NICE may be discouraging detection of postpartum depressionBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39150.424896.BE (Published 15 March 2007) Cite this as: BMJ 2007;334:550
All rapid responses
We are grateful to Coyne and Mitchell for drawing out attention to
the error in the NICE guideline on Antenatal and Postnatal Mental Health
in the recommendation on detecting depression. (1) (2) It should have been
clear in the recommendation that a positive response was required to only
one of the first two questions. The error was introduced during the final
stages of production of the guideline. Updated versions of the guideline
will be available on the NICE website shortly and NICE will be re-printing
the Quick Reference Guide. Coyne and Mitchell also suggest that this
recommendation was not evidence-based but this is not quite accurate. The
relevant reviews on which the recommendation was based are contained in
the full guideline downloadable from the NICE website; they come to
broadly the same conclusions as Coyne and Mitchell in their recent review
on this topic. (3)
Stephen Pilling (1) Rachel Burbeck (1) Dave Tomson (2)
(1) National Collaborating Centre for Mental Health
(2) Chair Antenatal and Postnatal Mental Health Guideline Development
1 Coyne JC, Mitchell AJ. Postpartum depression: NICE may be
discouraging detection of postpartum depression. BMJ 2007;334:550.
2 National Institute for Health and Clinical Excellence. Antenatal
and postnatal mental health: clinical management and service guidance.
London: NICE. www.nice.org.uk/guidance/CG45
3 Mitchell AJ, Coyne JC. Do ultra-short screening instruments
accurately detect depression in primary care? A pooled analysis and meta-
analysis of 22 studies. Br J Gen Pract 2007;57:144-51.
Competing interests: No competing interests
NICE is also encouraging the artificial intervention(1) of immediate cord clamping.
The NICE guideline for caesarean section includes a section on cord clamping. They state a number of “suggested” benefits and a number of “possible” harms. The reference is a review paper in a midwifery journal.(2) This review clearly provides evidence for the benefits, not simply a “suggestion”. The next paragraph in the NICE guideline references two controlled trials but fails to mention three others (3,4,5) that were discussed in the midwifery review. In particular they failed to mention a well designed UK trial published in the BMJ in 1993.(5) The two trials they did mention were criticised for having different endpoints and for being underpowered for the outcome measured. However these two trials (7,8) together with another (5) formed part of the Cochrane review published only a year later. This concluded there was a significant reduction in the need for neonatal transfusion after delayed cord clamping (Relative risk (RR) 2.01, 95% CI 1.24 to 3.27) in preterm infants.
In the NICE guideline on intra-partum care, due to be finalised soon, only term pregnancies are considered and delayed cord clamping is never mentioned. No doubt the authors would argue that the benefits of active management of the third stage are established and early clamping (precise interval not defined) is an integral part of the procedure. These authors recognise that “the birth of a baby is nothing short of a miracle. There are also major rapid physiological changes that take place to enable the baby to adapt to life outside the womb.” How rapid should we expect these changes to take place? Is it reasonable to expect these physiological changes to occur within a few seconds of birth and at the whim of a bystander? The authors may argue that most of the evidence is for preterm births and the evidence for term births has only been published quite recently. (9,10,11)
In the studies on the active management of the third stage, were adverse effects looked for in the babies subjected to immediate cord clamping? The Cochrane review (14) reports that “Neonatal outcomes were assessed in the two trials. No clinically important differences between the groups were detected. The rate of breastfeeding at hospital discharge and at six weeks was, however, higher in the active group.” Can reduced breast feeding not be considered an adverse effect? There were no reports of long term follow up. In the Bristol trial babies in the physiological group weighed a mean of 85 g more than those in the active group and this is consistent with the placental transfusion they would have received. Before we can conclude that active management of the third stage, incorporating immediate cord clamping, is safe for the newborn baby we need medium and long term follow up for anaemia and neurodevelopment.(12,13)
I question just how precise the practice needs to be. It is well recognized that the precise timing of the oxytocic varies amongst the studies and in different parts of the world. There is no real logic for incorporating early cord clamping in a strategy to reduce post-partum haemorrhage. Removing the clamp and draining the residual placental blood seems to shorten the 3rd stage!(15) This is also recommended practice in rhesus negative women, in an effort to reduce the risk of feto-maternal haemorrhage. (16) It is therefore totally illogical to recommend immediate cord clamping and cutting, followed by drainage of the residual placental blood. This is blood which is physiogically required by the newborn baby and it would be obviously better to “drain the placenta” into the newborn baby or at least provide the baby with the amount of blood which it requires. Any residual blood at that stage can be allowed to drain away.
Finally there is no place for “suggested adverse effects” with no evidence to back it up. Polycythemia, hyperviscosity and hyperbilirubinaemia are repeatedly mentioned as “concerns” but none of the many recent trials have shown these to be problems. It can be stated therefore that there are no recognised risks for delayed cord clamping.
NICE should clearly state that delayed cord clamping is the preferred management in caesarean section, vaginal delivery and preterm delivery, and stop encouraging the artificial intervention of immediate clamping.
1. Kent A What’s new in the other journals? BJOG 2007 114 3 379-380
2. Mercer JS. Current best evidence: a review of the literature on umbilical cord clamping. J Midwifery Womens Health 2001;46:402–14.
3. Nelle M, Fischer S, Conze S, Beedgen B, Grischke EM, Linderkamp O. Effects of late cord clamping on circulation in prematures (VLBWI). Pediatric Research 1998;44(3):454.
4. Oh W, Carlo WA, Fanaroff AA, McDonald S, Donovan EF, Poole K, et al. Delayed cord clamping in extremely low birth weight infants - a pilot randomised controlled Trial. Pediatric Research 2002;51(4 Suppl):365-6.
5. Kinmond S, Aitchison TC, Holland BM, Jones JG, Turner TL, Wardrop CAJ. Umbilical cord clamping and preterm infants: a randomised trial. BMJ 1993;306:172-5.
6. Hofmeyr GJ, Gobetz L, Bex PJM, Van Der Griendt M, Nikodem CV, Skapinker R, et al. Periventricular/intraventricular hemorrhage following early and delayed umbilical cord clamping: a randomized trial. Online Journal of Current Clinical Trials 1993 Doc No 110:
7. McDonnell M, Henderson Smart DJ. Delayed umbilical cord clamping in preterm infants: a feasibility study. Journal of Paediatrics and Child Health 1997;33(4):308-10.
8. Rabe H, Wacker A, Hulskamp G, Hornig-Franz I, Schulze-Everding A, Harms E, et al. A randomised controlled trial of delayed cord clamping in very low birth weight preterm infants. European Journal of Pediatrics 2000;159(10):775-7.
9. Ceriani Cernadas JM, Carroli G, Pellegrini L, Otana L, Ferreira M, Ricci C et al. The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized Controlled Trial. Pediatrics 2006;117:779-786
10. Rheenen PV, Brabin BJ. Late umbilical cord-clamping as an intervention for reducing iron deficiency anaemia in term infants in developing and industrialised countries: a systematic review. Annals of Tropical Paediatrics 2004;24:3-16
11. Hutchon DJR Delayed cord clamping may also be beneficial in rich settings BMJ 2006;333:1073
12. Rao R, Georgieff MK. Iron in fetal and neonatal nutrition. Seminars in Fetal & Neonatal medicine. 2007;12:54-63
13. Hurtado EK, Claussen AH, Scott KG. Early childhood anaemia and mild or moderate mental retardation. American Journal of Clincal Nutrition 1999;69:115-9
14. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active vs physiological management of the third stage of labour. BMJ 1988;297:1295-300
15. Placental cord drainage after spontaneous vaginal delivery as part of the management of the third stage of labour [Reviews] Soltani, H; Dickinson, F; Symonds. 2005
16. Prendiville W, Elbourne D. Care during the third stage of labour. In: Chalmers I, Enkin M, Keirse MJNC editor(s). Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989:1145-69.
Competing interests: No competing interests