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Original Investigation
November 19, 2019

Effect of Delayed vs Immediate Umbilical Cord Clamping on Maternal Blood Loss in Term Cesarean Delivery: A Randomized Clinical Trial

Author Affiliations
  • 1Columbia University Irving Medical Center, New York, New York
  • 2Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
  • 3Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
  • 4Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
  • 5Icahn School of Medicine at Mount Sinai, New York, New York
  • 6Brigham & Women’s Hospital, Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston
JAMA. 2019;322(19):1869-1876. doi:10.1001/jama.2019.15995
Visual Abstract.
Visual Abstract.
Effect of Delayed vs Immediate Umbilical Cord Clamping on Maternal Blood Loss in Term Cesarean Delivery
Effect of Delayed vs Immediate Umbilical Cord Clamping on Maternal Blood Loss in Term Cesarean Delivery
Key Points

Question  Is there a difference in maternal blood loss with delayed (60 seconds after birth) vs immediate umbilical cord clamping in term cesarean delivery?

Findings  In this randomized clinical trial that included 113 women undergoing scheduled cesarean delivery at term, there was no significant difference in the change in maternal hemoglobin at postoperative day 1 with delayed, compared with immediate, umbilical cord clamping (−1.90 g/dL vs −1.78 g/dL).

Meaning  In scheduled term cesarean deliveries, there was no significant difference in the change in maternal hemoglobin level at postoperative day 1 with delayed, compared with immediate, umbilical cord clamping.

Abstract

Importance  The American College of Obstetricians and Gynecologists recommends a delay in umbilical cord clamping in term neonates for at least 30 to 60 seconds after birth. Most literature supporting this practice is from low-risk vaginal deliveries. There are no published data specific to cesarean delivery.

Objective  To compare maternal blood loss with immediate cord clamping vs delayed cord clamping in scheduled cesarean deliveries at term (≥37 weeks).

Design, Setting, and Participants  Randomized clinical trial performed at 2 hospitals within a tertiary academic medical center in New York City from October 2017 to February 2018 (follow-up completed March 15, 2018). A total of 113 women undergoing scheduled cesarean delivery of term singleton gestations were included.

Interventions  In the immediate cord clamping group (n = 56), cord clamping was within 15 seconds after birth. In the delayed cord clamping group (n = 57), cord clamping was at 60 seconds after birth.

Main Outcomes and Measures  The primary outcome was change in maternal hemoglobin level from preoperative to postoperative day 1, which was used as a proxy for maternal blood loss. Secondary outcomes included neonatal hemoglobin level at 24 to 72 hours of life.

Results  All of the 113 women who were randomized (mean [SD] age, 32.6 [5.2] years) completed the trial. The mean preoperative hemoglobin level was 12.0 g/dL in the delayed and 11.6 g/dL in the immediate cord clamping group. The mean postoperative day 1 hemoglobin level was 10.1 g/dL in the delayed group and 9.8 g/dL in the immediate group. There was no significant difference in the primary outcome, with a mean hemoglobin change of −1.90 g/dL (95% CI, −2.14 to −1.66) and −1.78 g/dL (95% CI, −2.03 to −1.54) in the delayed and immediate cord clamping groups, respectively (mean difference, 0.12 g/dL [95% CI, −0.22 to 0.46]; P = .49). Of 19 prespecified secondary outcomes analyzed, 15 showed no significant difference. The mean neonatal hemoglobin level, available for 90 neonates (79.6%), was significantly higher with delayed (18.1 g/dL [95% CI, 17.4 to 18.8]) compared with immediate (16.4 g/dL [95% CI, 15.9 to 17.0]) cord clamping (mean difference, 1.67 g/dL [95% CI, 0.75 to 2.59]; P < .001). There was 1 unplanned hysterectomy in each group.

Conclusions and Relevance  Among women undergoing scheduled cesarean delivery of term singleton pregnancies, delayed umbilical cord clamping, compared with immediate cord clamping, resulted in no significant difference in the change in maternal hemoglobin level at postoperative day 1.

Trial Registration  ClinicalTrials.gov Identifier: NCT03150641

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