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Intervention Review

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Early versus delayed umbilical cord clamping in preterm infants

  1. Heike Rabe1,*,
  2. Graham J Reynolds2,
  3. Jose Luis Diaz-Rosello3

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 18 OCT 2004

Assessed as up-to-date: 30 JUN 2004

DOI: 10.1002/14651858.CD003248.pub2


How to Cite

Rabe H, Reynolds GJ, Diaz-Rosello JL. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD003248. DOI: 10.1002/14651858.CD003248.pub2.

Author Information

  1. 1

    Brighton and Sussex University Hospitals, Royal Sussex Country Hospital, Trevor Mann Baby Unit, Brighton, UK

  2. 2

    The Canberra Hospital, Department of Paediatrics and Child Health, Canberra, Australian Capital Territory, Australia

  3. 3

    Pan American Health Organization - World Health Organization, Montevideo, Uruguay

*Heike Rabe, Trevor Mann Baby Unit, Brighton and Sussex University Hospitals, Royal Sussex Country Hospital, Eastern Road, Brighton, BN2 5BE, UK. heike.rabe@bsuh.nhs.uk. hrabe@uni-muenster.de.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 OCT 2004

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This is not the most recent version of the article. View current version (15 AUG 2012)

 
Characteristics of included studies [ordered by study ID]
Hofmeyr 1988

MethodsRandomized controlled trial, randomization cards, stratified by birthweight < 1500 g.


Participants38 infants < 35 weeks. Exclusions: nil.


InterventionsControl: cord clamping immediately after birth.
Intervention 1: cord camping delayed for 60 s
Intervention 2: cord clamping delayed for 60 s and ergometrine given at delivery.


OutcomesPrimary outcome: cerebral Ultrasound 6-72 hours after birth. Secondary outcomes: Apgar scores, birthweight, systolic blood pressure at 5 minutes, cord blood gas, death.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Hofmeyr 1993

MethodsRandomized controlled trial, randomized sealed cards.


Participants86 infants < 2000 g.
Exclusion: cord around the neck.


InterventionsControl group: cord clamped immediately.
Intervention: cord clamping time 60-120 s, infant held at the level of the uterus for vaginal deliveries, infant held above the level of the uterus for caesarean section (on the mothers' thighs).


OutcomesPrimary outcome: cerebral ultrasound at 24 h.
Secondary outcome: Apgar score, cord-pH.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Kinmond 1993

MethodsRandomized controlled trial, sealed envelopes, stratification not given.


Participants36 infants > 27 to < 33 weeks' gestation, vaginal delivery.
Exclusions: haemolytic disease, major congenital malformations.


InterventionsRegulated group: positioning 20 cm below the introitus and cord clamped at 30 s.
Non-regulated group: time to cord clamping recorded, management at the attendant's discretion.


OutcomesPrimary outcome: initial packed red cell volume, peak serum bilirubin, transfusion requirement, respiratory impairment, arterial-alveolar oxygen ratio, duration of oxygen.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

McDonnell 1997

MethodsRandomized controlled trial, randomization by sealed opaque envelope, stratified by vaginal or caesarean section, 26 to 29 weeks, 30 to 33 weeks.


Participants46 infants 26 to 33 weeks, vaginal or caesarean section, single or multiple pregnancies. Exclusions: severe fetal distress, IUGR with abnormal umbilical Doppler waveforms, fetal hydrops, fetal malformations, Rhesus incompatibility.


InterventionsControl group: cord clamped immediately.
Intervention group: cord clamped at 30 s, infant positioned between legs of the mother, Syntocinon at birth of the infant.


OutcomesPrimary outcome: haematocrit at 4 h.
Secondary outcomes: Apgar score, temperature on admission, requirement for ventilation, oxygen, surfactant.
peak serum bilirubin, inotropic support, cerebral ultrasound, blood transfusion, death.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Nelle 1998

MethodsRandomized controlled trial. Randomization by sealed opaque envelopes.


Participants19 infants < 1500 g. Born by caesarean section.


InterventionsControl: cord clamped immediately after birth.
Intervention: cord clamping after 30 s and positioning of the infant 30 cm below placenta.


OutcomesPrimary outcomes: mean arterial blood pressure, left ventricular output, mean cerebral blood flow velocity, haemoglobin, haematocrit, systemic and cerebral haemoglobin transport, volume expansion during the first 24 h.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Oh 2002

MethodsRandomized controlled trial. Randomization method by sealed opaque envelopes.


ParticipantsInfants 24-28 weeks.


InterventionsControl group: immediate cord clamping < 5 s.
Intervention: delayed cord clamping 30-45 s.


OutcomesPrimary outcome: haematocrit at 4 h,
Secondary outcomes: resuscitation, Apgar score, blood pressure during the first 12 h, intraventricular haemorrhage, necrotizing enterocolitis, retinopathy of prematurity, late onset sepsis, patent ductus arteriosus, blood transfusions.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Rabe 2000

MethodsRandomized controlled trial,
opaque sealed envelopes.


Participants40 infants < 33 weeks.
Exclusions: multiple pregnancies, Rhesus incompatibility, fetal hydrops, congenital malformation, Apgar < 3 at 0 minutes.


InterventionsControl group: cord clamping at 20 s.
Intervention: cord clamping at 45 s and positioning of the infant below the level of placenta, if possible, oxytocin at delivery of the first shoulder.


OutcomesPrimary outcome: number of blood transfusions during first 6 weeks of life.
Secondary outcomes: Apgar score, temperature on admission, blood pressure at 1, 4 and 24 h, volume resuscitation during first 24 h, inotropic support, degree of respiratory distress, intraventricular haemorrhage, patent ductus arteriosus, phototherapy.


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

AitchisonTrial plan only. No data recorded with this citation.

Frank 1967This was a non-randomised study in which delayed cord clamping was defined as that performed after the second breath.

Ibrahim 2000Randomized trial with adequate concealment. The intervention consisted of a delay in cord clamping of 20 seconds. Control infants had their cord clamped immediately. The study was excluded for the reason that the intervention group at a cord clamping time of less than 30 seconds. Delay of cord clamping was defined in the protocol for this review to be of at least 30 seconds duration.

Narendra 1998Abstract only, further details on patients and study not available from the authors.

Saigal 1972Sequential allocation procedure, which is not a randomized trial.

Saigal 1977Sequential allocation procedure, which is not a randomized trial.

Spears 1966Randomisation procedure was unclear. Gestational age of the low birth eight infants was not given.

Strauss 2003Even though the title states "delayed versus immediate cord clamping", the intervention in delayed group less than 30 weeks' gestation consisted of harvesting and retransfusion of placental blood. No separate data are given for the group of 31 to 36 weeks' gestation.

Taylor 1963Inadequate randomization. Largely term infants.

 
Characteristics of ongoing studies [ordered by study ID]
Holland 1998

Trial name or titlePlacento-fetal (autologous) Transfusion at birth in infants born preterm: a randomized, controlled trial.

Methods

ParticipantsInfants < 33 weeks' gestation.

InterventionsPositioning of the infant below the placenta as far as possible.
Vaginal delivery: delay of cord clamping 40 to 90 seconds.
Caesarean section: cord clamping 40 to 90 seconds after syntocinon.

OutcomesPrimary outcome: median arterial/alveolar PO2 ratio over the first 24 hours of life.
Secondary outcome:
a. CRIB score
b. RCV
c. Transfusion requirements.

Starting date1998

Contact informationBM Holland
Queen Mother's Hospital
Glasgow G3 8SH

NotesTrial completed in 2001

Mercer 2004

Trial name or titleRandomized controlled trial of delayed cord clamping in infants born between 24 and 31 +6/7 weeks' gestation.

Methods

ParticipantsInfants between 24 and 31 +6/7 weeks' gestation stratified into 2 groups: 24 to 27 +6/7 and 28 to 31 +6/7 weeks' gestation.

InterventionsPositioning of infant 10-15 inches below mother's introitus at vaginal delivery or 10-15 inches below the level of the placenta at caesarean section, cord clamping time at 30 to 45 seconds.

OutcomesPrimary outcome: Chronic lung disease, NEC, medical morbidity at 7 months corrected age and neurodevelopmental outcome at 18 months corrected age.

Starting date2003

Contact informationJ Mercer
Women and Children's Hospital
Providence, Rhode Island
USA

NotesTrial ongoing

 
Comparison 1. Early versus delayed cord clamping

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death of the baby6278Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.41, 2.73]

 2 Transfused for anaemia3111Risk Ratio (M-H, Fixed, 95% CI)2.01 [1.24, 3.27]

 3 Transfused for low blood pressure258Risk Ratio (M-H, Fixed, 95% CI)2.58 [1.17, 5.67]

 4 Number of transfusions398Mean Difference (IV, Fixed, 95% CI)1.28 [0.58, 1.98]

 5 Haematocrit at birth or 1 hour (%)3112Mean Difference (IV, Fixed, 95% CI)-3.21 [-5.62, -0.80]

 6 Haematocrit at 4 hours of life (%)4134Mean Difference (IV, Fixed, 95% CI)-5.40 [-7.28, -3.52]

 8 Serum bilirubin peak (mmol/litre)3111Mean Difference (IV, Fixed, 95% CI)-21.49 [-38.04, -4.94]

 9 Hyperbilirubinemia (treated)139Risk Ratio (M-H, Fixed, 95% CI)0.95 [0.58, 1.56]

 11 Inotropics for low blood pressure3118Risk Ratio (M-H, Fixed, 95% CI)2.17 [0.51, 9.12]

 12 Patent ductus arteriosus3118Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.36, 1.72]

 13 Intraventricular haemorrhage5225Risk Ratio (M-H, Fixed, 95% CI)1.74 [1.08, 2.81]

 14 Severe intraventricular haemorrhage3161Risk Ratio (M-H, Fixed, 95% CI)0.86 [0.15, 4.75]

 15 Periventricular leucomalacia131Risk Ratio (M-H, Fixed, 95% CI)0.31 [0.01, 7.15]

 16 Respiratory distress syndrome275Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.59, 1.15]

 17 Severe respiratory distress syndrome139Risk Ratio (M-H, Fixed, 95% CI)1.27 [0.33, 4.93]

 18 Ventilated for respiratory distress syndrome3121Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.65, 1.28]

 19 Surfactant treatment285Risk Ratio (M-H, Fixed, 95% CI)0.78 [0.34, 1.79]

 21 Oxygen supplementation at 28 days136Risk Ratio (M-H, Fixed, 95% CI)6.3 [0.35, 113.81]

 22 Oxygen supplementation at 36 weeks265Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.35, 2.69]

 23 Necrotizing enterocolitis272Risk Ratio (M-H, Fixed, 95% CI)2.08 [0.52, 8.37]

 24 Cord pH3123Mean Difference (IV, Fixed, 95% CI)0.01 [-0.03, 0.05]

 25 Apgar score at 5th minute < 83161Risk Ratio (M-H, Fixed, 95% CI)1.17 [0.62, 2.20]

 26 Temperature on admission (degrees Celsius)139Mean Difference (IV, Fixed, 95% CI)-0.20 [-0.43, 0.03]