2007) suggest that by training staff effectively this should help decrease the risk of any harm. Therefore help improve this statistic the student suggests that each unit should re-educate their staff on the benefits of delayed cord clamping to help them diminish the idea that all babies will suffer from jaundice if they cord is not clamped immediately. This could be done in a simple way, such as a short discussion at hand over, or a short training day, to remind the staff of the harm that can be prevented by delaying the clamping of the cord for as little as one minute.
There is also no discussion in the guidelines of communication with the women about her thoughts on delayed cord clamping. In practice the student has never heard the benefits of delayed cord clamping and immediate cord clamping being discussed with the women herself. As WHO(2004) state communication is a huge part of the patient safety agenda. Women should be making informed choices about her and her babys’ care in which the midwives should be supportive. There should be an emphasis in practice to include the women more in her care. Midwives should discuss more freely these benefits with the women and not just presume that the women agrees with the midwives practices of cord clamping. The new guidelines in NHS Lanarkshire state that delayed cord clamping should be at one minute therefore the midwives should not have conflicting views over the timing.
After reviewing all the evidence, it suggests delaying cord clamping reduces harm to both the neonate and the mother by simple providing a greater blood supply. We should recognise that early cord clamping is a medical intervention and therefore should be standard practice throughout midwifery units as we now have medical statistics to back this up.

References * Airey, R. Farrer, D. Duley,L. (2008) Timing of Unblical Cord Clamping; Midwives Views and Practice.BJM. 16(4), 236-239

* Andersson, O. Hellstrom-Westas,L.Andersson, D.Domellof,M.(2011). Effects of Delayed versus Early Umbilical cord Clamping on Neonatal Outcomes and iron status at 4 months: a randomised controlled trial. BJM.343.

* Bluff, L. (2006). Early Versus Delayed Cord Clamping. IJCE .20 (4), 16-21.

* Cook, E. (2007). Delayed Cord Clamping or immediate Cord Clamping?; A Literature Review. British Journal of Midwifery. 15 (9), 562-571.

* Eastman HJ (1950) Williams Obstetrics, Tenth Edition, p 397-398

* Emhand, M.Van Rheenen, P. Brabin, B. (2004) The Early Effects of Delayed Cord Clamping born to Libyan Mothers. Tropical Doctor. 34(4). 218-222.

* Jaleel,R. Deeba,F. Khan,A.(2009). Timing of Umbilical Cord Clamping and Neonatal Haematological Status. J Pak Medical Association. 59(7), 468-470.

* Healthcare Improvement Scotland (2013). Scottish Confidential Audit of Severe Maternal Morbidity. 9th Annual Report. Healthcare Improvement Scotland.

* Hutton, EK. Hassan ES. (2007)Late Versus Early Clamping of the Umbilical Cord in Full- Term Neonates: Systematic Review and Mate- Analysis of Controlled Trails. Journal of the American Medical Association. 297(11). 1241-1252.

* Kinmond, S. (1993). Umbilical Cord Clamping and Preterm infants. A Randomised Trial. BMJ. 306(6871) 172-175 * McDonal,SJ. Middleton,P.(2008).Effect of timing of umbilical cors clamping of term infants on maternal and neonatal outcomes. Cochrane Database of systematic Reviews. Issue . Art No:CD004074.

* Mercer, J. McGrath, M. Hensman, A. Silver, Oh, W. (2003). Immediate and Delayed Cord Clamping in Infant Born Between 24 and 32 Weeks; a Piolt Randomised Controlled Trial. J Perinatal. 22(6). 466-72

* Mercer, J. Skovgaard, R. (2002). Neonatal Transitional Physiology; A New Paradigm. Journal of Perinatology and Neonatal Nursing. 15(4). 56-75.

* Mitra, U. Shahidullah, M D. Mannan, A. Nahar,Z. Kumar Dey,S. Mannan, I.(2009). Timing of Cord clamping and its effects on Haematocrit and Clinical Outcomes of neonate. Bangladesh J Child Health.33 (1),16-21.

* Morely ,G. (1998). Cord Closure; Can hasty clamping injure the newborn? OBG management. 29-36.

* National Institue of Health. (2012). Clinical Reaserch Trials and You. Available: [http://www.nih.gov/health/clinicaltrials/basics.htm]. Last accessed [22/3/2013].

* National Institute for Health and Care Excellence (2007) Intrapartum care: Care of healthy women and their babies during childbirth, GC55. London; National institute for Health and Care Excellence.

* NHS Scotland, Quality Improvement Scotland. (2007). Educational Resources, Clinical Governance. NHS.

* NHS.(2006).Safer Care, Improving Patient Safety. Available: [http://www.institute.nhs.uk/safer_care/safer_care/situation_background_assessment_recommendation.html.] Last accessed [27/03/2013.]

* Walsh,S. (1968) Maternal effects of early and late clamping of the umbilical cord. The Lancet. 997.

* World Health Organisation (WHO). (2002) What is Patient Safety. WHO report. Geneva.

* World Health Organisation. (2011). Patient Safety Curriculum Guide; Multi-professional Edition. WHO report. Geneva.

* World Health Organisation. (2007). Everybodys Business, Sthrengthinging Healthy Systems to Imporve Health Outcomes. WHO report. Geneva.

* Yoa, A. Lind,J. . (2009). Physiology and managemant of the third stage of labour. In: Fraser,D Cooper,M. Myles Textbook for Midwives. 15th ed. London: Churchill- Livingston. 537

Rationale- Appendix 1
The student has chosen the topic of delayed cord clamping versus immediate cord clamping for her independent study module. She has observed whilst in practice placement that midwives have conflicting views of this topic and although there is sufficient evidence to suggest midwives should practice delayed cord clamping there is no local protocol for midwives to adhere to.
Anderson et al(2011) state that young children are at higher risk of iron deficiency due to the need of iron for rapid growth. The authors recommend that to improve iron stores in infants then cord clamping should be delayed until 1 minute after the delivery of the baby. Findings from a number of previous studies have shown that post-partum haemorrhage can be reduced; also improved blood pressures and fewer blood transfusions are all benefits from delaying cord clamping.
In 1801 Erasmus Darwin suggested that it was injurious to an infant if the umbilicus cord was cut to soon. He advised it should always be left until the child has repeatedly breathed and the cord has stopped pulsating, otherwise the baby would be left much weaker than it should be, as the blood which should have been transferred to the baby would have been left in the placenta.
In the 1960s mismanagement of neonatal jaundice provoked a great deal of law suits against paediatricians who then urged obstetricians to minimise placental transfusion. This then became routine practise despite reports that it caused anaemia and hypovolemia. Early Cord Clamping is also linked to Respiratory Distress Syndrome. Necrotising Enterocolitis, Cerebral Palsy, Post-Partum Haemorrhage and many other illnesses (Bluff, 2006). Despite the evidence midwives still have not changed their clinical practices. Airey et al(2008) carried out a study to gather midwives views and practices on cord clamping. There were 63 midwives working on a delivery suite that took part in the survey, out of which 92% practiced immediate cord clamping which they defined as immediately after birth.
The overall aim of the study id to determine whether immediate or delayed cord clamping is more beneficial or positive outcome for neonates.
The learning outcomes; (1) Critically analyse the current literature relating to delayed cord clamping versus immediate cord clamping. (2) Examine midwives current practices and views regarding cord clamping and explore the challenges of conflicting evidence. (3) Make evidence based recommendations for future midwifery practice.

After reviewing all the evidence the student will make recommendations for practice, discuss the implications of both delayed cord clamping and immediate cord clamping to improve patient safety and reduce harm to both the neonate and the mother.

References * Airey, R. Farrer, D. Duley,L. (2008) Timing of Unblical Cord Clamping; Midwives Views and Practice.BJM. 16(4), 236-239

* Andersson, O. Hellstrom-Westas,L.Andersson, D.Domellof,M.(2011). Effects of Delayed versus Early Umbilical cord Clamping on Neonatal Outcomes and iron status at 4 months: a randomised controlled trial. BJM.343.

* Bluff, L. (2006). Early Versus Delayed Cord Clamping. IJCE .20 (4), 16-21.

References: * Airey, R. Farrer, D. Duley,L. (2008) Timing of Unblical Cord Clamping; Midwives Views and Practice.BJM. 16(4), 236-239 * Andersson, O. Hellstrom-Westas,L.Andersson, D.Domellof,M.(2011). Effects of Delayed versus Early Umbilical cord Clamping on Neonatal Outcomes and iron status at 4 months: a randomised controlled trial. BJM.343. * Bluff, L. (2006). Early Versus Delayed Cord Clamping. IJCE .20 (4), 16-21.