Kelebogile C. Seloka

Oswell Khondowe

Kim Harper

Clamping of the umbilical cord during birth isby far the oldest and most commoninterventions in humans (Hutton & Hassan2007).

Despite this, optimal cord clamping timeremains controversial (Van-Rheenen 2011).

The potential effect of time to cord clampinghas been reported.

Most practitioners in developed countriesclamp the cord immediately after birth(Hutton & Hassan 2007).

In developing countries the practice varieswidely (Van Rheenen & Brabin 2006).

In this review Early Cord Clamping (ECC)means; clamping within 30 seconds (Rabe,Reynolds & Diaz-Rossello 2004).

Delayed Cord Clamping (DCC); clamping donefrom 30 seconds and beyond (Rabe, Reynolds& Diaz-Rossello 2004).

Before the baby’s lungs start to fully function,the placental blood supplies the newbornwith oxygen for optimal survival.

The incidence of IVH is about 15-25% ininfants with low birth weight (Riskin et al2008) and is associated with neurologicalmorbidity and mortality (Ajayi & Nzeh 2003).

IVH originates in the germinal matrix, a veryhighly vascularised structure moresusceptible region to IVH (Vural et al 2007).

This periventricular region is selectivelyvulnerable to haemorrhage in LBW infants inthe first 48hrs of life (Ballahb 2010).

Grade I: Germinal matrix hemorrhage

Grade II: Bleeding inside the ventricles

Grade III: Ventricles enlarged by the blood

Grade IV: Bleeding into the brain tissuesaround the ventricles

10 to 15% in the Western world

43% in Africa

3rd leading cause of mortality and morbidity

AIM

To systematically appraise evidence on theeffects of DCC versus ECC on IVH among lowbirth weight infants

Secondary objective

To assess the risk of hyperbilirubinaemiabetween DCC versus ECC.

Eligibility criteria

Types of studies RCT’S

Types of participants •Infants with low birthweight (<2500g)regardless of gestationalage

Types of interventions •DCC versus ECC

Types of outcomemeasures

•Primary Outcomemeasures:IVH of all grades (i, ii, iiiand iv)

•Secondary outcomeMeasures:Hyperbilirubinaemia

Exclusion criteria

Trials that included women with multiplepregnancies

Studies that did not mention atleast oneoutcome of interest

Search methods for identification of studies

Electronic searches PubMed, CochraneRegister of ControlledTrials and CINAHL

Searching otherresources

Reference lists andexpert in the field

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Dealing with missing data

Potentially relevant studies (n=344)

Studies excluded, after reading titles (n=300)

Studies detailed evaluation (n=44)

Potentially appropriate (n=20)

Studies included (n=5)

Studies excluded after reading abstracts(n=24).

Studies excluded (n=15)

Figure 1: The risk of Intraventricularhaemorrhage

Study or Subgroup

Hofmeyr, 1988

Mercer, 2003

Mercer, 2006

Oh, 2011

Rabe, 2000

Total (95% CI)

Total events

Heterogeneity: Chi² = 2.90, df = 4 (P = 0.57); I² = 0%

Test for overall effect: Z = 2.79 (P = 0.005)

Events

8

3

5

4

1

21

Total

24

16

36

16

20

112

Events

10

5

13

3

3

34

Total

14

16

36

17

20

103

Weight

34.6%

13.7%

35.6%

8.0%

8.2%

100.0%

M-H, Fixed, 95% CI

0.47 [0.24, 0.90]

0.60 [0.17, 2.10]

0.38 [0.15, 0.97]

1.42 [0.37, 5.37]

0.33 [0.04, 2.94]

0.52 [0.33, 0.82]

DCC ECC Risk Ratio Risk Ratio

M-H, Fixed, 95% CI

0.01 0.1 1 10 100Favours experimental Favours control

Figure 2: The risk of hyperbilirubinaemia

Study or Subgroup

Mercer 2003

Mercer 2006

Total (95% CI)

Heterogeneity: Chi² = 0.21, df = 1 (P = 0.64); I² = 0%

Test for overall effect: Z = 1.04 (P = 0.30)

Mean

8.2

10.1

SD

3

2.4

Total

16

36

52

Mean

8.1

9.5

SD

2.3

2.1

Total

16

36

52

Weight

24.0%

76.0%

100.0%

IV, Fixed, 95% CI

0.10 [-1.75, 1.95]

0.60 [-0.44, 1.64]

0.48 [-0.43, 1.39]

DCC ECC Mean Difference Mean Difference

IV, Fixed, 95% CI

-1 -0.5 0 0.5 1Favours experimental Favours control

There is a reduced risk of intraventricularhaemorrhage if cord clamping is delayed forat least 30 seconds or more in low birthweight infants compared to early cordclamping

These results are consistent with previousstudies conducted in low birth weight infants.

There was no difference inhyperbilirubinaemia between the twointerventions.

Only 2 studies reported on the outcome The evidence reported is not yet conclusive on

optimum timing of umbilical cord clamping. Growing evidence from recent studies indicates

that this vulnerable population of neonates canbenefit from delayed cord clamping.

However, due to small sample size of includedstudies, the results should be interpreted withcaution and need confirmation through largescale randomised controlled trials (RCTs).

Further research is warranted on timing of theumbilical cord particularly in developingcountries

Another thing very injurious to the child, isthe tying and cutting of the navel string toosoon; which should always be left till the childhas not only repeatedly breathed but till allpulsation in the cord ceases. As otherwise thechild is much weaker than it ought to be, aportion of the blood being left in theplacenta, which ought to have been in thechild.

Erasmus Darwin(12 December 1731 – 18 April 1802)

In 2012, the American College ofObstetricians and Gynecologists endorseddelaying clamping of the umbilical cord for30–60 seconds with the newborn in all casesof preterm delivery.

Many modern medical facilities worldwide stilluse ECC

Ajayi, O. & Nzeh, D.A. 2003. Intraventricular haemorrhage and periventricularleukomalacia in Nigerian infants of very low birth weight. West African Journal ofMedicine, 22(2):164-166.

Ballabh, P. 2010. Intraventricular haemorrhage in premature infants: Mechanismofdisease. Pediatric Research, 67(1):1-8.

Hofmeyr, G.J., Bolton, K.D., Bowen, D.C. & Govan, J.J. 1988.Periventricular /Intraventricular haemorrhage and umbilicalcord clamping: Findings andhypothesis, South African Medical Journal, 73:104-106.

Hutton, E. K. & Hassan, E. S. 2007. Late versus early clamping of the umbilical cord infull-term neonates: Systematic Review and Meta-Analysis of Controlled Trials. TheJournal of the American Medical Association, 297(11):1241-1252.

Mercer, J.S., McGrath, M.M., Hensman, A., Silver, H. & Oh, W.2003. Immediate anddelayed cord clamping in infants bornbetween 24 and 32 weeks: A pilot randomizedcontrolled trial. Journal of Perinatology, 23:466-472.

Mercer, J.S., Vohr, B.R., McGrath, M.M., Padbury, J.F.,Wallach, M. & Oh, W. 2006. Delayedcord clamping in very preterm infants reduces the incidence of intraventricularhaemorrhage and late-onset sepsis: A randomized, controlled trial. Pediatrics,117:1235-1242.

Oh, W., Fanaroff, A.A., Carlo, W.A., Donovan, E.F., McDonald,S.A. & Poole, W.K. 2011.Effects of delayed cord clamping invery-low-birth-weight infants. Journal ofPerinatology, 31:68-71.

Rabe, H., Reynolds, G. & Diaz-Rossello, J. 2004. Early versus delayed umbilical cord

clamping in preterm infants. Cochrane Database Systematic Review 18; (14) [CD – ROM003248]. [Online]. Last updated on 18 October 2008. Available:http://www.ncbi.nlm.nih.gov/pubmed. [2010, March 31].

Rabe, H., Wacker, A., Hülskamp, G., Hönig-Franz, I., Schulze-Everding, A., Cirkel, U.,Louwen, F., Witteler, R. & Schneider,H.P.G.2000. A randomised controlled trial of delayedcord clamping in very low birth weight preterm infants. European Journal of Pediatrics,159:775-777.

Riskin, A., Riskin-Mashiah, S., Bader, D., Kulgeman, A., Lerner-Geva, L., Boyko,V. &Reichman, B. 2008. Delivery mode and severe intraventricular haemorrhage in singlevery low birth weight, vertex infants. Obstetrics and Gynecology,112(1):21-28.

Van-Rheenen, P. 2011. Delayed cord clamping and improved infant outcomes. BritishMedical Journal, 343:Bmj.d7127.

Vural, M., Yimalz, I., Illikkan, B., Erginoz, E. & Perk. 2007. Intraventricular haemorrhagein preterm newborns: Risk factors and results from a university hospital in Istanbul, 8years after. Paediatrics International, 49:341-344.