Effect of Delayed Cord Clamping on Breastfeeding Behaviors During the First Breastfeed: A Randomized Controlled Study

Abstract

Objective:

Delayed cord clamping (DCC) may increase the success of breastfeeding by improving neurological and cardiovascular function in neonates. In this study, we investigated the impact of DCC on breastfeeding behaviors, neonatal activity status, and maternal satisfaction during the first breastfeeding.

Methods:

This randomized controlled study was conducted in a tertiary hospital in Turkey with 100 term infants delivered by elective cesarean section with spinal anesthesia. The participants were randomly assigned to the early cord clamping (ECC) group or DCC group. The Infant Breastfeeding Assessment Tool (IBFAT) was used to assess infant alertness, breastfeeding behaviors, and maternal satisfaction with breastfeeding within the first 2 hours of life.

Results:

Scores on the IBFAT were significantly higher in the DCC group compared with the ECC group (p = 0.02). Maternal satisfaction with breastfeeding did not differ between the groups (p = 0.3). Infant alertness tended to be better in the DCC group, but the difference was not statistically significant (p = 0.08).

Conclusion:

The results of this study indicated that DCC was associated with more favorable breastfeeding behaviors compared with ECC.

Introduction

Clamping the umbilical cord after birth is classified as early cord clamping (ECC) when performed within the first 30 seconds and delayed cord clamping (DCC) when performed after 30 seconds or more. With the considerable research on the advantages of DCC conducted in recent years, many institutions now recommend DCC in their guidelines for the postnatal care of healthy term infants, including the World Health Organization (WHO). However, these guidelines give varying times for cord clamping. The WHO recommends waiting 1–3 minutes, while the American College of Obstetricians and Gynecologists (ACOG) recommends 30–60 seconds.^1–4

DCC is a cost-free method that allows continued placental transfusion after delivery and facilitates the physiological transition from fetal circulation to postnatal circulation. Studies investigating the advantages of DCC have reported higher hemoglobin and iron values, better neurodevelopment, and lower blood transfusion rates in term infants.^5–9 Potential risks include jaundice, polycythemia, and increased need for phototherapy.^10–11

To the best of our knowledge, very few studies have investigated the effect of DCC on breastfeeding.^12,13 Our hypothesis is that DCC may increase breastfeeding success as a result of improved neurological and cardiovascular functions in the neonate.

The primary aim of our study was to assess the impact of DCC on breastfeeding behavior, neonatal alertness, and maternal satisfaction with breastfeeding during the initial contact between infants and their mothers. These parameters were assessed with the Infant Breastfeeding Assessment Tool (IBFAT), which is used to evaluate the breastfeeding of term and healthy infants in the first 5 days of life.¹⁴

Methods

This randomized controlled study was conducted at Elazig Medical Park Hospital between April and December 2021. Ethical approval was obtained from the Non-Interventional Research Ethics Committee of Firat University before the initiation of the study (Ethics Committee date/no: 18.03.2021-1542).

Term infants (gestational age between 37°^/7 and 42^6/7 weeks) who were born by elective cesarean section with spinal anesthesia and did not require resuscitation at birth were included in the study. Infants with intrauterine growth retardation or major congenital anomalies, infants of diabetic mothers, and those born outside of working hours when the study team was not present were excluded from the study. Pregnant women who met the study criteria at the time of admission to the hospital were informed about the study, and informed consent was obtained before delivery from those who agreed to participate. The study included a total of 100 newborns, 50 in each group.

Sample size

In a previous study, the mean IBFAT score in a control group of healthy term infants was reported as 8.27 ± 1.76.¹⁵ In our study, the sample size required to detect a significant difference in IBFAT score (20% increase) after DCC with 90% power and a 0.05% alpha margin of error was calculated to be at least 50 infants in each group.

Randomization and blinding

After obtaining informed consent, a computer-generated randomized sequence was used to assign the participating women to the DCC and ECC groups at a 1:1 ratio.

Just before the cesarean section procedure, the obstetrician was informed how cord management would be performed by opening a sealed envelope. In cases where the infant was not eligible for the assigned group, the intervention in that envelope was applied to the next eligible infant. Recruitment for the study continued until there were 50 infants in each group.

The neonatal nurses who attended the first feeding of infants and researcher who performed the statistical analysis of the data were blinded to the treatment allocations. Since neonatal nurses work only in maternal wards, they were blinded to operating room procedures.

Cord management

In the ECC group, cord clamping was performed as soon as possible after the infant was born, regardless of ventilation status. In the DCC group, cord clamping was performed after the infant was held on the mother’s lap for at least 1 minute and was observed to be breathing regularly.

Data collection

The IBFAT was used to evaluate the infants’ breastfeeding behaviors. It consists of six items, the first of which assesses the infant’s state of alertness at the start of feeding (deeply asleep, drowsy, quiet alert, or crying) and is not included in the scoring as it is directly related to the “readiness for feeding” item of the IBFAT. Items 2–5 are directly related to breastfeeding behaviors and assess the infant’s readiness for feeding, rooting, latching, and suckling. These behaviors were scored between 0 and 3, with higher scores indicating better feeding behavior (maximum IBFAT score: 12). Mother satisfaction, the last item on the IBFAT, is evaluated independently on a scale of 1 (not pleased) to 4 (very pleased).

In this study, newborns were breastfed with the assistance of the neonatal nurse within the first 2 hours after birth, during their first contact with the mother. The mother was asked how she felt during the first breastfeeding and the neonatal nurse completed the IBFAT after the first breastfeeding session.

Maternal age, gravity, parity and neonatal birth weight, gestational age, Apgar scores, exclusive breastfeeding, and weight loss at discharge were recorded. The infant’s hematocrit and total bilirubin values were measured at postnatal 6 and 24 hours of age, respectively, with an ABL800 FLEX (Radiometer A/S, Denmark). Within the first 24 hours, blood glucose levels were assessed before four feeds using a blood glucose meter.

The primary outcome measures were breastfeeding behavior, maternal satisfaction, and infant status assessed with the IBFAT. Secondary outcomes included Apgar scores, hematocrit, bilirubin, blood glucose levels, exclusive breastfeeding rates, and weight loss at discharge.

Statistical analyses

The variables were investigated using visual (histograms and probability plots) and analytical methods (Kolmogorov–Smirnov/Shapiro–Wilk tests) to determine whether the data were normally distributed. Descriptive analyses were presented as mean and standard deviation for normally distributed variables and median and interquartile range for non-normally distributed variables. For intergroup comparisons, the independent samples t-test was used for normally distributed variables, and the Mann–Whitney U test was used for non-normally distributed variables. Chi-square tests were used to compare categorical variables between the groups. An overall 0.05 type-I error level was used to infer statistical significance.

Results

Our study included a total of 100 newborns, 50 in the DCC group and 50 in the ECC group. The mean gestational age and median birth weight of the infants in the study were 39 ± 0.87 weeks and 3294 ± 308 g, respectively.

Baseline characteristics of the groups are presented in Table 1. There were no significant differences in maternal demographics, gestational age, birth weight, sex, or APGAR scores.

Table 1.

Maternal and Neonatal Characteristics

	ECC	DCC	p value
Gestational age	39.06 ± 0.88	38.94 ± 0.86	0.49
Newborn weight, g	3.252 ± 283	3.335 ± 328	0.19
Mother’s age	30.36 ± 4.21	29.02 ± 4.75	0.14
Gravidity	2.00 (1.00–2.25)	2.00 (1.00–2.25)	0.70
Parity	1 (1.00–2.00)	1.5 (1.00–2.00)	0.93
Female (%)	23 (46)	26 (52)	0.55
5 minutes Apgar score	9.00 (8.75–10.00)	9.00 (9.00–10.00)	0.65

Data are expressed as n (%) median (interquartile range) or mean ± standard deviation. DCC, delayed cord clamping; ECC, early cord clamping.

When breastfeeding behaviors were evaluated, total IBFAT scores were significantly higher in the DCC group compared with the ECC group (9.00 [7.00–10.00] vs. 8.00 [6.00–9.00], p = 0.02). The mother’s satisfaction with breastfeeding was similar in both groups (p = 0.3). Although infant status tended to be better in the DCC group, there was no statistical difference (p = 0.08). The proportion of infants exclusively breastfeeding at discharge was higher in the DCC group, but not statistically (Table 2).

Table 2.

Clinical Outcomes

	ECC	DCC	p value
Total IBFAT score	8.00 (6.00–9.00)	9.00 (7.00–10.00)	0.02
Mother’s satisfaction with breastfeeding	Very pleased: 32 (64%)	Very pleased: 33 (66%)	0.3
	Pleased: 13 (26%)	Pleased: 16 (32%)
	Fairly pleased: 2 (4%)	Fairly pleased: 1 (2%)
	Not pleased: 3 (6%)	Not pleased: 0
Infant status at the start of the feed	Crying: 21 (42%)	Crying: 26 (52%)	0.08
	Quiet alert: 20 (40%)	Quiet alert: 22 (44%)
	Drowsy: 9 (18%)	Drowsy: 2 (4%)
	Deeply asleep: 0	Deeply asleep: 0

Data are expressed as n (%) or median (interquartile range). DCC, delayed cord clamping; ECC, early cord clamping; IBFAT, infant breastfeeding assessment tool.

Hematocrit values were 53.22% ± 6.62% in the ECC group and 56.86 ± 6.37% in the DCC group (p = 0.006). Blood glucose levels, bilirubin, and weight loss at discharge were similar in both groups (p > 0.05) (Table 3).

Table 3.

Measured Outcomes

	ECC	DCC	p value
Hematocrit	53.22 ± 6.62	56.86 ± 6.37	0.006
Bilirubin (mg/dL)	6.23 ± 1.60	5.88 ± 1.21	0.22
Blood glucose (mg/dL)	F1: 74.00 (64.00–78.00)	F1: 71.50 (57.00–81.25)	0.97
	F2: 71.50 (65.00–78.00)	F2: 70.50 (65.00–77.25)	0.85
	F3: 71.00 (64.75–76.25)	F3: 71.00 (65.75–80.25)	0.44
	F4: 73.00 (66.25–79.25)	F4: 72.00 (65.00–78.00)	0.60
Weight loss at discharge	59.00 (40.00–80.00)	55.50 (34.00–77.00)	0.27
Exclusive breastfeeding at discharge	29 (58)	38 (76)	0.06

Data are expressed as n (%), median (interquartile range) or mean ± standard deviation DCC, delayed cord clamping; ECC, early cord clamping.

Discussion

In this study, we utilized IBFAT scores to evaluate the effect of DCC on breastfeeding behaviors in term neonates born by cesarean section during the first breastfeed. Since all mothers received spinal anesthesia, the newborns could be breastfed within the first 2 hours. We observed that DCC was associated with significantly higher IBFAT scores than ECC. Although not statistically significant, more mothers were satisfied with breastfeeding, and newborns were more alert in the DCC group compared with the ECC group.

The main reason for the better IBFAT scores of infants who underwent DCC may be that these infants had better cardiopulmonary adaptation in the first hours of their lives and had a more comfortable transition period. In their review, Niermeyer et al. categorized the effects of DCC as immediate, short-term, and long-term benefits, and they stated that the reason for the immediate effects was the impact of DCC on cardiopulmonary adaptation. They emphasized that cord clamping before ventilation negatively affects all organs, particularly by causing reflex bradycardia, a decrease in left ventricular preload, and fluctuations in blood pressure in the first minutes after birth. They concluded that DCC may play a key role in cardiopulmonary adaptation, especially in mildly depressed babies.¹⁶ In a review of cord clamping and hemodynamic adaptation, Hooper described the concept of “physiological-based cord clamping” by explaining the role of lung aeration before cord clamping in cardiopulmonary adaptation, stating that cord clamping after ventilation protects the brain from vascular damage by preventing a decrease in cardiac output and sudden increases in blood pressure.¹⁷

In our study, although a specific time was determined for DCC, we particularly focused on the commencement of breathing before clamping the cords of infants who underwent DCC. This was done to gain the benefit of the additional time DCC provides for expected postnatal physiological changes to take place, as well as its transfusion effect.

Bhatt et al. showed that clamping the umbilical cord before the start of ventilation caused pulmonary blood flow to remain low for 90 seconds and resulted in pressure fluctuations in the carotid artery. They noted that although pulmonary blood flow increased with the start of ventilation in this group, it did not reach the values of the group in which ventilation started before cord clamping. Cord clamping after ventilation was shown to increase the pulmonary circulation of blood from the placenta and consequently left ventricular output, with this result sustained up to postnatal 30 minutes. Blood pressures and heart rates were shown to be more stable in the carotid and pulmonary arteries in this group, and it was speculated that this effect resulted in a more comfortable cardiopulmonary transition for these infants.¹⁸

In a recent randomized controlled trial, Soliman et al. investigated the impact of DCC on hemodynamic variables in full-term infants using an electrical cardiometry device. Their findings revealed that neonates subjected to cord clamping at 120 seconds exhibited significantly higher stroke volume and cardiac output at 5, 10, and 15 minutes compared with those with cord clamping at 30 seconds. Moreover, these effects persisted for 24 hours after birth.¹⁹

Since heart rate and arterial oxygen saturation (SpO2) are considered the most important indicators of an infant’s condition after birth, several studies have been conducted to assess the normal heart rate and SpO2 ranges of infants with DCC. Ashish et al. observed higher oxygen saturation and lower heart rates up to 10 minutes after birth in newborns who underwent DCC.²⁰ These findings align with those reported by Smit et al.²¹ In the observational study by Sanchez et al., higher SpO2 levels in the first 5 minutes after birth were detected in newborns with DCC compared with the previous reference ranges. They found that heart rates were higher within the first 2 minutes, and heart rate stabilization occurred earlier compared with the reference range. Differences in heart rates among studies may be attributed to other factors such as the method of heart rate assessment, breastfeeding during monitoring, mode of delivery, or skin-to-skin contact. Higher SpO2 levels and more stable heart rates indicate a smoother cardiopulmonary transition in newborns with DCC.²²

An observational study including 6488 woman–infant pairs in Nepal evaluated factors affecting breastfeeding within the first hour after birth and showed that infants who underwent DCC had 37% higher odds of timely initiation of breastfeeding. In our study, we observed an increase in effective breastfeeding among infants who underwent DCC, even though the rate of exclusive breastfeeding did not differ from that in the ECC group.²³

In a study by Pereira et al. examining the effect of DCC on the Apgar and reflex scores of 50 puppies in the first 5 minutes and 10 minutes after birth, Apgar score remained stable in the DCC group, consistent with our study. However, reflex scores (suckling, rooting, and righting reflexes), which are indicators of vitality, were significantly higher.²⁴ Although there was no statistical difference in alertness among the infants in our study, we consider the finding of higher breastfeeding scores to be compatible with the results of their study.

The only published study comparing cord clamping and breastfeeding scores is a study by Taskin and Kanbur in which LATCH scores and oxygen saturation were compared according to cord clamping time.¹³ Although a different breastfeeding assessment tool was used in their study, the results were consistent with ours. A major difference between these two studies is that our study included infants born by cesarean section, whereas their study included only babies born by vaginal delivery. Furthermore, in their study, skin-to-skin contact was provided by placing the babies on the mother’s abdomen after birth. It was speculated that skin-to-skin contact had a positive effect on infant breastfeeding and that DCC allowed the mother’s hormones to pass to the infant, which may have contributed to breastfeeding. The authors also compared oxygen saturation at 1, 5, 10, and 15 minutes after birth according to cord clamping time and found that oxygen saturation was significantly higher in the DCC group at 1, 5, and 10 minutes.¹³ They also observed higher 5-minute Apgar scores in the DCC group, in contrast to our results.

Limitations

One limitation of the study was its open-label nature, given the impracticality of blinding the delivery staff to group allocation. Second, as we focused on examining the effect of DCC on initial breastfeeding, its influence on long-term breastfeeding remains unknown.

Conclusion

This study examined the effect of DCC on breastfeeding behavior, maternal satisfaction with breastfeeding, and neonatal alertness using the IBFAT, which is an objective method for evaluating the breastfeeding skills of newborns. Our results indicated that newborns who underwent DCC exhibited higher IBFAT scores compared with those who underwent ECC. Further studies should be conducted to determine the mechanism responsible for this effect.

Footnotes

Authors’ Contributions

Both authors contributed to the study conception and design, data collection, and analysis. Both authors contributed to the article and approved the final version for publication.

Ethical Approval

Ethical approval was obtained from the Non-Interventional Research Ethics Committee of Firat University prior to initiation of the study (ethics committee date/no: 18.03.2021-1542).

Authors Disclosure Statement

The authors declare that they have no conflict of interest.

Funding Information

There is no funding source.

References

WHO Guidelines Approved by the Guidelines Review Committee. Guidelines on Basic Newborn Resuscitation. Geneva: World Health Organization; 2012.

Wyllie

, Perlman

, Kattwinkel

, et al. Part 7: Neonatal resuscitation: 2015 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 2015; 95:e169-201–e201.

Committee Opinion No. 684: Delayed umbilical cord clamping after birth. Obstet Gynecol, 2017; 129:e5-10.

Yamada

, Szyld

, Strand

, et al. 2023 American heart association and American academy of pediatrics focused update on neonatal resuscitation: An update to the American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2024; 149(1):e157–e166; doi: 10.1161/CIR.0000000000001181

Songthamwat

, Witsawapaisan

, Tanthawat

, et al. Effect of delayed cord clamping at 30 seconds and 1 minute on neonatal hematocrit in term cesarean delivery: A randomized trial. Int J Womens Health, 2020; 12:481–486; doi: 10.2147/IJWH.S248709

Andersson

, Hellström-Westas

, Andersson

, et al. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: A randomised controlled trial. BMJ, 2011; 343:d7157; doi: 10.1136/bmj.d7157

, Yue

, Wang

, et al. A review on development of placental transfusion in term and preterm infants. Front Pediatr, 2022; 10:890988; doi: 10.3389/fped.2022.890988

McDonald

, Middleton

, Dowswell

, et al. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev, 2013; 2013(7):CD004074; doi: 10.1002/14651858.CD004074.pub3

Andersson

, Lindquist

, Lindgren

, et al. Effect of delayed cord clamping on neurodevelopment at 4 years of age: A randomized clinical trial. JAMA Pediatr, 2015; 169(7):631–638; doi: 10.1001/jamapediatrics.2015.0358

10.

Qian

, Lu

, Shao

, et al. Timing of umbilical cord clamping and neonatal jaundice in singleton term pregnancy. Early Hum Dev, 2020; 142:104948; doi: 10.1016/j.earlhumdev.2019.104948

11.

Nakagawa

, Ishida

, Nagaoki

, et al. Correlation between umbilical cord hemoglobin and rate of jaundice requiring phototherapy in healthy newborns. Pediatr Int, 2015; 57(4):626–628; doi: 10.1111/ped.12583

12.

Van Rheenen

, Brabin

. Late umbilical cord-clamping as an intervention for reducing iron deficiency anaemia in term infants in developing and industrialised countries: A systematic review. Ann Trop Paediatr, 2004; 24(1):3–16; doi: 10.1179/027249304225013286

13.

Taşkin

, Kanbur

. The effect of delayed umbilical cord clamping on Newborn’s oxygen saturation and sucking success in primiparous pregnant. J Obstet Gynaecol Res, 2022; 48(11):2821–2829; doi: 10.1111/jog.15417

14.

Matthews

. Assessments and suggested interventions to assist newborn breastfeeding behavior. J Hum Lact, 1993; 9(4):243–248; doi: 10.1177/089033449300900425

15.

Mahmood

, Jamal

, Khan

. Effect of mother-infant early skin-to-skin contact on breastfeeding status: A randomized controlled trial. J Coll Physicians Surg Pak, 2011; 21(10):601–605; doi: 10.2011/JCPSP.601605

16.

Niermeyer

, Velaphi

. Promoting physiologic transition at birth: Re-examining resuscitation and the timing of cord clamping. Semin Fetal Neonatal Med, 2013; 18(6):385–392; doi: 10.1016/j.siny.2013.08.008

17.

Hooper

, Roberts

, Dekker

, et al. Issues in cardiopulmonary transition at birth. Semin Fetal Neonatal Med, 2019; 24(6):101033; doi: 10.1016/j.siny.2019.101033

18.

Bhatt

, Alison

, Wallace

, et al. Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol, 2013; 591(8):2113–2126; doi: 10.1113/jphysiol.2012.250084

19.

Soliman

, Elgendy

, Said

, et al. A randomized controlled trial of a 30—versus a 120-second delay in cord clamping after term birth. Am J Perinatol, 2024; 41(6):739–746; doi: 10.1055/a-1772-4543

20.

, Singhal

, Gautam

, et al. Effect of early versus delayed cord clamping in neonate on heart rate, breathing and oxygen saturation during first 10 minutes of birth—randomized clinical trial. Matern Health Neonatol Perinatol, 2019; 5:7; doi: 10.1186/s40748-019-0103-y

21.

Smit

, Dawson

, Ganzeboom

, et al. Pulse oximetry in newborns with delayed cord clamping and immediate skin-to-skin contact. Arch Dis Child Fetal Neonatal Ed, 2014; 99(4):F309–14; doi: 10.1136/archdischild-2013-305484

22.

Padilla-Sánchez

, Baixauli-Alacreu

, Cañada-Martínez

, et al. Delayed vs immediate cord clamping changes oxygen saturation and heart rate patterns in the first minutes after birth. J Pediatr, 2020; 227:149–156.e1; doi: 10.1016/j.jpeds.2020.07.045

23.

Gurung

, Sunny

, Paudel

, et al. Predictors for timely initiation of breastfeeding after birth in the hospitals of Nepal—A prospective observational study. Int Breastfeed J, 2021; 16(1):85; doi: 10.1186/s13006-021-00431-y

24.

Pereira

KHNP

, Correia

, Oliveira

ELR

, et al. Effects of clamping umbilical cord on the neonatal viability of puppies delivered by cesarean section. J Vet Med Sci, 2020; 82(2):247–253; doi: 10.1292/jvms.19-0078