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Delaying Umbilical Cord Clamping

Clamping and cutting of the umbilical cord should be delayed for three minutes after birth, particularly for pre-term infants, suggests a senior doctor, Dr. Andrew Weeks, in the British Medical Journal. 28/08/2007.
Early clamping and cutting of the umbilical cord is widely practiced as part of the management of labor, but recent studies suggest that it may be harmful to the baby. Dr Andrew Weeks, a senior lecturer in obstetrics at the University of Liverpool, looked at the evidence behind cord clamping. For the mother, trials show that early cord clamping has no ill effects, he writes. But what about the baby?

At birth, he says, the umbilical cord sends oxygen-rich blood to the lungs until breathing establishes. When a baby is born it must transfer from receiving oxygen from the placenta to receiving oxygen from its lungs. For this to happen, the baby’s lungs must first expand, and the burst of blood from the umbilical cord helps to get the newborn’s lungs to expand properly. So as long as the cord is unclamped, the average transfusion to the newborn is equivalent to 21 percent of the neonate’s final blood volume and three quarters of the transfusion occurs in the first minute after birth. For babies born at term, the main effect of this large autotransfusion is to increase their iron status.

This may be lifesaving in areas where anemia is endemic. In the developed world, however, there have been concerns that it could increase the risk of abnormally high levels of red blood cells and bile pigments in the bloodstream often leading to jaundice. But trials has shown this is not the case.

Umbilical cord blood is a baby’s life blood until its birth. It contains stem cells, red blood cells, and more recently scientists have discovered that umbilical cord blood contains cancer-fighting T-cells.
For pre-term babies the beneficial effects of delayed clamping is greater, he says. Delayed clamping is consistently associated with reductions in anemia, bleeding in the brain, and the need for transfusion.
He proposes that in normal births, delaying cord clamping for three minutes with the baby on the mother’s abdomen should not be too difficult. The situation is a little more complex for babies born by caesarean section or for those who need support soon after birth. Nevertheless, it is these babies who may benefit most from a delay in cord clamping. For them, a policy of ‘wait a minute’ would be pragmatic, he says.

The World Health Organization’s (WHO) policy supports delayed cord clamping, stating:

“The optimal time to clamp the umbilical cord for all infants regardless of gestational age or fetal weight is when the circulation in the cord has ceased, and the cord is flat and pulseless (approximately 3 minutes or more after birth).” 

They continue:
“Clamping the umbilical cord immediately (within the first 10 to 15 seconds after delivery) prevents the newborn from receiving adequate blood volume and consequently sufficient iron stores.
Immediate cord clamping has been shown to increase the incidence of iron deficiency and anemia during the first half of infancy, with lower birth weight. Waiting to clamp the umbilical cord allows a physiological transfer of placental blood to the infant which provides sufficient iron reserves for the first 6 to 8 months of life, preventing or delaying the development of iron deficiency …

For premature and low birth weight infants, immediate cord clamping can also increase the risk of intraventricular hemorrhage and late-onset sepsis.13 In addition, immediate cord clamping in these infants increases the need for blood transfusions for anemia and low blood pressure infants and infants born to iron-deficient mothers being at particular risk …

Numerous research studies and experts are also confirming that waiting to clamp the cord offers significant benefits. Among them:
• In the Journal of Cellular and Molecular Medicine, researchers say delayed cord clamping is “mankind’s first stem cell transfer and propose that it should be encouraged in normal births.”
• In a BMJ editorial, James Neilson, professor of obstetrics and gynecology, states that delayed clamping should be practiced.

Resources, Support:
“Early versus delayed umbilical cord clamping in preterm infants”. Rabe H, Reynolds GJ, Diaz-Rosello JL http://tinyurl.com/4w63wv8 (Cochrane Review)

ACOG Recommends Delayed Umbilical Cord Clamping for All Healthy Infants http://tinyurl.com/lopdtn8

Pregnancy Increases Risk of Severe H1N1 Disease

Pregnant women are at greater risk for severe disease and complications from H1N1 pandemic flu than the general public, researchers said. Pregnant women should be treated promptly with antiviral drugs if the pandemic flu strain is suspected, according to Denise Jamieson, MD, of the CDC, and colleagues. The recommendation is based on an analysis of cases and deaths of pregnant women from the pandemic strain in the early weeks of the U.S. outbreak, Dr. Jamieson and colleagues reported online in The Lancet.

The findings underscore the CDC recommendation that pregnant women with the flu should receive prompt antiviral treatment and may also have implications for the use of a vaccine against the pandemic. “If a pregnant woman feels like she may have influenza, she needs to call her healthcare provider right away,” Dr. Jamieson said in a statement.

In addition, she said, doctors treating/caring for pregnant women need a triage system to screen for influenza-like symptoms “and they should not delay in initiating appropriate antiviral therapy.” Dr. Jamieson said some doctors hesitate to use antiviral drugs in pregnant women “because of concerns for the developing fetus, but this is not the correct approach in this instance. It is critical that pregnant women, in particular, be treated promptly.”

During the first month of the outbreak of the H1Nl virus, from April 15 to May 18, 34 (thirty four) confirmed or probable cases of pandemic H1N1 in pregnant women were reported to the CDC from 13 states, the researchers found. Confirmed cases were those with laboratory evidence of H1N1; probable cases were those in which the victim had an acute febrile respiratory illness and was positive for influenza A, but negative for H1 and H3, Dr. Jamieson and colleagues said. Of the 34 cases, 11 (eleven) — or 32% — required inpatient care, for an estimated hospital admission rate of 0.32 per 100,000 pregnant women, compared with 0.076 per 100,000 in the general population at risk, they said. By June 16, 6 (six) H1N1-related deaths in pregnant women had been reported to the CDC, all in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation (a tube inserted to help the patient breathe.) That was 13% of the 45 deaths reported during that period, the researchers said. Of the six who died, one was in the first trimester, one in the second trimester, and four were in the third trimester ; all were “fairly healthy” pregnant women before their illness, the researchers said. All the women were treated with oseltamivir (Tamiflu) and the time from symptom onset to treatment ranged from six to 15 days, they said.

The five patients with viable pregnancies had cesarean sections and none of the infants were born with flu. Four have been discharged home in good health, while the fifth — born at 27 weeks gestation — remains in the hospital and is doing well, Dr. Jamieson and colleagues said.

Meanwhile, the issue seems likely to kindle debate over who should get the H1N1 vaccine when it becomes available. “There are two broad goals in using a vaccine,” said Marc Lipsitch, DPhil, of Harvard University, “to protect people who are likely to get severely ill if they are infected, and to slow down transmission by vaccinating the people who are most likely to get infected and pass the virus on.” But the second goal is going to be difficult to reach since current estimates show the vaccine arriving on the scene well after the second wave of the pandemic starts this fall, he said. “Therefore,” Dr. Lipsitch said, “it is very wise to plan to use vaccines mainly to protect those most vulnerable.” But he cautioned that it will be vital to monitor vaccine safety, since pregnant women, and some other potentially high-risk groups, are also at higher risk for other adverse events. “This means that even with a perfectly safe vaccine, there will be (by chance) people who receive the vaccine and then very shortly after experience adverse health events,” he said. To avoid a possible backlash, Dr. Lipsitch said, “it is critical for the public and the health community to understand in advance that adverse events in vaccinated people are expected to happen, and their occurrence is not in itself an indication that the vaccine is unsafe.”

Carlos del Rio, MD, of Emory University in Atlanta, concurred that safety is an important issue. “The vaccine (as far as I can tell) has not yet been tested for safety in pregnancy,” he said. Dr. del Rio said it’s not surprising that pregnancy appears to be a risk factor for severe H1N1 disease. “Pregnancy is also a risk factor for other infectious diseases to be more severe,” he said. “Thus, it makes sense that (pregnant women) should be immunized.”

On the other hand, he said, obesity also appears to be a risk factor for more severe disease, so this group might also be considered as a priority group. The principle that should guide vaccine use is that “limited vaccine needs to go where it will do most good and prevent the most serious cases or deaths,” according to Howard Markel, MD, PhD, of the University of Michigan in Ann Arbor. Pregnant women, the obese, and those with asthma and diabetes appear to be such groups, he said, “but we also need to think of first responders,” including doctors, nurses, police, and fire personnel. “Even the people who keep our power lines, coal, water, electricity, and energy lines going — we don’t want any of these people out in time of a national crisis,” Dr. Markel said.

The CDC’s former director, Julie Gerberding, MD, said vaccinating pregnant women would have a double benefit. It “protects mom and also likely protects newborns until they are old enough to be vaccinated or take antivirals, she said.

The authors noted several limitations of the study including the fact that “ascertainment of women infected with pandemic H1N1 influenza virus was dependent on surveillance and laboratory testing methods used by state public health authorities during the outbreak. These methods varied by state and by the timing during the outbreak.” Other limitations include the fact that that pregnant women might be less likely to be tested than were those who were not pregnant and that “healthcare providers might be more likely to admit a pregnant woman than a nonpregnant person with similar findings, which could lead to an exaggerated admission rate in pregnant women.”

The study was supported by the CDC. Dr. Jamieson and several other authors are employees of the agency. No other potential conflicts were reported.

By Michael Smith, North American Correspondent, MedPage Today
Published: July 29, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Primary source: The Lancet
Source reference:
Jamieson DJ, et al “H1N1 2009 influenza virus infection during pregnancy in the USA” Lancet 2009; DOI: 10.1016/S0140-6736(09)61304-0.