Included studies

Three randomised control trials (RCTs) were included for this review (Jain 2020, Mansaray 2015, Vain 2014).

The included studies are summarised in Table 2.

Two different comparisons were identified for optimum position for the baby during delayed cord clamping; 2 studies compared placing the baby at the mother’s abdomen versus holding the baby below the vaginal level (Jain 2020, Mansaray 2015), and 1 study compared placing the baby at the mother’s abdomen or chest versus holding the baby at the vaginal level (Vain 2014).

This review also considered cohort studies (prospective and retrospective) as the included RCTs did not report data on all critical and important outcomes, however no eligible studies were found.

See the literature search strategy in appendix B and study selection flow chart in appendix C.

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix J.

Included studies

A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.

The outcomes that matter most

Babies are susceptible to jaundice in the first few days after birth due to the rapid transition from the intrauterine to the extrauterine pattern of heme catabolism. This leads to the circulation of unconjugated bilirubin that the neonatal liver may be unable to metabolise in time, resulting in neonatal jaundice. The risk of jaundice may therefore be increased in babies with delayed cord clamping who have a larger volume of placental transfusion and therefore an increased number of red blood cells. The committee therefore chose jaundice requiring phototherapy or exchange transfusion as critical outcomes to indicate the safety of different positions prior to cord clamping. Infant haemoglobin concentration 24 hours after birth and 3 to 6 months after birth were chosen as critical outcomes to assess the effects of different positions during cord clamping on placental transfusion and resulting haemoglobin levels at these time points. An Apgar score <7 at 5 minutes indicates that a baby has not transitioned well to life ex-utero and may need support and so this was also chosen as a critical outcome for this review.

The committee also chose important outcomes for this review. The committee agreed that it was important to find out about women’s experience and whether holding the baby at or below vaginal level (and therefore not passing it to the mother or placing it on her abdomen) had an impact on this. The committee recognised the great importance of this outcome, however they were aware that the evidence was likely to be sparse, and unlikely to inform decision-making in a meaningful way, so they prioritised other outcomes as critical. The committee agreed that it was also important to look at outcomes that promote emotional attachment with the baby, such as skin-to-skin contact and breastfeeding, as again these can impact on the overall wellbeing of the baby, as well as being important for thermostasis and nutrition. The committee chose neonatal admission as an important outcome as, along with Apgar score, this would indicate whether there were any post-birth complications related to the different positions of the baby prior to cord clamping.

The quality of the evidence

The quality of the evidence ranged from moderate to very low, with most of the evidence being low to very low quality. Some of the evidence was downgraded for risk of bias due to the lack of an available prespecified protocol and imprecision around the estimate of effect. Due to the nature of the interventions, it was not possible to blind the study participants or midwives for all of the comparisons. Whilst this may have introduced some bias and most of the outcomes (with the exception of breastfeeding) are measured with appropriate standardised methods, the committee interpreted the evidence taking this limitation into account.

Benefits and harms

The committee discussed the evidence presented on the optimum position for the baby during delayed cord clamping. The committee’s discussion initially focused on the outcome of infant haemoglobin at 3 to 4 months. The evidence showed that babies held at the mother’s abdomen level had lower haemoglobin levels at 3 to 4 months (−0.3 g/dL) than those held below vaginal level. The committee agreed that despite not being a large difference in absolute terms, it was important to consider as babies have higher haemoglobin levels at birth, which then fall up until 6-8 weeks which is considered the nadir. The committee considered the 95% confidence interval reported for the fall in haemoglobin at 3 to 4 months (−0.58 to −0.02 g/dL) and discussed that for some babies this decrease could potentially move them into the pathological range, with the baby suffering from anaemia.

The committee then moved onto discussing the outcome of fall in haemoglobin between birth and 3 to 4 months. For this outcome there was no difference between the babies held below vaginal level or at the mother’s abdomen level. The committee discussed that this might mean that the babies with the low haemoglobin at 3 to 4 months had a lower haemoglobin at birth, but as the haemoglobin levels at birth were not reported, it was not possible to verify this.

Overall, the committee came to the consensus agreement that the effects on haemoglobin were unclear, but the evidence suggested that holding the baby at abdominal level during delayed cord clamping might have an adverse effect on haemoglobin levels but that the effect was likely to be very small and may or may not be clinically significant.

The committee agreed that as there was no difference between the positions for any of the other reported outcomes it was not possible to recommend that either abdominal/chest or vaginal level be used in preference to the other during delayed cord clamping.

The committee also discussed whether the benefits of holding the baby below the vaginal level outweighed the benefits of immediate skin to skin contact between the mother and the baby. The committee came to an informal consensus that parents want to do what is most beneficial for the baby, and that the benefits of immediate skin to skin contact may outweigh the small drop in haemoglobin but as none of the included studies had reported on this, they were unable to reach a definitive conclusion.

The committee discussed that the evidence had only looked at two main positions for the baby – abdominal/chest level and vaginal level or below – with the assumption that most women would be semi-recumbent. However, there were many other positions in which a woman could give birth including kneeling, squatting, standing, or sitting in a birthing pool. The committee considered the practical implications of holding the baby below the vaginal level straight after birth in these positions, and the fact that in women who were standing, raising the baby to chest level would be a greater height difference than in women who were semi-recumbent. The committee noted that after caesarean birth, women often wanted to see their baby immediately and so it was common practice to lift the baby to show the mother over the screen, before cord clamping, which was also at a greater height above the vaginal level. The committee also considered the practicalities of the vaginal level position for physiological management where the cord is clamped once it has stopped pulsing, so the baby would need to be held at the vaginal level for longer. The committee also added that holding the baby in set position after birth may result in the midwife or obstetrician not being able to address other care needs, and that in the case of a water birth this practice would not be feasible.

The committee were concerned about the low quality of the evidence for the outcome of infant haemoglobin at 3 to 4 months. There were concerns about the risk of bias for the outcome, the sample size, and the lack of data for the same outcome in the other included studies. The committee discussed the impact that holding the baby for longer would have on the outcome, and there were concerns that the included studies only considered the effect of position and not time. In their view, the time the baby is held and the position cannot be isolated, and timing might be more important as it may affect the blood volume more than the actual position of the baby. As a result, the committee agreed that there was not enough evidence to support holding the baby in a specific position, therefore they agreed not to make a definitive recommendation on this topic.

Based on the lack of evidence to guide advice on the optimal position of the baby, the committee agreed to make a research recommendation on the effect of holding the baby below vaginal level versus the mother’s abdomen for a wider range of birthing positions including standing as well as during different modes of birth including caesarean and birth with forceps or ventouse as no evidence had been found on this.

Cost effectiveness and resource use

The committee did not think that there were resource implications arising from different birth positions and therefore agreed that cost effectiveness would be determined by clinical effectiveness. However, the lack of evidence meant that the committee did not advise one position or another for the baby prior to delayed cord clamping. As birth position does not impact resource use and because the recommendations do not change current practice there will be no resource implications.