Kelebogile C. Seloka Oswell Khondowe Kim Harper

Kelebogile C. Seloka
Oswell Khondowe
Kim Harper
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Clamping of the umbilical cord during birth is
by far the oldest and most common
interventions in humans (Hutton & Hassan
2007).
Despite this, optimal cord clamping time
remains controversial (Van-Rheenen 2011).
The potential effect of time to cord clamping
has been reported.
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Most practitioners in developed countries
clamp the cord immediately after birth
(Hutton & Hassan 2007).
In developing countries the practice varies
widely (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 done
from 30 seconds and beyond (Rabe, Reynolds
& Diaz-Rossello 2004).
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Before the baby’s lungs start to fully function,
the placental blood supplies the newborn
with oxygen for optimal survival.
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The incidence of IVH is about 15-25% in
infants with low birth weight (Riskin et al
2008) and is associated with neurological
morbidity and mortality (Ajayi & Nzeh 2003).
IVH originates in the germinal matrix, a very
highly vascularised structure more
susceptible region to IVH (Vural et al 2007).
This periventricular region is selectively
vulnerable to haemorrhage in LBW infants in
the first 48hrs of life (Ballahb 2010).
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Grade I: Germinal matrix hemorrhage
Grade II: Bleeding inside the ventricles
Grade III: Ventricles enlarged by the blood
Grade IV: Bleeding into the brain tissues
around the ventricles
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10 to 15% in the Western world
43% in Africa
3rd leading cause of mortality and morbidity
AIM
To systematically appraise evidence on the
effects of DCC versus ECC on IVH among low
birth weight infants
Secondary objective
 To assess the risk of hyperbilirubinaemia
between DCC versus ECC.
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Eligibility criteria
Types of studies
RCT’S
Types of participants
•Infants with low birth
weight (<2500g)
regardless of gestational
age
Types of interventions
•DCC versus ECC
Types of outcome
measures
•Primary Outcome
measures:
IVH of all grades (i, ii, iii
and iv)
•Secondary outcome
Measures:
Hyperbilirubinaemia
Exclusion criteria
 Trials that included women with multiple
pregnancies
 Studies that did not mention atleast one
outcome of interest
 Search methods for identification of studies
Electronic searches
PubMed, Cochrane
Register of Controlled
Trials and CINAHL
Searching other
resources
Reference lists and
expert in the field
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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)
Studies excluded after reading abstracts
(n=24).
Potentially appropriate (n=20)
Studies excluded (n=15)
Studies included (n=5)
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Figure 1: The risk of Intraventricular
haemorrhage
Study or Subgroup
Hofmeyr, 1988
Mercer, 2003
Mercer, 2006
Oh, 2011
Rabe, 2000
Total (95% CI)
DCC
ECC
Events Total Events Total Weight
8
3
5
4
1
24
16
36
16
20
112
10
5
13
3
3
14
16
36
17
20
Risk Ratio
M-H, Fixed, 95% CI
34.6%
13.7%
35.6%
8.0%
8.2%
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]
103 100.0%
0.52 [0.33, 0.82]
Total events
21
34
Heterogeneity: Chi² = 2.90, df = 4 (P = 0.57); I² = 0%
Test for overall effect: Z = 2.79 (P = 0.005)
Risk Ratio
M-H, Fixed, 95% CI
0.01
0.1
1
10
100
Favours experimental Favours control
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Figure 2: The risk of hyperbilirubinaemia
DCC
ECC
Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI
Mercer 2003
Mercer 2006
Total (95% CI)
8.2 3
10.1 2.4
16
36
8.1 2.3
9.5 2.1
52
Heterogeneity: Chi² = 0.21, df = 1 (P = 0.64); I² = 0%
Test for overall effect: Z = 1.04 (P = 0.30)
Mean Difference
IV, Fixed, 95% CI
16 24.0% 0.10 [-1.75, 1.95]
36 76.0% 0.60 [-0.44, 1.64]
52 100.0% 0.48 [-0.43, 1.39]
-1 -0.5 0 0.5 1
Favours experimental Favours control
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There is a reduced risk of intraventricular
haemorrhage if cord clamping is delayed for
at least 30 seconds or more in low birth
weight infants compared to early cord
clamping
These results are consistent with previous
studies conducted in low birth weight infants.
There was no difference in
hyperbilirubinaemia between the two
interventions.
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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 can
benefit from delayed cord clamping.
However, due to small sample size of included
studies, the results should be interpreted with
caution and need confirmation through large
scale randomised controlled trials (RCTs).
Further research is warranted on timing of the
umbilical cord particularly in developing
countries
Another thing very injurious to the child, is
the tying and cutting of the navel string too
soon; which should always be left till the child
has not only repeatedly breathed but till all
pulsation in the cord ceases. As otherwise the
child is much weaker than it ought to be, a
portion of the blood being left in the
placenta, which ought to have been in the
child.
Erasmus Darwin
(12 December 1731 – 18 April 1802)
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In 2012, the American College of
Obstetricians and Gynecologists endorsed
delaying clamping of the umbilical cord for
30–60 seconds with the newborn in all cases
of preterm delivery.
Many modern medical facilities worldwide still
use ECC
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Ajayi, O. & Nzeh, D.A. 2003. Intraventricular haemorrhage and periventricular
leukomalacia in Nigerian infants of very low birth weight. West African Journal of
Medicine, 22(2):164-166.
Ballabh, P. 2010. Intraventricular haemorrhage in premature infants: Mechanism
ofdisease. 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 and
hypothesis, South African Medical Journal, 73:104-106.
Hutton, E. K. & Hassan, E. S. 2007. Late versus early clamping of the umbilical cord in
full-term neonates: Systematic Review and Meta-Analysis of Controlled Trials. The
Journal of the American Medical Association, 297(11):1241-1252.
Mercer, J.S., McGrath, M.M., Hensman, A., Silver, H. & Oh, W.2003. Immediate and
delayed cord clamping in infants bornbetween 24 and 32 weeks: A pilot randomized
controlled trial. Journal of Perinatology, 23:466-472.
Mercer, J.S., Vohr, B.R., McGrath, M.M., Padbury, J.F.,Wallach, M. & Oh, W. 2006. Delayed
cord clamping in very preterm infants reduces the incidence of intraventricular
haemorrhage 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 of
Perinatology, 31:68-71.
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Rabe, H., Reynolds, G. & Diaz-Rossello, J. 2004. Early versus delayed umbilical cord
clamping in preterm infants. Cochrane Database Systematic Review 18; (14) [CD – ROM
003248]. [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 delayed
cord 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 single
very low birth weight, vertex infants. Obstetrics and Gynecology,112(1):21-28.
Van-Rheenen, P. 2011. Delayed cord clamping and improved infant outcomes. British
Medical Journal, 343:Bmj.d7127.
Vural, M., Yimalz, I., Illikkan, B., Erginoz, E. & Perk. 2007. Intraventricular haemorrhage
in preterm newborns: Risk factors and results from a university hospital in Istanbul, 8
years after. Paediatrics International, 49:341-344.