Abstract
Background: Early cord clamping and cutting of the umbilical cord at birth may contribute to anemia in infancy thus it can deprive the infant of 60 to 100 ml of whole blood representing 30-50 mg/kg of iron. The umbilical cord milking is a safe technique.
Aim of the study:b> The aim of the study to assess the effects of umbilical cord milking as compared with early cord clamping on hematological parameters (hemoglobin, packed cell volume, bilirubin and ferritin) among term and near term neonates.
Materials & methods:b> This study was carried out as randomized, controlled clinical trial. The subjects were divided randomly into two groups (200 neonates who the cord was milked after cutting and clamping at 25 cm from the umbilicus as a study group and 200 neonates who were received early cord clamping without milking as a control group) in term and near term infants.
Results:b> the hemoglobin level significantly increased in study group at 12, 48 hours and 6 weeks of birth (16.9, 16.9 &15.5 gm/dl) as compared with control group (16.2, 16.2 &15.0 gm/dl) and serum ferritin level significantly increased in study group at 6 weeks of birth (135.4 μg/ml) as compared with control group (128.8 μg/ml). The hematocrit level at 12 and 48 hours after birth was significantly higher in study group (p= 0.016). Serum bilirubin was slightly elevated in study group but there were not any infants of them needed phototherapy.
Conclusions: Umbilical cord milking improved hemoglobin and iron status in term and near term neonates.
Keywords: Delayed cord clamping; Term and preterm; early cord clamping; Umbilical cord milking
Introduction
Current evidences suggest that the practice of immediate clamping and cutting of the umbilical cord at birth may contribute to anemia in infancy [1]. Immediate clamping can deprive a full term infant of 60 to 100 ml of whole blood representing 30-60 mg/ kg of iron [2]. The low tech-low cost” intervention of delayed cord clamping can reduce anemia in infancy by enhancing placentalinfant transfusion at birth. Delayed cord clamping (DCC), in which the cord is clamped after a short delay after birth, and umbilical cord milking (UCM), in which cord blood is stripped or milked toward the baby, have been shown to prevent anemia in infants [3].
These procedures allow the transfer of additional blood volume and hemoglobin (Hb %) from the placenta to the neonate. This process can improve the infant’s iron stores, which may be of particular value in settings in which nutrition is poor [4]. However, a recent meta-analysis reported that delayed cord clamping is only marginally beneficial in reducing anemia in term neonates [5]. Moreover, there are concerns about delayed initiation of resuscitation and increased incidence of hypothermia among preterm neonates undergoing these procedures [6]. Also, the risk of maternal bleeding makes a delay in cord clamping at the time of cesarean section challenging [3].
One clinical trial and a secondary analysis from the same trial have compared milking of a 20 cm segment of the umbilical cord versus immediate umbilical cord clamping on preterm singleton infants born (> 34 weeks ) of gestation. Significant findings in the clinical study included higher initial Hb concentration, mean systemic blood pressure, reduced need for blood transfusion and higher urine output during the first 72 hours in the group that underwent umbilical cord milking compared with the group that underwent umbilical cord clamping. Also the group that underwent umbilical cord milking required a shorter duration of supplemental oxygen and mechanical ventilation [7].
Recent studies have demonstrated that UCM and DCC result in comparable increases in Hb in premature neonates. However, there are insufficient data about the effect of UCM in full-term neonates. The aim of the present will be to investigate the effects of umbilical cord milking in term (gestational age ≥37 - 40+6 weeks) and near term infants (gestational age >34- 36+6 weeks) as regard hematological values, incidence of anemia and hemodynamics [8].
Patients and methods
This is randomized, controlled clinical trial study conducted at Obstetrics and Gynecology department of Suez Canal University hospitals among all pregnant women of fetal age > 34 weeks for cesarean delivery and randomly divided into two groups:
1) Study group: enrolled neonates were allocated to umbilical cord milking technique.
2) Control group: enrolled neonates were allocated to early umbilical cord clamping without milking technique.
Exclusion criteria include had Infants with congenital anomalies, intrauterine growth restriction, Infants with short umbilical cord length (<25 cm) , Delivery by cesarean section for fetal distress, Rhesus factor negative mothers, Cord prolapsed, Hydropesfetalis, Placenta previa, Placental abruption, Cord abnormalities as true knots, multiple gestation and Women with chronic medical illness (diabetes mellitus, Hypertension, cardiac diseases) or pregnancy related illness (gestational diabetes mellitus, preeclampsia). And this study estimated sample size was: n=400 (200 patients for each group).
Study procedure
An informed written consent was obtained from each participant before enrollment in the study. All enrolled women before lower uterine segment cesarean section delivery, were subjected to the following:
1) Full history (age, LMP, socioeconomic status)
2) Maternal weight
3) Maternal high and then BMI
4) Maternal hemoglobin
5) History of medical disorders, history of anemia, and history of antenatal iron supplementation and
6) Gestational age based on date of last menstrual period and documented and proved by first trimester ultrasonographic examination.
In all cases after birth, the neonates were held on the thighs of mother in cesarean section while the umbilical cord was cut and clamped.
In the study group
The cord was cut at approximately 25 cm of length from umbilical stump within 30 seconds of birth (early clamping). Then the neonate was placed under the radiant warmer. The umbilical cord was raised and milked from the cut end toward infant 3 times with speed at 10 cm/ sec, and then clamped 2-3 cm from the umbilical stump.
In the control group
The umbilical cord was clamped early (within 30 seconds) near the umbilicus and was cut without doing cord milking [3].
After clamping the cord, the neonates of both groups were received the routine care by the attending pediatrician according to standard protocols of neonatal post-delivery newborn care [9].
All neonates of both groups were evaluated for the following:
a) Before discharge of mother and infant hemoglobin and packed cell volume was measured at first 12 hours and 48 hours of postnatal life.
b) Serum bilirubin was measured at 48 hours of postnatal life.
c) Assessment of hemodynamic parameters of heart rate, respiratory rate and blood pressure in the first 48 hours of postnatal life (30 min, 12 hours and 48 hours).
d) All neonates were followed up till age of six weeks and a follow up visit was scheduled for all infants with evaluation of hemoglobin, and serum ferritin at that visit for assessment of incidence of anemia.
Statistical analysis
Gathered data was processed using SPSS version 15 (SPSS Inc., Chicago, IL, USA) 21st edition (2013). Quantitative data was expressed as mean±SD while qualitative data was expressed as numbers and percentages (%). Student t test and ANOVA test was used to test significance of difference for quantitative variables and Chi Square were used to test significance of difference for qualitative variables. A probability value of p-value < 0.05 was considered statistically significant.
Results
As shown in (Table1) there were not significant differences in the baseline demographic characteristics of two groups. Most of maternal age was < 35 years (64% in study group & 56% in control group), were house wife (93.5 % in study group &89.5% in control group) and lived in Urban (66%in study group & 56% in control group). Most of the mothers in this study their socioeconomic status were moderate 53% of mothers in early cord clamping group and 48% of mothers milking group and it was no significant difference in both groups..
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