Washington, DC—The American College of Obstetricians and Gynecologists (ACOG) now recommends a delay in umbilical cord clamping for all healthy infants for at least 30-60 seconds after birth given the numerous benefits to most newborns.
The latest Committee Opinion is an update to ACOG’s 2012 guidance. The revision is based on more recent research that shows that, while preterm infants are likely to benefit the most from the additional blood volume gained from the placenta, term infants can also benefit and these benefits may have a favorable effect on developmental outcomes.
In preterm infants, delayed umbilical cord clamping is associated with significant neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume and decreased need for blood transfusion. It also lowers the incidence of brain hemorrhage and an intestinal disease called necrotizing enterocolitis. For term infants, it increases hemoglobin levels at birth and improves iron stores for several months, which helps prevent iron deficiency during the first year of life. Iron deficiency has been linked to impaired cognitive, motor and behavioral development.
“While there are various recommendations regarding optimal timing for delayed umbilical cord clamping, there has been increased evidence that shows that the practice in and of itself has clear health benefits for both preterm and term infants,” said Maria A. Mascola, MD, the lead author of the Committee Opinion. “And, in most cases, this does not interfere with early care, including drying and stimulating for the first breath and immediate skin-to-skin contact.”
There is a small increase in the incidence of jaundice that requires phototherapy in term infants undergoing delayed umbilical cord clamping. With that in mind, ob-gyns and other health care providers should ensure that the proper mechanisms are in place to monitor and treat it.
Research does not show that delayed cord clamping increases the risk of maternal hemorrhage. According to the Committee Opinion, delayed clamping should not interfere with the active management of the third stage of labor, including efforts to minimize maternal bleeding after birth. In situations when there is maternal hemorrhage or hemodynamic instability, abnormal placentation, need for immediate resuscitation of the infant, or when infant placental circulation is not intact, immediate clamping is appropriate.
Umbilical cord milking is when the blood is manually pushed through the cord toward the infant before clamping and is sometimes considered for rapid blood transfer when a 30-60 second delay after birth is not possible. Currently, there is not enough evidence to support or refute the benefits of milking, although more research is underway. In the case of umbilical cord blood banking, delayed clamping significantly decreases the yield of cord blood, making it less likely to meet donation or banking criteria. While ACOG finds that the benefits of transfusion at birth likely exceed those of banking blood for future use, immediate cord clamping may increase the amount of cord blood obtained and patients and families who are considering umbilical cord blood banking should be counseled accordingly.
The Committee Opinion, “Delayed Umbilical Cord Clamping After Birth,” #684, will be available in the January 2017 issue of Obstetrics and Gynecology.
Other recommendations issued in the January Obstetrics & Gynecology:
A key element of an organizational safety culture is maintaining an environment of professionalism that encourages communication and promotes high-quality care. Behavior that undermines a culture of safety, including disruptive or intimidating behavior, has a negative effect on the quality and safety of patient care. Intimidating behavior and disruptive behavior are unprofessional and should not be tolerated. Confronting disruptive individuals is difficult. Co-workers often are reluctant to report disruptive behavior because of fear of retaliation and the stigma associated with “blowing the whistle” on a colleague. Additionally, negative behavior of revenue-generating physicians may be overlooked because of concern about the perceived consequences of confronting them. The Joint Commission requires that hospitals establish a code of conduct that “defines acceptable behavior and behavior that undermines a culture of safety.” Clear standards of behavior that acknowledge the consequences of disruptive and intimidating behavior must be established and communicated. Institutions and practices should develop a multifaceted approach to address disruptive behavior. Confidential reporting systems and assistance programs for physicians who exhibit disruptive behavior should be established. A concerted effort should be made within each organization to educate staff (i.e., medical, nursing, and ancillary staff) about the potential negative effects of disruptive and inappropriate behavior. A clearly delineated hospital-wide policy and procedure relating to disruptive behavior should be developed and enforced by hospital administration. To preserve professional standing, physicians should understand how to respond to and mitigate the effect of complaints or reports.
Gender nonconforming youth are an underserved population who obstetrician–gynecologists are seeing increasingly in their practices. Currently, there are large gaps in training, knowledge, and comfort with transgender patients among obstetrician–gynecologists. The purpose of this document is to review current recommendations that apply to an obstetrician–gynecologist. It is important for obstetrician–gynecologists to be aware of the social and mental health risks for the transgender population. Consensus guidelines support initiating medical therapy after an adolescent has an established diagnosis of transgender identity and has reached Tanner stage II development. Medical management involves the suppression of puberty (typically in the form of gonadotropin-releasing hormone agonists) followed by cross-sex hormone therapy to induce puberty at age 16 years. A variety of surgical options are available, including bilateral mastectomy, hysterectomy with bilateral salpingo-oophorectomy or salpingectomy, and possible neophallus creation. Transgender patients are an at-risk population, and preventive medicine is imperative to their health. This includes proper screening for sexually transmitted infections, screening for suicidal thoughts and mental health issues, and appropriate vaccination. Like all patients, transgender adolescents should have a source for ongoing primary care.
The obstetrician–gynecologist may receive requests from adolescents and their families for advice, surgery, or referral for conditions of the breast or vulva to improve appearance and function. Appropriate counseling and guidance of adolescents with these concerns require a comprehensive and thoughtful approach, special knowledge of normal physical and psychosocial growth and development, and assessment of the physical maturity and emotional readiness of the patient. Individuals should be screened for body dysmorphic disorder. If the obstetrician–gynecologist suspects an adolescent has body dysmorphic disorder, referral to a mental health professional is appropriate. As with other surgical procedures, credentialing for cosmetic procedures should be based on education, training, experience, and demonstrated competence.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org