Guideline for the management of Caesarean Section deliveries

Recent published papers including the Cochrane review on the timing of cor clamping all show some beneficial reflect in both term and preterm infants for clamping to be delayed by at least 30 seconds. The studies include both vaginal and Caesarean deliveries. The benefits for preterm babies are greatest, reducing the risk of intra-ventricular haemorrhage, and the need for transfusion. For the very low birth weight infants there is also a reduced risk of late onset sepsis and a trend towards less necrotising enterocolitis and mortality. There was no suggestion that the delay resulted in any harm although sophisticated warming or resuscitation measures were not used. In the papers showing the greatest benefit, the cord was clamped with the baby held 20 cm below the wound incision. This will require the baby in the wrapped towel to be held to the right side of the motherís pelvis as the cord is clamped and cut.

The protocol should be applied at the discretion of the obstetrician and paediatrician but in all deliveries the interval of the cord clamping after delivery should be recorded in seconds. (The time of the first breath by the baby should also be recorded ie before or after the cord was clamped.)

Guideline for Caesarean Section deliveries

A paediatrician or paediatric nurse is scrubbed and holding a warmed sterile towel. The resuscitaire heater is on and a green sterile drape is place over the resuscitation area. The sterile towel is left on the sterile towel under the heater until the baby is ready to be delivered. The baby is delivered onto the motherís thighs and time of delivery recorded. The baby is wrapped in the warm towel and held on the right side of the motherís thigh about 20 cm below the height of the incision. 40 seconds after delivery the cord is clamped and cut and the baby taken for resuscitation if necessary.

The time of the delivery of the baby and the interval before clamping the cord must be recorded.

This guideline does not apply to Crash Caesarean sections for acute fetal distress, Ceasarean sections for abruption placenta and placenta praevia or vasa praevia.

Guideline for the management of spontaneous vaginal deliveries

A normal vaginal deliveries the cord should not be clamped until 40 seconds after delivery. The mother should be encouraged to sit forwards and hold her baby lying on the delivery couch. The time of the cord clamp is recorded. As soon as the cord is clamped and cut the baby should be brought up to the motherís chest for skin to skin contact and breast suckling if wished.

Guideline for the management of instrumental vaginal deliveries

A midwife or paediatrician should be ready with a warmed towel to receive the baby. The time of delivery is recorded. The baby should be wrapped in the towel and held 20 cm below the vulva until the cord is clamped 40 seconds after delivery. The time of the cord clamp is recorded. According to the condition of the baby, it can then be transferred to the resuscitaire or given to mother for skin to skin contact if desired.

References

Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants (Cochrane review). Cochrane Library. Issue 4. Chichester: John Wiley, 2004.

Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Dellayed cord clamping in very preterm infants reduces the incidence of intraventricular haemorrhage and late-onset sepsis: A randomised, controlled trial. Pediatrics 2006; 117;1235-1242

Ceriani Cernadas JM, Carroli G, Pellergrini L, Otano L, Ferreira M, Ricci C, Casac O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcomes at term: A randomised, controlled trial. Pediatrics 2006;117;779-786

Rheenen PV, Brabin BJ. Late umbilical cord-clamping as an intervention for reducing iron deficiency anaemia in term infants in developing and industrialised countries; a systematic review. Annals of Tropical Paediatrics (2004);24:3-16

Kinmond S, Aitchison TC, Holland BM, Jones JG, Turner TL, Wardrop CAJ. Umbilical cord clamping and preterm infants; a randomised trial. BMJ (1993):306;172-175

Chaparro CM, Neufeld LM, Alavez GT, Cedillo RE, Dewey KG. Effect of timing of umbilical cord clamping on iron status in Mexican infants; a randomised trial. The Lancet ((2206) 367;1997-2004

Under development by DJR Hutchon and B Ononeze. Comments to DJRHutchon@Postmaster.co.uk August 2006 For review August 2008 >