延遲斷臍對新生兒黃疸與產時出血的影響－臨床隨機實驗

The Impact of Late Umbilical Cord Clamping on Neonatal Jaundice and Postpartum Hemorrhage: A Randomized Controlled Trail

10.6224/JN.62.4.41

簡珮君(Pei-Chun Chien)；楊誠嘉(Cherng-Chia Yang)；高美玲(Meei-Ling Gau)；劉介宇(Chieh-Yu Liu)；李慈音(Tzu-Ying Lee)

延遲斷臍 ； 新生兒黃疸 ； 產後出血 ； delayed cord clamping ； neonatal jaundice ； postpartum hemorrhage

護理雜誌

62卷4期（2015 / 08 / 01）

41 - 53

繁體中文

背景　雖然國外實證研究支持延遲斷臍可以增加胎盤血流灌注至嬰兒，因而可以減少嬰兒時期的鐵質缺乏，也能透過幹細胞的補充幫助嬰兒各系統的發展；但國內臨床上多數醫療院所因為擔心增加高膽紅素血症及產時出血量而採立即性斷臍。目的　探討斷臍時間對於嬰兒黃疸及產時出血的影響。方法　研究對象為北部某區域教學醫院所生產的孕婦及新生兒，採實驗性研究，隨機分派105對母嬰至實驗組（n = 44）及控制組（n = 61）。實驗組採延遲斷臍，嬰兒娩出後3分鐘斷臍，控制組採立即斷臍，斷臍時間控制在嬰兒娩出後1分鐘內，藉以比較嬰兒黃疸及產時出血的相關性。採用結構式問卷及生理計量測量方式進行資料收集，包括母嬰人口學及產科學資料、產時出血量、新生兒出生前三天之體重變化及經皮膽紅素值、出生後七天是否因黃疸而住院照光治療。結果　兩組出生三天的嬰兒其經皮膽紅素值皆隨著出生天數而上升，但兩組的經皮膽紅素值、住院期間及產後四至七天的照光治療率、住院期間照光治療時數皆無統計上之差異；延遲斷臍與產時出血量沒有相關性。結論／實務應用　本研究結果證實延遲斷臍不會增加產時的出血及產後三天的黃疸值。建議醫護人員採用延遲斷臍，並於生產教育教導個案延遲斷臍的好處，及澄清延遲斷臍對母嬰健康影響之相關疑慮。

Background: The current evidence supports the clinical benefits of late umbilical cord clamping. These benefits include increased blood volume and total body iron. Furthermore, delayed cord clamping facilitates the transplantation of stem cells, which helps the development of infant bodily systems. However, due to concerns related to postpartum hemorrhaging and neonate jaundice, most maternity units still clamp the cord immediately after a child is born. Purpose: This study investigates the impact of delaying cord clamping on neonatal jaundice and postpartum hemorrhage. Methods: A randomized, controlled trial was conducted at a regional teaching hospital in northern Taiwan. One hundred and five healthy nulliparous women at 36 weeks of pregnancy were included and allocated randomly to the experiment group (n = 44) and the control group (n = 61). Participants in the experiment group received delayed cord clamping (DCC) at 3 minutes after delivery. Participants in the control group received early cord clamping (ECC) at around 1 minute after delivery. Clinical measures of the outcomes were measured by the infant transcutaneous bilirubin levels (TcB) and postpartum hemorrhage at birth. A structured questionnaire and biophysical measures were used to collect data on participant demographics, obstetrical information, maternal blood loss at birth, neonate weight and TcB level at hospitalization, and whether or not the infant received phototherapy at 4-7 days postpartum. Results: Overall, there was no significant difference between the two groups in terms of neonatal jaundice, maternal hemorrhage at birth, and phototherapy rates at time of hospitalization and at 4-7 days postpartum. Conclusion / Implications for Practice: The findings of the present study support that late umbilical cord clamping does not increase the risk of maternal postpartum hemorrhaging or neonate jaundice. Thus, we suggest that clinicians inform clients during prenatal classes of the benefits of delayed cord clamping and also use current, evidence-based knowledge to dispel client worries regarding the dangers to maternal-neonate health of delayed cord clamping.

1. American Academy of Pediatrics(2012).Breastfeeding and the use of human milk.Pediatrics,129(3),e827-e841.
2. American College of Obstetricians and Gynecologists(2002).ACOG educational and practice bulletins: The following educational and technical bulletins has been withdrawn from circulation #216.Obstetrics and Gynecology,99(2),361.
3. Bertini, G.,Dani, C.,Tronchin, M.,Rubaltelli, F. F.(2001).Is breastfeeding really favoring early neonatal jaundice?.Pediatrics,107(3),e41-e45.
4. Bhutani, V. K.,Stark, A. R.,Lazzeroni, L. C.,Poland, R.,Gourley, G. R.,Kazmierczak, S.,Stevenson, D. K.(2013).Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy.The Journal of Pediatrics,162(3),477-482.
5. Chaparro, C. M.(2011).Timing of umbilical cord clamping: Effect on iron endowment of the newborn and later iron status.Nutrition Reviews,69(1, Suppl),S30-S36.
6. Chaparro, C. M.,Neufeld, L. M.,Tena Alavez, G.,Eguia-Líz Cedillo, R.,Dewey, K. G.(2006).Effect of timing of umbilical cord clamping on iron status in Mexican infants: A randomised controlled trial.The Lancet,367(9527),1997-2004.
7. Coggins, M.,Mercer, J.(2009).Delayed cord clamping: Advantages for infants.Nursing for Women’s Health,13(2),132-139.
8. Cohen, S. M.(2006).Jaundice in the full-term newborn.Pediatric Nursing,32(3),202-208.
9. Cook, E. L.(2007).Delayed cord clamping or immediate cord clamping? A literature review.British Journal of Midwifery,15(9),562-571.
10. Emhamed, M. O.,van Rheenen, P.,Brabin, B. J.(2004).The early effects of delayed cord clamping in term infants born to Libyan mothers.Tropical Doctor,34(4),218-222.
11. Farrar, D.,Airey, R.,Law, G. R.,Tuffnell, D.,Cattle, B.,Duley, L.(2011).Measuring placental transfusion for term births: Weighing babies with cord intact.BJOG: An International Journal of Obstetrics & Gynaecology,118(1),70-75.
12. Fual, F.,Erdfelder, E.,Lang, A.-G.,Buchner, A.(2007).G*Power 3: A flexible statistical power analysis program for social, behavioral, and biomedical sciences.Behavior Research Methods,39(2),175-191.
13. Huang, M. J.,Kua, K. E.,Teng, H. C.,Tang, K. S.,Weng, H. W.,Huang, C. S.(2004).Risk factors for severe hyperbilirubinemia in neonates.Pediatrics Research,56(5),682-689.
14. Hutton, E. K.,Hassan, E. S.(2007).Late vs early clamping of the umbilical cord in full-term neonates: Systematic review and meta-analysis of controlled trials.JAMA: The Journal of the American Medical Association,297(11),1241-1252.
15. Jahazi, A.,Kordi, M.,Mirbehbahani, N. B.,Mazloom, S. R.(2008).The effect of early and late umbilical cord clamping on neonatal hematocrit.Journal of Perinatology,28(8),523-525.
16. Kaynak-Türkmen, M.,Aydoğdu, S. A.,Gökbulut, C.,Yenisey, Ç.,Söz, Ö,Çetinkaya-Çakmak, B.(2011).Transcutaneous measurement of bilirubin in Turkish newborns: Comparison with total serum bilirubin.The Turkish Journal of Pediatrics,53(1),67-74.
17. Keren, R.,Bhutani, V. K.,Luan, X.,Nihtianova, S.,Cnaan, A.,Schwartz, J. S.(2005).Identifying newborns at risk of significant hyperbilirubinaemia: A comparison of two recommended approaches.Archives of Disease in Childhood,90(4),415-421.
18. Keren, R.,Luan, X.,Friedman, S.,Saddlemire, S.,Cnaan, A.,Bhutani, V. K.(2008).A comparison of alternative risk-assessment strategies for predicting significant neonatal hyperbilirubinemia in term and near-term infants.Pediatrics,121(1),e170-e179.
19. Kramer, L. I.(1969).Advancement of dermal icterus in the jaundiced newborn.American Journal of Diseases of Children,118(3),454-458.
20. Kuzniewicz, M. W.,Escobar, G. J.,Wi, S.,Liljestrand, P.,McCulloch, C.,Newman, T. B.(2008).Risk factors for severe hyperbilirubinemia among infants with borderline bilirubin levels: A nested case-control study.The Journal of Pediatrics,153(2),234-240.
21. Levy, T.,Blickstein, I.(2006).Timing of cord clamping revisited.Journal of Perinatal Medicine,34(4),293-297.
22. Maisels, M. J.,Deridder, J. M.,Kring, E. A.,Balasubramaniam, M.(2009).Routine transcutaneous bilirubin measurements combined with clinical risk factors improve the prediction of subsequent hyperbilirubinemia.Journal of Perinatology,29(9),612-617.
23. Maisels, M. J.,Ostrea, E. M.,Touch, S.,Clune, S. E.,Cepeda, E.,Kring, E.,Huang, R.(2004).Evaluation of a new transcutaneous bilirubinometer.Pediatrics,113(6),1628-1635.
24. McDonald, S. J.,Middleton, P.,Dowswell, T.,Morris, P. S.(2014).Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.Evidence Based Child Health: A Cochrane Review Journal,9(2),303-397.
25. Mercer, J. S.,Erickson-Owens, D. A.(2012).Rethinking placental transfusion and cord clamping issues.The Journal of Perinatal & Neonatal Nursing,26(3),202-217.
26. Mishra, S.,Agarwal, R.,Deorari, A. K.,Paul, V. K.(2008).Jaundice in the newborns.The Indian Journal of Pediatrics,75(2),157-163.
27. National Collaborating Centre for Women’s and Children’s Health(2010).Neonatal jaundice: Clinical guideline.London, England:Royal College of Obstetricians and Gynaecologists.
28. National Institute for Health and Care Excellence. (2014). Intrapartum care: Active and physiological management. Retrieved from http://pathways.nice.org.uk/pathways/intrapartum-care#path=view%3A/pathways/intrapartum-care/care-in-third-stage-of-labour.xml&content=view-node%3Anodes-active-and-physiological-management view%3A/pathways/intrapartum-care/care-in-third-stage-of-labour.xml&content
29. Newman, T. B.,Xiong, B.,Gonzales, V. M.,Escobar, G. J.(2000).Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health maintenance organization.Archives of Pediatrics & Adolescent Medicine,154(11),1140-1147.
30. Prendiville, W. J. P.,Elbourne, D.,McDonald, S. J.(2009).Active versus expectant management in the third stage of labour.Cochrane Database Systematic Reviews,3,CD000007.
31. Saghaei, M.(2004).Random allocation software.Isfahan, Iran:Isfahan University of Medical Sciences.
32. Seidman, D. S.,Ergaz, Z.,Paz, I.,Laor, A.,Revel-Vilk, S.,Stevenson, D. K.,Gale, R.(1999).Predicting the risk of jaundice in full-term healthy newborns: A prospective population-based study.Journal of Perinatology,19,564-567.
33. Selkirk, L.,Blumberg, R.,Broadhurst, E.,Penrice, J.,Klaber, R.(2008).A clinical guide to umbilical cord clamping.British Journal of Midwifery,16(11),714-716.
34. Setia, S.,Villaveces, A.,Dhillon, P.,Mueller, B. A.(2002).Neonatal jaundice in Asian, white, and mixed-race infants.Archives of Pediatrics and Adolescent Medicine,156(3),276-279.
35. Soltani, H.,Dickinson, F.,Symonds, I.(2005).Placental cord drainage after spontaneous vaginal delivery as part of the management of the third stage of labour.Cochrane Database Systematic Reviews,4,CD004665.
36. Urs, A.,Shivashankar, S.,Simon, C.(2010).Neonatal jaundice.InnovAiT: Education and Inspiration for General Practice,3(12),708-713.
37. Van Rheenen, P.,De Moor, L.,Eschbach, S.,De Grooth, H.,Brabin, B.(2007).Delayed cord clamping and haemoglobin levels in infancy: A randomised controlled trial in term babies.Tropical Medicine & International Health,12(5),603-616.
38. World Health Organization(2012).WHO recommendations for the prevention and treatment of postpartum haemorrhage.
39. Yao, A. C.,Moinian, M.,Lind, J.(1969).Distribution of blood between infant and placenta after birth.The Lancet,294(7626),871-873.
40. 王淑芳（校閱）, S. F.(Ed.),陳昭惠（校閱）, C. H.(Ed.)(2012).母乳哺育—理論與實務.台北市=Taipei City, Taiwan, ROC:台灣母乳哺育聯合學會=Taiwan Academy of Breastfeeding.
41. 吳俊穎, C. Y.,楊增暐, T. W.,賴惠蓁, H. J.,陳榮基, R. C.(2010)。醫療糾紛民事訴訟時代的來臨：台灣醫療糾紛民國91年至96年訴訟案件分析。台灣醫學，14(4)，359-369。
42. 黃郁惠, Y. H.,陳惠紋, H. W,黃美智, M. C.(1999)。建立經皮測黃疸器在嬰兒室之使用指標。慈濟醫學雜誌，11(4)，359-364。