Impact of Delayed Cord Clamping on Incidence of Newborn Jaundice
Impact of Delayed Cord Clamping on Incidence of Newborn Jaundice
Impact of Delayed Cord Clamping on Incidence of Newborn Jaundice
Student Name
Minnesota State University Mankato
NURS 320W: Critical Inquiry and Evidence-based Practice for RNs
Dr. Ellen Vorbeck, DNP, ANP-BC, APRN
date
Abstract
The purpose of this research review was to understand the impact of delayed cord clamping on the incidence of newborn jaundice and if there seemed to be a correlation or causation. The research review specifically looked at incidences of jaundice within the first week. Discussion was focused on causes of newborn jaundice and the benefits and disadvantages of delayed cord clamping. Eight studies were reviewed for this paper. Evidence suggested that delaying clamping of the umbilical cord was helpful in promoting increased iron and blood volume and did not appear to increase the occurrence of jaundice with a need for treatment in the newborn. Data supported the routine use of delayed cord clamping.
Keywords: jaundice, delayed cord clamping, hyperbilirubinemia
Findings
A qualitative study by Faucher et al. (2016) involved a pre-test and post-test to increase knowledge related to the benefits of delayed cord clamping and increase usage of delayed cord clamping among a group of midwives in India. This study found that providing a simulation and lecture increased the knowledge and practice of delayed cord clamping. There were 31 participants in this study and the mean pre-test score was 3.5/7 while the immediate post-test score was 5.5/7 which shows a significant increase. This specific population in India experiences a high level of anemia, and delayed cord clamping has been shown to increase hemoglobin, hematocrit and serum ferritin levels in the newborn which improves the iron status (Faucher et al., 2016). This was a qualitative study and is low on the Melnyk and Fineout-Overholt (2019) strength-of-evidence pyramid. It is also weaker evidence due to the delayed cord clamping policy being developed and not tested, which provides a lower level of reliability. Refer to Appendix A for more information about this study.
A systematic review and meta-analysis by Fogarty et al. (2018) reviewed eighteen randomized controlled trials from different databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Chinese articles to determine the effects of delayed cord clamping versus early cord clamping on preterm infant morbidity and mortality. As a meta-analysis of randomized controlled trials, this is strong evidence and falls at the top of the Melnyk and Fineout-Overholt strength-of-evidence pyramid (2019). The results of these reviews were analyzed with Review Manager and had a 95% confidence interval for continuous and dichotomous variables. 2834 infants were included in this review, and it was found that delayed cord clamping did reduce the incidence of hospital mortality (Risk ratio 0.68, 95% confidence interval) and morbidity. This supports the PICOT and use of delayed cord clamping.
Looking at the effects of jaundice from a genetic and psychologic viewpoint, Horinouchi et al. (2021) utilized a genetic analysis to examine the relationship between neonatal jaundice and Autism Spectrum Disorder (ASD). There has been some research pointing to an association of ASD with neonatal jaundice due to the damage high levels of bilirubin can have on the brain when crossing the blood-brain barrier. This study included 79 children with ASD who were clinically assessed and evaluated with the Children Autism Rating Scale (CARS) or Parent-interview ASD Rating Scale-Text Revision (PARS-TR). Their medical histories, including previous history of phototherapy for jaundice, were taken from medical records. A sample of their dried umbilical cord was taken for the study and the Fisher’s exact test, Spearman’s rank correlation coefficient, Mann-Whitney U test and Kruskal-Wallis test were used in this study. The UGT1A1*6 gene was examined, and it was shown that there was no significant difference (OR = 1.34, p = 0.26) in the subjects and control population, as well as the UGT1A1*28 gene (OR = 0.80, p = 0.54). These results indicate that neonatal jaundice is not associated with ASD (Horinouchi et al., 2021). This is a nonexperimental study and falls towards the bottom of the strength-of-evidence pyramid as it is not as strong as if it were experimental (Melnyk & Fineout-Overholt, 2019).
A synthesis of findings from computerized databases by Qian et al. (2019) reviewed the harms and benefits of delayed cord clamping. This review included 19 studies related to delayed cord clamping and jaundice and revealed conflicting results indicating a need for more research. In some studies, there was no significant difference in hyperbilirubinemia in infants who experienced delayed cord clamping between 50-60 seconds and those who experienced early cord clamping. Delayed cord clamping did not affect bilirubin levels at 24 hours or incidence of clinical jaundice (Qian et al., 2019). In other studies, however, the serum bilirubin was higher after six hours in term newborns who experienced delayed cord clamping, and some Japanese newborns required increased rates of phototherapy (Qian et al., 2019). These inconsistent results point to a need for greater research before coming to a conclusion. This was a nonexperimental study and is therefore weaker evidence on the Melnyk and Fineout-Overholt (2019) strength-of-evidence rating pyramid.
A meta-analysis of randomized controlled trials performed by Rabe et al. (2019) sought to assess the effects of early versus delayed cord clamping using 48 studies with 5721 infants and their mothers. The results of this meta-analysis included a difference of 234 recorded outcomes of hyperbilirubinemia in the group with delayed cord clamping versus 261 total in those with early cord clamping. There is no significant difference in outcomes of hyperbilirubinemia in those with delayed cord clamping versus early cord clamping, while delayed cord clamping is beneficial in preventing deaths in premature infants (Rabe et al., 2019). The GRADE approach was used for this study and a risk ratio of 95% confidence interval is presented for dichotomous data. This is an experimental study and is a high level of evidence at the top of the Melnyk and Fineout-Overholt strength-of-evidence pyramid (2019). See Appendix A for more information on this study.
A randomized clinical trial performed by Rana et al. (2020) included 540 participants and split the newborns into two groups to determine any difference in outcomes between those who received delayed cord clamping versus those who did not. Out of those in the early cord clamping group, 85/261 newborns were classified as intermediate and high-risk for jaundice compared with 92/263 newborns in the delayed cord clamping group. 22/261 of the newborns in the early group compared with 25/263 of the newborns in the delayed group were subsequently high risk for hyperbilirubinemia (Rana et al., 2020). These results reveal no increase in risk of hyperbilirubinemia in newborns with delayed cord clamping. For this trial the chi-square test, t test and MANOVA were all used. This is an experimental research study and is a high level of evidence on the Melnyk and Fineout-Overholt strength-of-evidence pyramid (2019). Refer to Appendix A for further information on this trial.
A retrospective cohort study was performed by Shinohara and Kataoka (2021) to determine risk factors of hyperbilirubinemia. Data was collected from a birth center practicing delayed cord clamping including 1211 patient charts. An independent t-test was performed as well as odds ratios and 95% confidential intervals. The results revealed that 4.7% of neonates were diagnosed with hyperbilirubinemia while 1.8% needed phototherapy. Six variables were identified as risk factors for hyperbilirubinemia and relate to the metabolism of bilirubin. For this study, the numbers of infants who did develop hyperbilirubinemia was not greater than previous studies and supports the conclusion that delayed cord clamping is not a risk factor for hyperbilirubinemia (Shinohara & Kataoka, 2021). This is a nonexperimental study and is a lower level of evidence on the strength-of-evidence pyramid (Melnyk & Fineout-Overholt, 2019).
A randomized controlled trial by Yunis et al. (2021) studied the effect that delayed cord clamping had on preterm infants. Infants were grouped into delayed cord clamping plus placental insufficiency (n = 30), immediate cord clamping plus placental insufficiency (n = 30), and delayed cord clamping with a normal placenta (n = 30). The Mann-Whitney U test, Chi-square test or Fisher exact test were used as appropriate. Infants in the delayed cord clamping with placental insufficiency were found to have considerably higher levels of hemoglobin directly after birth as well as at their two-month follow-up compared to the immediate cord clamped group. Peak serum bilirubin was higher in the delayed cord clamping group with placental insufficiency than in either the immediate cord clamping group or the delayed cord clamping with normal placenta. The need for phototherapy, however, was not significant and none of the infants in the study required exchange transfusion. In term infants, delayed cord clamping was associated with increased bilirubin levels as well as a diagnosis of jaundice but without the need for phototherapy (Yunis et al., 2021). This is an experimental research study and is a high level of evidence, falling at the top of Melnyk and Fineout-Overholt’s strength-of-evidence pyramid (2019). This study supports the PICOT as it reveals that despite increased bilirubin, delayed cord clamping did not increase a need for phototherapy and the levels of jaundice were managed without treatment.
Discussion
These studies indicate that delayed cord clamping is not associated with an increased incidence of jaundice requiring phototherapy. In studies where there was a higher incidence of jaundice in newborn with delayed cord clamping, it was not significant enough to require phototherapy (Yunis et al., 2021). Delayed cord clamping is beneficial in decreasing mortality and morbidity (Fogarty et al. 2018), preventing death in premature infants (Rabe et al. 2019), and increasing hemoglobin and blood levels in the newborn (Faucher et al. 2016). While delayed cord clamping has been proven beneficial, more research is needed to determine the best timing. Despite many studies, it is still unclear just how long is the optimal amount of time to delay the clamping of the umbilical cord. Some limitations of these reviewed studies include the specificity of the populations included, small sample sizes, and the retrospective nature of some of the studies. Despite these limitations, the information gathered from this research encourages a change in how nursing care handles deliveries and the timing of cord clamping.
Recommendations for Nursing Practice
The research supports a change in how nursing practice has cared for clamping and cutting the umbilical cord. Research indicates that delaying the clamping of the umbilical cord provides enough benefits and is safe enough to implement as a routine response in the delivery process. More research related to exactly how long to delay cord clamping is needed; however, there is enough research that has shown that it is beneficial to delay clamping of the umbilical cord for at least 30 seconds. Further research involving larger sample sizes and increased populations would be useful to determine timing.
When looking to make a practice change, Melnyk and Fineout-Overholt (2019) describe the important of including stakeholders. Some of the stakeholders involved in this change include nurses involved in the care of the pregnant or laboring women, physicians and midwives involved in the care, unlicensed personnel, and management. Another important part of looking at evidence-based research is deciding how to disseminate the evidence. Melnyk and Fineout-Overholt (2019) include many different examples and descriptions of ways to begin this process. For this research question and purpose, practice change is specific to the labor and delivery unit and should begin at the unit level. There are several ways to begin to implement this change at the unit level including roundtable presentations, poster presentations, and evidence-based clinical rounds (Melnyk & Fineout-Overholt, 2019). All three of these methods involve a more casual approach that would be plausible to implement on a day-to-day basis while still providing information and evidence to all parties involved to begin this change.
Conclusion
This research project sought to determine whether delayed cord clamping is safe and should be implemented in all labor and delivery units, or if it is a cause of jaundice resulting in further damage and should be avoided. Evidence from many levels of Melnyk and Fineout-Overholt’s (2019) strength-of-evidence rating pyramid was reviewed and included in this project. The review of this evidence suggests that delayed cord clamping is beneficial and safe. Delayed cord clamping has not been shown to increase jaundice with a need for phototherapy. The next step on the JHNEBP model (Melnyk & Fineout-Overholt, 2019) is to implement a practice change of delayed cord clamping across labor and delivery units. Further research utilizing larger sample sizes and more diverse populations would be useful in determining the best timing related to how long to delay the clamping of the umbilical cord.
References
Faucher, M. A., Riley, C., Prater, L., & Reddy, M. P. (2016). Midwives in India: a delayed cord
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Fogarty, M., Osborn, D. A., Askie, L., Seidler, A. L., Hunter, K., Lui, K., Simes, J., & Tarnow-
Mordi, W. (2018). Delayed vs early umbilical cord clamping for preterm infants: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology, 218(1), 1-18. https://doi-org.ezproxy.mnsu.edu/10.1016/j.ajog.2017.10.231
Horinouchi, T., Maeyama, K., Nagai, M., Mizobuchi, M., Takagi, Y., Okada, Y., Kato, T.,
Nishimura, M., Kawasaki, Y., Yoshioka, M., Takada, S., Matsumoto, H., Nakamachi, Y., Saegusa, J., Fukushima, S., Fujioka, K., Tomioka, K.,Nagase, H., Nozu, K., Iijima, K., … Nishimura, N. (2021). Genetic Analysis of UGT1A1 Polymorphisms Using Preserved Dried Umbilical Cord for Assessing the Potential of Neonatal Jaundice as a Risk Factor for Autism Spectrum Disorder in Children. Journal of autism and developmental disorders, 10.1007/s10803-021-04941-w. Advance online publication. https://doi-org.ezproxy.mnsu.edu/10.1007/s10803-021-04941-w
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Rana, N., Ranneberg, L. J., Malqvist, M.,KC, A., & Andersson, O. (2020). Delayed cord
clamping was not associated with an increased risk of hyperbilirubinaemia on the day of birth or jaundice in the first 4 weeks. Acta Paediatrica, 109(1), 71-77. https://doi-org.ezproxy.mnsu.edu/10.1111/apa.14913
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Yunis, M., Nour, I., Gibreel, A., Darwish, M., Sarhan, M., Shouman, B., & Nasef, N. (2021).
Effect of delayed cord clamping on stem cell transfusion and hematological parameters in preterm infants with placental insufficiency: a pilot randomized trial. European Journal of Pediatrics, 180(1), 157-166. https://doi-org.ezproxy.mnsu.edu/10.1007/s00431-020-03730-4
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