Placental transfusion, plays crucial role in neonatal circulatory and haematological health. (1) It is estimated that 25–60% of total fetal blood volume, including RBCs and hematopoietic stem cells, remains within feto-placental circulation at birth. This natural process significantly increases the newborn’s blood volume by approximately 30% if allowed to continue after delivery. (2) Timing of umbilical cord clamping directly influences extent of placental transfusion, impacting neonatal haemoglobin levels and iron stores. (3).

Umbilical cord, consisting of two arteries and single vein, serves as fetus’s primary channel for oxygen and nutrient exchange. (4) At birth, cord clamping marks physiological transition from placental to independent circulation. (5) Traditionally, early cord clamping (ECC) is performed within first 5 to 15 seconds after birth, abruptly halting placental transfusion. However, growing evidence suggests that delaying cord clamping (DCC) for 1–3 minutes, or until cord pulsation ceases, allows for enhanced blood volume transfer, leading to improved neonatal iron reserves and haemoglobin levels. (6) Despite these benefits, timing of cord clamping remains inconsistent due to absence of standardized guidelines and varying clinical practices.

Iron deficiency anemia is significant cause of neonatal morbidity and mortality, particularly in low-resource settings such as Pakistan.(7) Since iron stores at birth influence infant’s risk of developing anemia later in infancy, optimizing cord clamping practices could play critical role in neonatal health.(8) Studies indicate that neonates who undergo ECC experience blood volume reduction of approximately 20–40 mL/kg compared to those who undergo DCC, which may predispose them to hypovolemia and iron deficiency.(9, 10) This remains major concern in developing countries, where access to healthcare, diagnostic resources, and awareness about neonatal anemia is limited.

The practice of DCC has been widely debated in management of third stage of labor. While global research supports its advantages, its adoption remains inconsistent, particularly in settings where national guidelines are lacking. Given the potential benefits of DCC in preventing neonatal anemia and improving long-term health outcomes, further investigation is necessary to provide evidence-based recommendations for its implementation. This study aims to compare neonatal outcomes between early cord clamping (ECC) and delayed cord clamping (DCC) to evaluate how the timing of cord clamping affects neonatal outcome.

This quasi experimental study was conducted at Obstetrics Department, DHQ Hospital/Hafizabad over 6 months from July 2024 to January 2024 after taking ethical approval [No: 1877, Dated: 03-06-2024]. Females aged 18-40 years, in 2nd stage of labor having singleton term (37-41 weeks) pregnancy, and Parity <5 were included. Females with chronic or gestational hypertension/diabetes, pervious history of C-section, fetal distress and maternal anemia (Hb <11g/dl) were excluded. Sample size of 70 pregnant females (35/group) estimated using 5% significance level, 80% power of test and expected Hb taken as 16.51 ± 1.71 g/dl and 15.16 ± 2.27 g/dl, in delayed and early cord clamping groups. (11) For sample size calculation, WHO sample size calculator was used. Participants enrollment was done using non-probability consecutive sampling. Total 70 Participants meeting the selection criteria were recruited from labor room after receiving approval from the hospital's ethical committee. Consent was acquired with knowledge before enrollment. Name, age, gestational age, parity, and maternal Hb were documented. After second stage of labor, participants were randomly assigned to two equal groups using lottery method. Group A: Early Cord clamping (within 15 seconds of birth) and group B delayed cord clamping (clamping cord at 180 seconds after birth). After 12 hours of birth 3 cc syringe was used to take 1cc blood sample from the newborn while maintaining aseptic procedures and sample was sent to the hospital lab so that hemoglobin levels could be determined. Hemoglobin levels were recorded and reports evaluated. A pre-made performa was used to gather all of this data. In addition, Apgar scores at 1 and 5 minutes were recorded by attending paediatrician using standard clinical criteria. Respiratory distress was labelled if oxygen support was required. Neonates were observed for jaundice daily during hospital stay. If jaundice was suspected, total serum bilirubin (TSB) was measured at 48 hours of life. Based on age-specific guidelines, the need for phototherapy was assessed. SPSS version 26 was used to analyze the data and independent sample t-test was used to compare quantitative variables and chi-square for qualitative variables among groups, p-value ≤0.05 was taken as significant.

The comparison of maternal characteristics between the early cord clamping (ECC) group (N=35) and the delayed cord clamping (DCC) group (N=35) showed no significant differences. The mean maternal age was similar in both groups, with 27.87 ± 7.09 years in the ECC group and 28.94 ± 8.52 years in the DCC group (p = 0.419). Gestational age was also comparable, averaging 37.44 ± 1.84 weeks for ECC and 37.92 ± 1.71 weeks for DCC (p = 0.943). Additionally, maternal hemoglobin levels did not differ significantly between groups, with mean values of 12.47 ± 5.19 g/dl in ECC and 12.98 ± 5.42 g/dl in DCC (p = 0.688). These results indicate that the two groups were well matched regarding key maternal demographic and clinical characteristics. (Table 1)

Table 1: Comparison of patient related characteristics among groups

 The distribution of parity between the early cord clamping (ECC) group (N=35) and the delayed cord clamping (DCC) group showed no significant difference (p = 0.677). In the ECC group, 37% of women were primigravida compared to 40% in the DCC group. Women with parity 1–2 accounted for 26% in the ECC group and 17% in the DCC group, while those with parity 3–4 represented 37% and 43% of the ECC and DCC groups, respectively. (Figure 1)

Figure 1. Distribution of parity among participants in the Early Cord Clamping (ECC) and Delayed Cord Clamping (DCC) groups.

Table 2: Comparison of neonatal Hb g/dl among groups

Neonates in the delayed cord clamping (DCC) group demonstrated significantly higher hematological values compared to those in the early cord clamping (ECC) group. The mean neonatal hemoglobin level was 16.5 ± 1.2 g/dl in the DCC group versus 15.4 ± 1.3 g/dl in the ECC group (p < 0.001). Similarly, hematocrit values were higher in the DCC group (41.0 ± 8.1%) compared to the ECC group (41.65 ± 9.03%) with a statistically significant difference (p = 0.002). Ferritin levels, indicating iron stores, were also elevated in neonates with delayed cord clamping (363.72 ± 51.09 ng/mL) compared to early clamping (296.02 ± 29.02 ng/mL) (p < 0.001). These findings suggest that delayed cord clamping positively impacts neonatal hematological status by increasing hemoglobin concentration, hematocrit, and iron stores at birth as shown in table 2.

Neonatal outcomes were compared as shown in table 3; Apgar scores at 1 and 5 minutes showed no significant difference between groups, though 5-minute scores were slightly better in DCC group (p = 0.05). Respiratory distress was slightly less common in DCC group (8.5% vs 11.4%, p = 0.690). Incidences of jaundice (14.2% vs 20%) and need for phototherapy (2.8% vs 11.4%) were lower in DCC group, but differences were not statistically significant.

Table 3: Comparison of neonatal outcomes among study groups.

According to current study, ECC group found to have significantly lower mean Hb level, as compared DCC group, p-value<0.001. Improved APGAR score, decrease incidence of respiratory distress, jaundice and need for phototherapy observed in DCC group however, this difference was not significant p>0.05. Similar results observed by Ofojebe et al, mean Hb found to be higher in group with DCC vs group with ECC (16.51 ± 1.71 g/dl vs 15.16 ± 2.27 g/dl; p < 0.001).(11) Enyinna et al, have also observed similar findings in their trial, supporting that DCC associated with higher neonates Hb level at 48 hours post-delivery.(12) However, in current study neonates Hb levels were assessed at 12 hours post-delivery. Mohammad et al, have compared neonatal Hb levels at 12 hours, post-delivery and found results similar to current observation.(13) It was found by Güner and Saydam, that delaying umbilical cord clamping by at least one minute after birth positively influences infants' hematological outcomes and may help prevent anemia.(14) In study by Jaiswal et al, cord clamping was done at different intervals from 15 sec to 180 sec and has shown gradual increase in Hb levels, with maximum Hb observed in those with cord clamping done at 180 sec.(15) In contrast Shao et al, declared that cord clamping beyond 60 s did not further improve Hb levels in neonates.(16) However, this observation was carried for neonates delivered via C-section. Padilla et al, in line with current study revealed that term newborns delivered vaginally and given DCC have shown higher SpO₂ within first 5 minutes after birth compared to those who had ECC. (17) Gomersall et al, found that, DCC leads to higher hemoglobin levels immediately after birth compared to ECC. However, impact of DCC on major health outcomes remains unclear, limiting their definitive recommendation in clinical guidelines. (18) While nurse-midwives and obstetricians often practiced ECC, Mwakawanga et al, also recognized that DCC could benefit newborn oxygenation, especially if resuscitation is needed. To enhance maternal and newborn care, it is crucial to provide thorough pre-service education and professional training. (19) Promoting delayed cord clamping more broadly may help improve neonatal health outcomes as observed in current study. Furthermore, Qian et al also supported that DCC not only improves Hb levels, also found to be associated with less frequency of neonatal jaundice and requirement of phototherapy. (20). Current study was limited to term neonates only; we did not include or compare outcomes among preterm or post-term infants, which could have provided broader understanding of effects of cord clamping across gestational ages. These factors could further inform the safety and efficacy of DCC and should be explored in future research.

Delayed cord clamping improves neonatal haemoglobin haematocrit, and ferritin levels without significantly affecting immediate neonatal outcomes. Slight increase in jaundice is manageable with routine monitoring.

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