Effect of Delayed vs Immediate Umbilical Cord Clamping on Maternal Blood Loss in Term Cesarean Delivery

Abstract

recommends a delay in umbilical cord clamping in term neonates for at least 30 to 60 seconds after birth. Most literature supporting this practice is from low-risk vaginal deliveries. There are no published data specific to cesarean delivery. OBJECTIVE To compare maternal blood loss with immediate cord clamping vs delayed cord clamping in scheduled cesarean deliveries at term (Ն37 weeks). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial performed at 2 hospitals within a tertiary academic medical center in New York City from October 2017 to February 2018 (follow-up completed March 15, 2018). A total of 113 women undergoing scheduled cesarean delivery of term singleton gestations were included. INTERVENTIONS In the immediate cord clamping group (n = 56), cord clamping was within 15 seconds after birth. In the delayed cord clamping group (n = 57), cord clamping was at 60 seconds after birth. MAIN OUTCOMES AND MEASURES The primary outcome was change in maternal hemoglobin level from preoperative to postoperative day 1, which was used as a proxy for maternal blood loss. Secondary outcomes included neonatal hemoglobin level at 24 to 72 hours of life. RESULTS All of the 113 women who were randomized (mean [SD] age, 32.6 [5.2] years) completed the trial. The mean preoperative hemoglobin level was 12.0 g/dL in the delayed and 11.6 g/dL in the immediate cord clamping group. The mean postoperative day 1 hemoglobin level was 10.1 g/dL in the delayed group and 9.8 g/dL in the immediate group. There was no significant difference in the primary outcome, with a mean hemoglobin change of −1.90 g/dL (95% CI, −2.14 to −1.66) and −1.78 g/dL (95% CI, −2.03 to −1.54) in the delayed and immediate cord clamping groups, respectively (mean difference, 0.12 g/dL [95% CI, −0.22 to 0.46]; P = .49). Of 19 prespecified secondary outcomes analyzed, 15 showed no significant difference. The mean neonatal hemoglobin level, available for 90 neonates (79.6%), was significantly higher with delayed (18.1 g/dL [95% CI, 17.4 to 18.8]) compared with immediate (16.4 g/dL [95% CI, 15.9 to 17.0]) cord clamping (mean difference, 1.67 g/dL [95% CI, 0.75 to 2.59]; P < .001). There was 1 unplanned hysterectomy in each group. CONCLUSIONS AND RELEVANCE Among women undergoing scheduled cesarean delivery of term singleton pregnancies, delayed umbilical cord clamping, compared with immediate cord clamping, resulted in no significant difference in the change in maternal hemoglobin level at postoperative day 1.

<p>Effect of Delayed Cord Clamping at 30 Seconds and 1 Minute on Neonatal Hematocrit in Term Cesarean Delivery: A Randomized Trial</p>

“…Blood loss during cesarean delivery in this study was similar in both groups. This is also similar to Purisch et al study 21 that compared postoperative maternal hemoglobin between early cord clamping and DCC group. The mean neonatal blood concentration after DCC in this study was similar to a Thai report 22 but was lower than other western reports which the mean neonatal hematocrit of DCC infants at 24-48 hours was 55.8±5.1% 7 and mean hemoglobin was 18.5-18.9 g/dl.…”

“…DCC has been advised by many guidelines from around the world (WHO, ACOG, and NICE) 4,8,10 with many studies supporting DCC's advantage in reducing anemia in neonates. 9,15-20 A randomized study by Purisch et al, 21 compared immediate cord clamping (within 15 seconds after birth) with DCC (60 seconds after birth) in cesarean delivery. This study demonstrated that mean neonatal hemoglobin level was higher in the DCC group (18.1 g/dl vs 16.4 g/dl).…”

Quantifying Maternal Blood Loss from the Hysterotomy at Cesarean Delivery

“…A recent clinical trial by Purisch et al randomized 113 patients to immediate cord clamping or delayed cord clamping. Change in hemoglobin in the delayed cord clamping group was 1.9 g/dL compared to a change in hemoglobin of 1.8 g/dL in the immediate cord clamping group, a result not statistically different when powered to detect a 0.9 g/dL difference maternal hemoglobin [1]. This study was limited in that it included only patients undergoing scheduled cesarean deliveries, and cannot be extrapolated to labored cesareans, which are more likely to be complicated by hysterotomy extensions.…”

“…While uterine atony and abnormal placentation are frequently mentioned in this discussion, normative data regarding blood loss from the non-pathologic components of this surgical procedure are lacking. With newer protocol, such as delayed cord clamping, becoming routine practice, determining the potential maternal consequences is important [1]. In particular, establishing normative values for blood loss from the hysterotomy would be helpful in addressing techniques to minimize total blood loss for cesarean deliveries.…”

Prevention of iron deficiency anemia in infants and toddlers

“…There appears to be no risk to the mother of a delay of 1-3 minutes to clamping the umbilical cord, and this practice could potentially prevent the mother from becoming anemic during the third stage of labor by facilitating optimal delivery of the placenta and reducing the risk of PPH (88,89). Studies have shown that the incidence of PPH is not increased with DCC for 1-3 minutes (67,90,91). The 2012 WHO guidelines for the management of PPH strongly endorse DCC for all infants that do not require immediate resuscitation after both vaginal and caesarean births (87).…”