Latest research on cord clamping
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We will continously blog on our own and others results on cord clamping, as well as other news related to the subject, such as umbilical cord milking and resuscitation.
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When a baby is born, it's an exciting moment for all involved. But there are still some important decisions to be made in the moments after birth – one of which is when to clamp and cut the umbilical cord. While most parents may feel inclined to do this immediately following delivery, experts suggest that waiting a few minutes has many potential benefits for both mother and child. In this article, we'll discuss three of these advantages associated with delaying umbilical cord clamping.
As soon as a baby enters the world, they must now learn how to survive outside the womb on their own. During this time, having access to blood from the placenta can help them make this transition easier. This vital resource includes essential nutrients like iron along with oxygen-rich red blood cells – giving newborns a much needed boost at such a fragile stage in life. Clamping too quickly can mean depriving your little one of these critical elements right when they require them most.
Finally, delayed cord clamping also offers certain health benefits for mothers as well. When babies receive more placental blood before cutting ties with mom, research suggests it might reduce risk factors associated with postpartum hemorrhage – something no new parent wants to experience! So if you're expecting or already have welcomed your bundle of joy into the family, consider taking extra time before severing that special bond between parent and child via the umbilical cord!
Benefits Of Delayed Cord Clamping
Clamping the umbilical cord is a significant step in childbirth and can have long-term impacts on both mother and baby. Delayed cord clamping has many benefits that should not be overlooked; here we examine three reasons to wait before clamping the umbilical cord.
Firstly, delayed cord clamping helps promote better iron levels in newborns. By waiting for at least 30 seconds after birth to cut the cord, babies can receive more oxygenated blood from mom's placenta, which boosts their iron stores significantly. This allows infants to develop higher hemoglobin levels in their bodies, reducing the risk of anemia down the road into childhood.
Secondly, delayed cord clamping encourages healthy growth in newborns by providing additional nutrients through placental transfusion. Studies show that these unique transfers can increase birth weight and ward off potential problems such as hypoglycemia, bradycardia and respiratory distress syndrome. Allowing time for further placental transfusions may also lead to improved breastfeeding rates since it gives babies access to colostrum – mom's special milk full of antibodies - right away.
Finally, delaying cord clamping allows for longer bonding between mom and baby immediately following birth. Without rushing this process with early clamping, mothers get a chance to experience skin-to-skin contact with their infant shortly after delivery while still connected via the umbilical cord. This provides ample opportunity for moms and babies alike to share meaningful moments together even amidst all the chaos of labor and delivery!
Delaying or avoiding immediate cutting of the umbilical cord comes with several important advantages for parents looking for ways to nurture their little ones throughout pregnancy and beyond. With these numerous benefits associated with delayed cord clamping come certain risks which will be discussed next...
Risks Of Early Cord Clamping
When it comes to clamping the umbilical cord, timing is everything. A newborn’s health and wellbeing depend on when this important step occurs. Early clamping carries its own risks, making delayed clamping a far better option for both mother and baby.
The image of a pair of scissors snipping through the lifeline that connects mother and child can be jarring; however, understanding why early cord clamping must be avoided is crucial. The possible consequences include:
- Impaired iron stores leading to anemia
- Disrupted thermoregulation (body temperature control)
- Difficulty transitioning from intrauterine to extra uterine life
These potential issues run the gamut from mild to severe in their effects – ranging anywhere from short-term fatigue or jaundice to long-term neurodevelopmental impairments. Additionally, as research continues into other areas such as immune system development, more complications may become apparent with early cord clamping.
Given all these considerations, delaying cord clamping until after birth offers many advantages without any known disadvantages. It's essential for parents to have access to accurate information regarding safe delay practices so they can make informed decisions about their care during labor and delivery.
How To Safely Delay Clamping The Umbilical Cord
The umbilical cord is a vital lifeline between mother and child, yet many parents opt to have the umbilical cord clamped immediately after birth. Ironically, this seemingly innocuous action could actually be harmful – so how can you safely delay clamping it?
It’s important not to rush into clamping the umbilical cord. It's best practice that both baby and mother benefit from delayed cord clamping by allowing time for placental transfusion of oxygen-rich blood as well as essential nutrients and iron stores. In addition, waiting a few minutes allows gravity to reduce the pressure in the placenta, which helps reduce bleeding at delivery.
To ensure a safe transition for your newborn, keep him or her warm during skin-to-skin contact with mom (known as “kangaroo care”). This will help maintain their temperature while stabilizing heart rate and respiratory rates. During this time, an experienced midwife should monitor both mother and baby closely, including checking blood pressures every five minutes until stabilized. This period usually lasts about fifteen minutes before considering cutting the umbilical cord if medically necessary.
In order to minimize any risks associated with early clamping of the umbilical cord, delaying for even three more minutes beyond when baby has been delivered gives them valuable extra time on the life-giving connection they shared throughout pregnancy — one last chance to receive what they need before entering into this new world!
Conclusion
In conclusion, waiting to clamp the umbilical cord is beneficial for both the baby and mother. Delayed cord clamping increases a newborn's iron stores and red blood cells, which can help prevent anemia in infancy. It also reduces risks of preterm infants developing intraventricular hemorrhage or necrotizing enterocolitis later on. Additionally, it helps ensure that a newborn receives all the placental transfusions they need while reducing their risk of needing a blood transfusion.
Research shows that delaying cord clamping by just one minute can increase hemoglobin levels in term babies by 10%. So even if you're pressed for time after delivery, taking a minute to wait before cutting the umbilical cord could be life-changing for your little one!
Research
Latest posts on NEW research
Two of the persons involved in the development of Lifestart trolley (http://www.inditherm.com/medical/neonatal-resuscitation-lifestart/) has published a review in Maternal Health, Neonatology and Perinatology.
"Abstract: The rationale for keeping the mother and her newborn together even when neonatal resuscitation is required is presented. The development of a customised mobile resuscitation trolley is detailed explaining how the resuscitation team can be provided with all the facilities of a standard resuscitation trolley to resuscitate the neonate at the mother’s side with an intact cord. Alternative low tech solutions which may be appropriate in low resource setting and with a low risk population are also described."
http://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-016-0034-9
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We were originally intending to do delayed clamping for the umbilical cord so that our baby benefits from the maximum amount of blood from placenta.
cord clamping newborn
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Resource availability and barriers to delivering quality care for newborns in hospitals in the southern region of Malawi: A multisite observational study
PLOS Glob Public Health. 2022 Dec 5;2(12):e0001333. doi: 10.1371/journal.pgph.0001333. eCollection 2022.ABSTRACTFacility-based births have increased in low and middle-income countries, but babies still die due to poor care. Improving care leads to better newborn outcomes. However, data are lacking on how well facilities are prepared to support. We assessed the availability of human and material resources and barriers to delivering quality care for newborns and barriers to delivering quality care for newborns. We adapted the WHO Service Availability and Readiness Assessment tool to evaluate the resources for delivery and newborn care and barriers to delivering care, in a survey of seven hospitals in southern Malawi between January and February 2020. Data entered into a Microsoft Access database was exported to IBM SPSS 26 and Microsoft Excel for analysis. All hospitals had nursery wards with at least one staff available 24 hours, a clinical officer trained in paediatrics, at least one ambulance, intravenous cannulae, foetal scopes, weighing scales, aminophylline tablets and some basic laboratory tests. However, resources lacking some or all of the time included anticonvulsants, antibiotics, vitamin K, 50% dextrose, oxytocin, basic supplies such as cord clamps and nasal gastric tubes, laboratory tests such as bilirubin and blood culture and newborn clinical management guidelines. Staff reported that the main barriers to providing high-quality care were erratic supplies of power and water, inadequacies in the number of beds/cots, ambulances, drugs and supplies, essential laboratory tests, absence of newborn clinical protocols, and inadequate staff, including paediatric specialists, in-service training, and support from the management team. In hospitals in Malawi, quality care for deliveries and newborns was compromised by inadequacies in many human and material resources. Addressing these deficiencies would be expected to lead to better newborn outcomes.PMID:36962885 | PMC:PMC10021306 | DOI:10.1371/journal.pgph.0001333… -
Delayed cord clamping during deliveries with meconium-stained amniotic fluid
Early Hum Dev. 2023 Apr;179:105753. doi: 10.1016/j.earlhumdev.2023.105753. Epub 2023 Mar 15.ABSTRACTIn this cohort study of deliveries affected with meconium, the perinatal factors that were significantly associated with non-performance of delayed cord clamping were primigravida, maternal diabetes, chorioamnionitis, rupture of membranes ≥18 h, assisted vaginal delivery, cesarean section, breech presentation, thick meconium, fetal distress and nonvigorous status of the newborn.PMID:36947989 | DOI:10.1016/j.earlhumdev.2023.105753… -
Cord blood presepsin as a predictor of early-onset neonatal sepsis in term and preterm newborns
Ital J Pediatr. 2023 Mar 21;49(1):35. doi: 10.1186/s13052-023-01420-z.ABSTRACTBACKGROUND: To date, no studies on presepsin values in cord blood of term infants with risk factors for early-onset sepsis (EOS) are available, whereas only one study reported presepsin values in cord blood of preterm infants at risk. In this study, we investigated the presepsin values in cord blood of term and preterm infants with documented risk factors for EOS.METHODS: In this single-center prospective pilot study, we enrolled neonates presenting with documented risk factors for EOS. P-SEP levels were assessed in a blood sample collected from the clamped umbilical cord after the delivery in 93 neonates, using a point-of-care device. The primary outcome of our study was to evaluate the role of cord blood P-SEP in predicting clinical EOS in term and preterm infants.RESULTS: During the study period, we enrolled 93 neonates with risk factors for EOS with a gestational age ranging between 24.6 and 41.6 weeks (median 38.0). The median P-SEP value in all infants was 491 pg/ml (IQR 377 - 729). Median cord P-SEP values were significantly higher in infants with clinical sepsis (909 pg/ml, IQR 586 - 1307) rather than in infants without (467 pg/ml, IQR 369 - 635) (p = 0.010). We found a statistically significant correlation between cord P-SEP value at birth and the later diagnosis of clinical sepsis (Kendall's τ coefficient 0.222, p = 0.002). We identified the maximum Youden's Index (best cut-off point) at 579 pg/ml, corresponding to a sensitivity of 87.5% and a specificity of 71.8% in predicting clinical sepsis.CONCLUSIONS: Maximum Youden's index was 579 pg/ml for clinical EOS using cord P-SEP values. This could be the starting point to realize multicenter studies, confirming the feasibility of dosing P-SEP in cord blood of infants with risk factors of EOS to discriminate those who could develop clinical sepsis and spare the inappropriate use of antibiotics.PMID:36945009 | PMC:PMC10029283 | DOI:10.1186/s13052-023-01420-z… -
How the Clamping Distance of the Umbilical Cord affects Microbial Colonization and Cord Separation Time: A Randomized Trial
P R Health Sci J. 2023 Mar;42(1):50-56.ABSTRACTOBJECTIVE: This study aimed to explore how umbilical cord separation time and microbial colonization are affected by umbilical cord clamping distance.METHODS: The randomized controlled study included 99 healthy newborns and was conducted at a hospital in Kahramanmaras, Turkey. The newborns were randomly divided into 3 groups: intervention group I (cord length: 2 cm); intervention group II (cord length: 3 cm; control group (not measured). On postpartum day 7, a sample of the umbilical cord was taken to assess microbial colonization. The mothers were contacted via mobile phone on the 20th day for an at-home follow-up. The data were analyzed by applying Pearson's chi-square test, Fisher's exact test, a 1-way analysis of variance test, and Tukey's post hoc Honest Significant Difference test.RESULTS: The mean umbilical cord separation time of the newborns was found to be 6.9 (±2.1) days in the intervention group I, 8.8 (±2.9) days in the intervention group II, and 9.5 (±3.4) days in the control group. The difference between the groups was statistically significant (P < .01). Microbial colonization was detected in 5 of the newborns, across the groups; no significant differences were found between the groups (P > .05).CONCLUSION: In this study, it was determined that clamping the umbilical cord from a distance of 2 cm in vaginally delivered full-term newborns contributed to the shortening of the cord fall time and did not affect microbial colonization.PMID:36941099… -
Premature infants receiving delayed cord clamping with and without cord milking: a randomized control trial
BMC Pediatr. 2023 Mar 18;23(1):123. doi: 10.1186/s12887-023-03933-2.ABSTRACTBACKGROUND: Preterm infants often have long hospital stays and frequent blood tests; they often develop anemia requiring multiple blood transfusions. Placental transfusion via delayed cord clamping (DCC) or umbilical cord milking (UCM) helps increase blood volume. We hypothesized umbilical cord milking (UCM), together with DCC, would be superior in reducing blood transfusions.OBJECTIVES: To compare the effects of DCC and DCC combined with UCM on hematologic outcomes among preterm infants.METHODS: One hundred twenty singleton preterm infants born at 280/7- 336/7 weeks of gestation at Thammasat University Hospital were enrolled in an open-label, randomized, controlled trial. They were placed into three groups (1:1:1) by a block-of-three randomization: DCC for 45 s, DCC with UCM performed before clamping (DCM-B), and DCC with UCM performed after clamping (DCM-A). The primary outcomes were hematocrit levels and number of infants receiving blood transfusions during the first 28 days of life. Intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) were secondary outcomes. Analyses were performed with an intent-to-treat approach.RESULTS: One hundred twenty preterm infants were randomized. There was no statistically significant difference in neonatal outcomes; hematocrit on admission 54.0 ± 5.5, 53.3 ± 6.0, and 54.3 ± 5.8 (p = 0.88), receiving blood transfusions 25%, 20%, and 12.5% (p = 0.24), incidence of NEC 7.5, 0 and 10% (p = 0.78) in the DCC, DCM-B and DCM-A groups, respectively. There were no preterm infants with severe IVH, polycythemia, maternal or neonatal death.CONCLUSION: The placental transfusion techniques utilized, DCC and DCC combined with UCM, provided the same benefits for preterm infants born at GA 28 and 33 weeks in terms of reducing the need for RBC transfusions, severities of IVH and incidence of NEC without increasing comorbidity.TRIAL REGISTRATION: TCTR20190131002 . Registered 31 January 2019-Retrospectively registered.PMID:36932370 | PMC:PMC10024362 | DOI:10.1186/s12887-023-03933-2… -
Hemodynamic changes with umbilical cord milking in non-vigorous newborns: A randomized cluster crossover trial
J Pediatr. 2023 Mar 11:S0022-3476(23)00179-8. doi: 10.1016/j.jpeds.2023.03.001. Online ahead of print.ABSTRACTOBJECTIVE: To assess the hemodynamic safety and efficacy of umbilical cord milking (UCM) compared with early cord clamping (ECC) in non-vigorous newborn infants enrolled in a large multicenter randomized cluster-crossover trial.STUDY DESIGN: Two-hundred-twenty-seven non-vigorous term/near-term infants who were enrolled in the parent UCM vs. ECC trial consented for this sub-study. An echocardiogram was performed at 12±6 hours of age by sonographers blinded to randomization. The primary outcome was left ventricular output (LVO). Pre-specified secondary outcomes included measured superior vena cava (SVC) flow, right ventricular output (RVO), peak systolic strain, and peak systolic velocity by tissue doppler of the RV lateral wall and the interventricular septum.RESULTS: Non-vigorous infants receiving UCM had increased hemodynamic echocardiographic parameters as measured by higher LVO (225±64 vs. 187±52 ml/kg/min, p<.001), RVO (284±88 vs. 222±96 ml/kg/min, p<.001) and SVC flow (100±36 vs. 86±40 ml/kg/min, p<.001) compared with the ECC group. Peak systolic strain was lower (-17±3 vs. -22±3%, p<.001) but there was no difference in peak tissue doppler (.06 (.05, .07) vs. .06 (.05, .08) m/s).CONCLUSION: (s): Umbilical cord milking increased cardiac output (as measured by LVO) compared with ECC in non-vigorous newborns. Overall increases in measures of cerebral and pulmonary blood flow (as measured by SVC and RVO flow respectively) may explain improved outcomes associated with UCM (less cardiorespiratory support at birth and fewer cases of moderate-to-severe HIE) among non-vigorous newborn infants.PMID:36914049 | DOI:10.1016/j.jpeds.2023.03.001… -
Effects of a small-baby protocol on early and long-term outcomes in extremely preterm infants: A quality improvement study
Early Hum Dev. 2023 Apr;179:105733. doi: 10.1016/j.earlhumdev.2023.105733. Epub 2023 Feb 22.ABSTRACTBACKGROUND: Extremely preterm (EPT) infants (≤28 weeks) remain at risk for poor outcomes. Small baby protocols (SBPs) may improve outcomes, but optimal strategies are unknown.METHODS: This study evaluated whether EPT infants managed using an SBP would have better outcomes compared to a historical control (HC) group. The study compared a HC group of EPT infants 23 0/7 weeks to 28 0/7 weeks GA (2006-2007), to a similar SBP group (2007-2008). Survivors were followed until 13 years of life. The SBP emphasized antenatal steroids, delayed cord clamping, respiratory and hemodynamic minimalism, prophylactic indomethacin, early empiric caffeine, and control of sound and light.RESULTS: There were 35 HC subjects and 35 SBP subjects. The SBP group had less severe IVH-PVH (9 % vs. 40 %, risk ratio 0.7, 95 % CI 0.5-0.9, P = 0.002) mortality (17 % vs. 46 %, risk ratio 0.6, 95 % CI 0.5-0.9, P = 0.004), and acute pulmonary hemorrhage (6 % vs. 23 %, risk ratio 0.8, 95 % CI 0.7-1.0, P = 0.04). Compliance with the SBP protocol was excellent. For the SBP group in the first 72 h, no subjects received inotropes, hydrocortisone, or sodium bicarbonate. Intubation, mechanical ventilation, fluid boluses, sedation, red blood cell transfusions, and insulin use decreased. At 10-13 years, more SBP subjects had survived without NDI (51 % vs. 23 %, risk ratio = 1.6, 95 % CI = 1.1-2.4, P = 0.01). More SBP subjects also survived without NDI and with a Vineland Adaptive Behavior Composite score > 85 (44 % vs. 11 %, risk ratio = 2.0, 95 % CI = 1.2-3.2, P ≤0.001). The SBP group had less visual impairment.CONCLUSION: An SBP was associated with improved outcomes, including normal neurologic survival after 10 years.PMID:36870188 | DOI:10.1016/j.earlhumdev.2023.105733… -
Cardiac Asystole at Birth Re-Visited: Effects of Acute Hypovolemic Shock
Children (Basel). 2023 Feb 15;10(2):383. doi: 10.3390/children10020383.ABSTRACTBirths involving shoulder dystocia or tight nuchal cords can deteriorate rapidly. The fetus may have had a reassuring tracing just before birth yet may be born without any heartbeat (asystole). Since the publication of our first article on cardiac asystole with two cases, five similar cases have been published. We suggest that these infants shift blood to the placenta due to the tight squeeze of the birth canal during the second stage which compresses the cord. The squeeze transfers blood to the placenta via the firm-walled arteries but prevents blood returning to the infant via the soft-walled umbilical vein. These infants may then be born severely hypovolemic resulting in asystole secondary to the loss of blood. Immediate cord clamping (ICC) prevents the newborn's access to this blood after birth. Even if the infant is resuscitated, loss of this large amount of blood volume may initiate an inflammatory response that can enhance neuropathologic processes including seizures, hypoxic-ischemic encephalopathy (HIE), and death. We present the role of the autonomic nervous system in the development of asystole and suggest an alternative algorithm to address the need to provide these infants intact cord resuscitation. Leaving the cord intact (allowing for return of the umbilical cord circulation) for several minutes after birth may allow most of the sequestered blood to return to the infant. Umbilical cord milking may return enough of the blood volume to restart the heart but there are likely reparative functions that are carried out by the placenta during the continued neonatal-placental circulation allowed by an intact cord.PMID:36832512 | PMC:PMC9955546 | DOI:10.3390/children10020383… -
The Respiratory Management of the Extreme Preterm in the Delivery Room
Children (Basel). 2023 Feb 10;10(2):351. doi: 10.3390/children10020351.ABSTRACTThe fetal-to-neonatal transition poses an extraordinary challenge for extremely low birth weight (ELBW) infants, and postnatal stabilization in the delivery room (DR) remains challenging. The initiation of air respiration and the establishment of a functional residual capacity are essential and often require ventilatory support and oxygen supplementation. In recent years, there has been a tendency towards the soft-landing strategy and, subsequently, non-invasive positive pressure ventilation has been generally recommended by international guidelines as the first option for stabilizing ELBW in the delivery room. On the other hand, supplementation with oxygen is another cornerstone of the postnatal stabilization of ELBW infants. To date, the conundrum concerning the optimal initial inspired fraction of oxygen, target saturations in the first golden minutes, and oxygen titration to achieve desired stability saturation and heart rate values has not yet been solved. Moreover, the retardation of cord clamping together with the initiation of ventilation with the patent cord (physiologic-based cord clamping) have added additional complexity to this puzzle. In the present review, we critically address these relevant topics related to fetal-to-neonatal transitional respiratory physiology, ventilatory stabilization, and oxygenation of ELBW infants in the delivery room based on current evidence and the most recent guidelines for newborn stabilization.PMID:36832480 | PMC:PMC9955623 | DOI:10.3390/children10020351… -
Cardiac and cerebral hemodynamics with umbilical cord milking compared with early cord clamping: A randomized cluster crossover trial
Early Hum Dev. 2023 Mar;177-178:105728. doi: 10.1016/j.earlhumdev.2023.105728. Epub 2023 Feb 14.ABSTRACTOBJECTIVE: A large, randomized cluster cross-over trial (N = 1730) comparing intact umbilical cord milking (UCM) to early cord clamping (ECC) in non-vigorous near-term/term newborns demonstrated a reduction in cardiorespiratory interventions at birth and less moderate to severe hypoxic ischemic encephalopathy. We evaluated changes in cerebral tissue oxygenation (StO2), pulse oximetry (SpO2), pulse rate and fraction of inspired oxygen (FiO2) during the first 10 min of life in a subset of infants enrolled in the parent trial.STUDY DESIGN: Infants enrolled in the Milking in Non-Vigorous Infants trial that had StO2 monitoring at birth were included in the sub-study conducted at 3 hospitals the US and Canada. A near-infrared spectroscopy sensor, pulse oximeter and electrocardiogram electrodes were placed. Pulse rate, StO2, SpO2, and FiO2 were collected for the first 10 min after birth. Longitudinal models were used to compare effects of UCM and ECC.RESULTS: Thirty-four infants had StO2 data. Fifteen of these infants received UCM and 19 had ECC. Infants receiving UCM had similar heart rates, SpO2, and StO2 values, but were exposed to less FiO2 over the first 10 min of life than infants with ECC (0.26 ± 0.12 vs. 0.81 ± 0.05 at 10 min).CONCLUSION: Non-vigorous term/near term infants who received UCM at birth required lower FiO2 after delivery when compared to infants who umbilical cords were clamped soon after birth while achieving similar peripheral and cerebral oxygenation. Cord milking may be a potential option for placental transfusion in non-vigorous near term/term infants when delayed cord clamping cannot be performed.PMID:36827750 | PMC:PMC10034920 | DOI:10.1016/j.earlhumdev.2023.105728… -
Arterial blood gases in newborn infants: Early extraction without prior clamping versus extraction after delayed clamping
Midwifery. 2023 Apr;119:103635. doi: 10.1016/j.midw.2023.103635. Epub 2023 Feb 18.ABSTRACTOBJECTIVES: To compare the postpartum arterial blood gas parameters recorded early before cord clamping and after delayed cord clamping (DCC). To explore adverse effects and complications of the cord blood gas collection technique without clamping.DESIGN: Randomised controlled trial.SETTING: Birthing room of La Ribera University Hospital (Valencia, Spain).PARTICIPANTS: 122 full-term infants born between February 2020 and January 2021. Two groups were established: the experimental group (early sampling prior to clamping and sampling again after DCC) and the non-experimental group (sampling only after DCC).MEASUREMENTS AND FINDINGS: The comparison of arterial blood gas parameters was made using the Student t-test, while the Fisher's exact test was used to compare the proportion of the adverse effects recorded. The pH and base excess values in the experimental group were significantly greater when the sampling was performed without prior clamping. No statistically significant differences were observed in relation to pCO2 or the appearance of adverse effects between the two groups. No complications were recorded.KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The pH and base excess values were higher when the arterial blood gas measurements were made prior to performing the umbilical cord clamping than when the sampling was performed after the DCC. Arterial blood gas sampling without prior clamping was found to be safe, since no complications or increased adverse effects were observed. The use of this technique is therefore advised in normal births of full-term infants.PMID:36821977 | DOI:10.1016/j.midw.2023.103635… -
Embracing Change: A Quality Improvement Project to Introduce Deferred Cord Clamping
Hosp Pediatr. 2023 Mar 1;13(3):265-273. doi: 10.1542/hpeds.2022-006681.ABSTRACTOBJECTIVES: The aim of this quality improvement (QI) project was to increase deferred cord clamping (DCC) rates in preterm infants (≤36 + 6 weeks) to 50% of eligible infants over an 18-month period.METHODS: The multidisciplinary neonatal quality improvement team collaboratively developed a driver diagram to address the key issues and tasks to launching DCC. Serial plan-do-study-act cycles were used to implement successive changes and integrate DCC as normal practice. Statistical process control charts were used to track and share project progress.RESULTS: This QI project has increased rates of deferred cord clamping for preterm infants from zero to 45%. Our DCC rates have sequentially increased with each plan-do-study-act cycle and have shown sustained increases without significant compromise in other aspects of neonatal care, such as thermoregulation.CONCLUSIONS: DCC is a core element of good quality perinatal care. This QI project encountered several limiting factors to progress, including resistance to change from clinical staff and the impact on staffing and education secondary to the coronavirus disease 2019 pandemic. Our QI team used a range of approaches, such as virtual education strategies and narrative storytelling to overcome these obstacles to QI progress.PMID:36807679 | DOI:10.1542/hpeds.2022-006681… -
What Helping Babies Breathe knowledge and skills are formidable for healthcare workers?
Front Pediatr. 2023 Jan 30;10:891266. doi: 10.3389/fped.2022.891266. eCollection 2022.ABSTRACTINTRODUCTION: Most neonatal deaths occur in the first week of life, due to birth asphyxia. Helping Babies Breathe (HBB), is a simulation-based neonatal resuscitation training program to improve knowledge and skills. There is little information on which knowledge items or skill steps are challenging for the learners.METHODS: We used training data from NICHD's Global Network study to understand the items most challenging for Birth Attendants (BA) to guide future curriculum modifications. HBB training was provided in 15 primary, secondary and tertiary level care facilities in Nagpur, India. Refresher training was provided 6 months later. Each knowledge item and skill step was ranked from difficulty level 1 to 6 based on whether 91%-100%, 81%-90%, 71%-80%, 61%-70%, 51%-60% or <50% of learners answered/performed the step correctly.RESULTS: The initial HBB training was conducted in 272 physicians and 516 midwives of which 78 (28%) physicians and 161 (31%) midwives received refresher training. Questions related to timing of cord clamping, management of a meconium-stained baby, and steps to improve ventilation were most difficult for both physicians and midwives. The initial steps of Objective Structured Clinical Examination (OSCE)-A i.e. equipment checking, removing wet linen and immediate skin-to-skin contact were most difficult for both groups. Midwives missed stimulating newborns while physicians missed cord clamping and communicating with mother. In OSCE-B, starting ventilation in the first minute of life was the most missed step after both initial and 6 months refresher training for physicians and midwives. At the retraining, the retention was worst for cutting the cord (physicians level 3), optimal rate of ventilation, improving ventilation & counting heart rate (midwives level 3), calling for help (both groups level 3) and scenario ending step of monitoring the baby and communicating with mother (physicians level 4, midwives 3).CONCLUSION: All BAs found skill testing more difficult than knowledge testing. The difficulty level was more for midwives than for physicians. So, the HBB training duration and frequency of retraining can be tailored accordingly. This study will also inform subsequent refinement in the curriculum so that both trainers and trainees will be able to achieve the required proficiency.PMID:36793503 | PMC:PMC9922883 | DOI:10.3389/fped.2022.891266… -
Antenatal corticosteroid administration-to-birth interval and neonatal outcomes in very preterm infants: A secondary analysis based on a prospective cohort study
PLoS One. 2023 Feb 10;18(2):e0281509. doi: 10.1371/journal.pone.0281509. eCollection 2023.ABSTRACTINTRODUCTION: Despite the prevalent use of antenatal corticosteroids (ACS) to prevent preterm infants' adverse neonatal complications, there is currently no consensus on administration-to-birth intervals of ACS. International guidelines broadly agree that the administration of antenatal corticosteroids should be within 7 days prior to preterm birth. However, there is little evidence to support narrower optimal ACS administration-to-birth interval time. This study was undertaken to investigate the association between the administration-to-birth interval of ACS which is bounded by 48 hours and neonatal outcomes in very preterm infants.MATERIALS AND METHODS: This is a single-center prospective observational study. Data were collected prospectively from eligible infants from January 2008 to April 2014 at the Santa Clara Valley Medical Center, neonatal outcomes were compared between two groups based on the interval of antenatal corticosteroid administration-to-birth: the interval of <48h, and the interval of >48h. It was noted that the entire study was completed by Dongli Song et al., and uploaded the data to the DATADRYAD website. The author only used this data for secondary analysis.RESULTS: After adjusting potential confounders (gestational age, sex, birth weight, duration of cord clamping and delivery mode), the interval of >48h group compared to the interval of <48h group had significant reductions in mortality (OR: 0.17; 95% CI: 0.05-0.59), any retinopathy of prematurity (OR: 0.36; 95% CI: 0.16-0.82), severe retinopathy of prematurity (OR: 0.07; 95% CI: 0.01-0.45), any intubation (OR: 0.39; 95% CI: 0.20-0.75) and higher 1 min Apgar (β: 0.56; 95% CI: 0.10-1.02).CONCLUSION: This study shows that in very preterm infants, compared with the interval of ACS<48h, the interval of ACS>48 hours has a significant health promotion effect.PMID:36763575 | PMC:PMC9916588 | DOI:10.1371/journal.pone.0281509… -
Feasibility of cord blood collection for autologous cell therapy applications in extremely preterm infants
Cytotherapy. 2023 Feb 3:S1465-3249(23)00007-5. doi: 10.1016/j.jcyt.2023.01.001. Online ahead of print.ABSTRACTBACKGROUND AIMS: Umbilical cord blood (UCB)-derived cells show strong promise as a treatment for neonatal brain injury in pre-clinical models and early-phase clinical trials. Feasibility of UCB collection and autologous administration is reported for term infants, but data are limited for preterm infants. Here the authors assessed the feasibility of UCB-derived cell collection for autologous use in extremely preterm infants born at less than 28 weeks, a population with a high incidence of brain injury and subsequent neurodisability.METHODS: In a prospective study at a tertiary hospital in Melbourne, Australia, UCB was collected from infants born at less than 28 weeks and processed to obtain total nucleated cells (TNCs), CD34+ cells, mononuclear cells and cell viability via fluorescence-activated cell sorting prior to cryopreservation. Feasibility was pre-defined as volume adequate for cryopreservation (>9 mL UCB collected) and >25 × 106 TNCs/kg retrieved.RESULTS: Thirty-eight infants (21 male, 17 female) were included in the study. Twenty-four (63.1%) were delivered via cesarean section, 30 (78.9%) received delayed cord clamping before collection and 11 (28.9%) were a multiple birth. Median (interquartile range [IQR]) gestational age was 26.0 weeks (24.5-27.5) and mean (standard deviation) birth weight was 761.5 g (221.5). Median (IQR) UCB volume collected was 19.1 mL/kg (10.5-23.5), median (IQR) TNC count was 105.2 × 106/kg (57.4-174.4), median (IQR) CD34+ cell count was 1.5 × 106/kg (0.6-2.1) and median (IQR) cell viability pre-cryopreservation was 95% (92.1-96.0). Feasibility of collection volume and cell count suitable for cell cryopreservation was achieved in 27 (71%) and 28 (73.6%) infants, respectively.CONCLUSIONS: UCB-derived cell collection adequate for cryopreservation and subsequent autologous reinfusion was achieved in 70% of extremely preterm infants. Extremely preterm UCB demonstrated a higher CD34+:TNC ratio compared with published full-term values. Recruitment to demonstrate safety of UCB cell administration in extremely premature infants is ongoing in the CORD-SAFE study (trial registration no. ACTRN12619001637134).PMID:36740465 | DOI:10.1016/j.jcyt.2023.01.001… -
Does physiological-based cord clamping improve cerebral tissue oxygenation and perfusion in healthy term neonates? - A randomized controlled trial
Front Pediatr. 2023 Jan 9;10:1005947. doi: 10.3389/fped.2022.1005947. eCollection 2022.ABSTRACTOBJECTIVES: To evaluate cerebral tissue oxygenation index (cTOI) during neonatal transition in a group of healthy full-term neonates receiving either a physiological-based approach of deferred cord clamping (CC) after the onset of stable regular breathing (PBCC group) or a standard approach of time-based CC < 1 min (control group). Secondary aim was to evaluate changes in cerebral blood volume (ΔCBV), peripheral arterial oxygen saturation (SpO2) and heart rate (HR) in those neonates.MATERIALS AND METHODS: We conducted a randomized controlled trial (clinicaltrials.gov: NCT02763436) including vaginally delivered healthy full-term neonates. Continuous measurements of cTOI and ΔCBV using near-infrared spectroscopy, and of SpO2 and HR using pulse oximetry were performed within the first 15 min after birth. Data of each minute of the PBCC group were compared to those of the control group.RESULTS: A total of 71 full-term neonates (PBCC: n = 35, control: n = 36) with a mean (SD) gestational age of 40.0 (1.0) weeks and a birth weight of 3,479 (424) grams were included. Median (IQR) time of CC was 275 (197-345) seconds and 58 (35-86) seconds in the PBCC and control group, respectively (p < 0.001). There were no significant differences between the two groups regarding cTOI (p = 0.319), ΔCBV (p = 0.814), SpO2 (p = 0.322) and HR (p = 0.878) during the first 15 min after birth.CONCLUSION: There were no significant differences in the course of cTOI as well as ΔCBV, SpO2 and HR during the first 15 min after birth in a group of healthy full-term neonates, who received either deferred CC after the onset of stable regular breathing or standard CC < 1 min. Thus, deferring CC ≥ 1 min following a physiological-based approach offers no benefits regarding cerebral tissue oxygenation and perfusion after uncomplicated vaginal delivery compared to a time-based CC approach.PMID:36699304 | PMC:PMC9869382 | DOI:10.3389/fped.2022.1005947… -
Care at the first postnatal hour in two hospitals of the Adequate Birth Project: qualitative analysis of experiences in two stages of the Healthy Birth research
Reprod Health. 2023 Jan 12;20(Suppl 2):14. doi: 10.1186/s12978-022-01540-5.ABSTRACTBACKGROUND: The Adequate Childbirth Project (PPA) is a quality improvement project that aims to enhance normal delivery and reduce cesarean sections with no clinical indication in the Brazilian supplementary health care system. This study aims to analyze the care model of the first postpartum hour in hospitals that participated in the PPA.METHODS: Qualitative analysis based on the narrative of 102 women attended at two hospitals participating in the evaluative "Healthy Birth" research that analyzed the degree of implementation and the effects of the PPA. We assessed three practices within the first hour after delivery: skin-to-skin contact, breastfeeding and appropriate clamping of the umbilical cord. Data was collected through semi-structured interviews by telephone and submitted to thematic content analysis.RESULTS: The categories that emerged from the analysis of the results were "Dimension of time and care expressed in the lived experience" and "Interferences in care in the first hour of life". In the first category, women reported that in the first hour after delivery the newborn was placed on the mother's chest, but the length of time of the newborn's stay in skin-to-skin contact was less than one hour. This experience, even in a shorter period of time, was said to be positive by the women interviewed. Two barriers were observed: interruption of skin-to-skin contact for neonatal care and the transfer to the recovery room, both separating baby from mother without observing the duration of the "golden hour". It was identified that a process of improvement of the quality of care for childbirth is underway, with a gradual incorporation of recommended practices for care in newborn's first hour of life.CONCLUSIONS: Women reported access to the three care practices at two hospitals participating in the PPA quality improvement project. All practices were valued by women as a positive experience and should be promoted. Information during antenatal care to increase women´s autonomy, review of hospital practices to reduce barriers, and support from health care providers during the first hour after birth are needed to improve the implementation of these practices and access to their health benefits.PMID:36635687 | PMC:PMC9835209 | DOI:10.1186/s12978-022-01540-5… -
Increased risk of bradycardia in vigorous infants receiving early as compared to delayed cord clamping at birth
J Perinatol. 2022 Dec 31. doi: 10.1038/s41372-022-01593-1. Online ahead of print.ABSTRACTOBJECTIVE: To compare HR pattern of vigorous newborns during the first 180 s with early (≤60 s, ECC) or delayed (>60 s, DCC) cord clamping.STUDY DESIGN: Observational study including dry-electrode ECG monitoring of 610 vaginally-born singleton term and late-preterm (≥34 weeks) who were vigorous after birth.RESULTS: 198 received ECC while 412 received DCC with median cord clamping at 37 s and 94 s. Median HR remained stable from 30 to 180 s with DCC (172 and 170 bpm respectively) but increased with ECC (169 and 184 bpm). The proportion with bradycardia was higher among ECC than DCC at 30 s and fell faster in the DCC through 60 s. After adjusting for factors affecting timing of cord clamping, ECC had significant risk of bradycardia compared to DCC (aRR 1.51; 95% CI; 1.01-2.26).CONCLUSION: Early heart instability and higher risk of bradycardia with ECC as compared to DCC supports the recommended clinical practice of DCC.PMID:36587054 | DOI:10.1038/s41372-022-01593-1… -
Implementing intact cord resuscitation in very preterm infants: feasibility and pitfalls
Eur J Pediatr. 2023 Mar;182(3):1105-1113. doi: 10.1007/s00431-022-04776-2. Epub 2022 Dec 28.ABSTRACTThe purpose of this study is to evaluate the feasibility of intact cord resuscitation (ICR) in very preterm infants using a custom-equipped mobile resuscitation trolley (LifeStart®). We collected maternal and neonatal data of all inborn infants < 32 weeks eligible for ICR per our protocol over 9 months from ICR implementation. We compared rates of ICR between the beginning and the end of the study period. We reviewed maternal and neonatal adverse events related to the procedure and direct outcomes. In order to assess potential quality improvements related to the procedure, we collected the same data in the infants born in the 9-month period preceding ICR implementation. Out of 44 infants born < 32 weeks during the period, 27 were eligible for ICR. Failure to initiate ICR occurred in 9/27, exclusively in the first 5.5 months of the study. In one infant, ICR was interrupted prior to 2 min due to placental abruption. No ICR procedure had to be interrupted due to insufficient cord length. Among the 18 infants who completed ICR, cord clamping timing increased significantly over the study period, from 3.0 [2.5-3.5] to 4.2 min [3.1-8.3] (p = 0.02). No significant maternal blood loss or wound complications were noted. No infant deaths were attributable to failure or direct consequence of ICR, and no infant experienced hypoxic respiratory failure (intubation, FiO2 ≥ 0.4), asphyxia (pH < 7.2), or blood pressure instability (< 2 SD) following stabilization. Hemoglobin level after cord clamping was higher in the ICR cohort than in the pre-implementation group. Seven out of 18 infants exposed to ICR had a temperature < 36.5 °C on admission. Conclusion: ICR is feasible in very preterm infants. Temperature management requires special attention. Multidisciplinary simulation training before implementation and systematic post-implementation quality improvement meetings may significantly increase ICR program success. What is Known: • Because infants born < 32 weeks often require cardiorespiratory resuscitation at birth, they are not offered delayed cord clamping in the majority of neonatal intensive care units. • Recently, fully equipped mobile trolleys have been developed in order to allow bedside resuscitation with an intact cord. What is New: • Variable timing of cord clamping based on the infant's transition and respiratory stability, i.e., "physiology-based cord clamping," is safely achievable in very preterm infants. • Intact cord resuscitation requires specific equipment, operational protocols, and a high level of preparation from both obstetrical and neonatal teams, with a learning curve that can be streamlined by multidisciplinary simulation training.PMID:36575308 | DOI:10.1007/s00431-022-04776-2… -
The Anemic Newborn at Birth: From Diagnosis to Treatment
Curr Pediatr Rev. 2023;19(4):331-341. doi: 10.2174/1573396319666221220110156.ABSTRACTNeonatal anaemia is a very frequent clinical condition that may be due to apparent or not evident blood loss, decreased red blood cells (RBCs) production, or increased destruction of RBCs. RBCs transfusion criteria are clearly defined by several national and locally agreed guidelines. However, it is not possible to define a unique cut-off to guide clinicians' transfusion practice, which needs a multiparametric analysis of demographic variables (gestational age, postnatal age, birth weight), clinical evaluation, conventional and new generation monitoring (such as echocardiography and near-infrared spectroscopy). Unfortunately, few tools are available in the delivery room to help neonatologists in the management of newborn with acute anaemia. Early volume replacement with cristalloids and RBCs transfusion could be life-saving in the delivery room when a hypovolaemic shock is suspected, but the use of un-crossmatched whole is not risk-free nor easily available in clinical practice. Placental transfusion could be an extremely effective and inexpensive method to increase haemoglobin (Hb), to improve oxygen delivery, and to increase cardiac output with a reduced need for RBCs transfusions, a reduced risk of intraventricular haemorrhages, and an improved survival of the newborn.PMID:36545739 | DOI:10.2174/1573396319666221220110156… -
Delayed umbilical cord clamping - benefits and risks
Ceska Gynekol. 2022;87(6):424-426. doi: 10.48095/cccg2022424.ABSTRACTDelayed umbilical cord clamping is a standard procedure for active management of the 3rd stage of labour. There are benefits associated with more than a 30 second delay, but 1 minute is usually recommended. For newborns, increased iron reserves are important having a positive impact on further development. A reduction in the risk of necrotizing enterocolitis and intraventricular hemorrhage is often reported in preterm births. In delayed umbilical cord clamping, no increased maternal blood loss was recorded, even in multiple pregnancies and caesarean sections.PMID:36543591 | DOI:10.48095/cccg2022424… -
AMBAR: A midwifery-led training program to improve obstetric and neonatal practices among low-risk births in Mexico
Birth. 2023 Mar;50(1):151-160. doi: 10.1111/birt.12699. Epub 2022 Dec 18.ABSTRACTBACKGROUND: Birth care in Mexican health institutions is highly medicalized and of poor quality because of the prevalence of outdated and dangerous practices. AMBAR-a training program for health care providers on the use of evidence-based midwifery practices-was implemented during 2016-2018 and evaluated to assess the impact of training on key practices.METHODS: For this mixed-methods study, we evaluated the effects of a training program implemented in three public hospital networks in Mexico. Qualitative data were collected and integrated into the program before evaluating the effects of the intervention on 10 birth practices, 5 beneficial and 5 potentially harmful. Quantitative data on birth practices and covariates were collected at six time points (baseline and 5 follow-ups) in a final sample of 330 direct observations. Effect estimates were obtained by longitudinal logistic and Poisson regression models, adjusted for confounding variables.RESULTS: AMBAR had a significant effect on 4 of the 10 birth practices that were evaluated. Beneficial practices, such as skin-to-skin contact (P = 0.003) and delayed cord clamping (P = 0.039), increased significantly. Harmful when overused birth practices, such as vaginal examinations (P = 0.001), and cesarean birth (P < 0.001) decreased significantly.CONCLUSIONS: Midwifery-based training programs for health care providers can have an impact on the quality of care of birthing people and newborns, increasing the use of evidence-based practices and decreasing frequently overused practices.PMID:36529703 | DOI:10.1111/birt.12699… -
Postoperative infections after non-elective cesarean section - a retrospective cohort study of prevalence and risk factors at a single center in Denmark administering prophylactic antibiotics after cord clamping
BMC Pregnancy Childbirth. 2022 Dec 17;22(1):945. doi: 10.1186/s12884-022-05300-y.ABSTRACTBACKGROUND: Mothers giving birth by non-elective cesarean section have considerably higher risk of developing postoperative infection, than mothers giving birth by elective cesarean section. Meta-analyses have shown that the risk of infection is reduced when administering antibiotics at least 30 min prior to skin incision rather than after cord clamping. If given prior to incision, antibiotics are present in the neonatal bloodstream for up to 24 h after delivery, with early exposure to antibiotics potentially disturbing development of the gut microbiome. We aimed to retrospectively assess the prevalence of postoperative infection after non-elective cesarean section at a single labor ward administering antibiotics after cord clamping, additionally investigating risk factors for developing postoperative infections.METHODS: In this retrospective cohort study, we included a total of 2,725 women giving birth by non-elective cesarean section in 2010-2017 with a review of records for prenatal risk factors, labor management, and perinatal outcomes. The primary outcomes were a main composite infection of development of either endometritis, surgical-site infection, or sepsis in conjunction with a relevant antibiotic prescription. Secondary outcomes included infection of unknown focus, mastitis, urinary tract infection, and pneumonia.RESULTS: A total of 88 patients developed a main composite infection (3.2%). These infections subdivide into endometritis (n = 37/2725, 1.4%), surgical-site infection (n = 35/2725, 1.3%) and sepsis (n = 15/2725, 0.6%). We found a high body mass index (aOR = 3.38, 95%CI 1.93-5.92) and intrapartum fever (aOR = 2.26, 95%CI 1.22-4.59) to be independent risk-factors for developing postoperative infection after non-elective cesarean section. Furthermore, we found delivery by a more expedient emergency grade 2 cesarean section (aOR = 0.61 95%CI 0.37-0.998) compared to grade 3 to be a protective factor for developing postoperative infection after non-elective cesarean section.CONCLUSION: In a labor ward administering antibiotics after cord clamping at non-elective cesarean births, we find a low prevalence of main composite infections when compared to estimates from meta-analyses on the topic. We conclude that administration of prophylactic antibiotics after cord clamping appears to result in acceptable rates of postoperative infection and avoids transplacental-transmission of antibiotics to the infant.PMID:36528589 | PMC:PMC9758935 | DOI:10.1186/s12884-022-05300-y… -
Placental Transfusion Strategies in Preterm Infants in Low- and Middle-Income Countries: A Systematic Review and Network Meta-Analysis
Neonatology. 2023;120(1):118-133. doi: 10.1159/000527454. Epub 2022 Dec 14.ABSTRACTINTRODUCTION: Placental transfusion strategies in preterm newborns have not been evaluated in low- and middle-income countries (LMICs). The objective of this systematic review was to compare placental transfusion strategies in preterm newborns in LMICs, including delayed cord clamping (DCC) for various time intervals, DCC until cord pulsations stop, umbilical cord milking, and immediate cord clamping (ICC).METHODS: Medline, Embase, CINAHL, and CENTRAL were searched from inception. Observational studies and randomized controlled trials (RCTs) were included. Two authors independently extracted data for Bayesian random-effects network meta-analysis (NMA) if more than 3 interventions reported an outcome or a pairwise meta-analysis was utilized.RESULTS: Among newborns <34 weeks of gestation, NMA of 9 RCTs could not rule out benefit or harm for survival from DCC 30-60 s compared to ICC: relative risk (RR) (95% credible interval) 0.96 (0.78-1.12), moderate certainty, or any included strategy compared to each other (low to very low certainty). Among late preterm newborns, DCC 120 s might be associated with improved survival: RR (95% confidence interval) 1.11 (1.01-1.22), very low certainty. We could not detect differences in the risk of intraventricular hemorrhage grade > II and bronchopulmonary dysplasia for any included intervention (low to very low certainty). DCC 60 s and 120 s might improve the hematocrit level among all preterm newborns (very low certainty), and DCC 45 s may decrease the risk of receipt of inotropes among newborns <34 weeks of gestation (low certainty).CONCLUSIONS: In LMICs, DCC for 60 s and 120 s might improve hematocrit level in preterm newborns, and DCC for 45 s may decrease the risk of receipt of inotropes in newborns <34 weeks, with no conclusive effect on survival.PMID:36516794 | DOI:10.1159/000527454… -
EBNEO commentary on "umbilical cord milking in nonvigorous infants: A cluster-randomised crossover trial"
Acta Paediatr. 2023 Feb;112(2):324-325. doi: 10.1111/apa.16611. Epub 2022 Dec 10.NO ABSTRACTPMID:36495103 | DOI:10.1111/apa.16611… -
Adherence to humanized care practices for newborns with good vitality in the delivery room
Rev Gaucha Enferm. 2022 Dec 2;43:e20210248. doi: 10.1590/1983-1447.2022.20210248.en. eCollection 2022.ABSTRACTOBJECTIVE: To know the intervening factors in the adherence of health professionals to humanized care practices for newborns with good vitality in the delivery room.METHOD: Qualitative research, through an online form with 36 health professionals working in delivery rooms in Rio de Janeiro. Data processed in the Interface de R pour Analyses Multidimensionnelles de Textes Et de Questionnaires and analyzed according to Thematic Content Analysis.RESULTS: Skin-to-skin contact was identified as a factor that is directly related to timely clamping of the umbilical cord and breastfeeding in the first hour of life. Other intervening factors were: acceptance, training and professional category; type of delivery; qualification and training of teams.CONCLUSIONS: Professional improvement combined with encouragement from the leadership, partnership between peers, good working conditions, human resources and infrastructure and guidance to families provide adherence to humanized care practices for the newborn in the delivery room.PMID:36478001 | DOI:10.1590/1983-1447.2022.20210248.en… -
Lung Aeration During Deferred Cord Clamping-No Additional Benefits in Infants Born Preterm?
J Pediatr. 2022 Dec 2:S0022-3476(22)01087-3. doi: 10.1016/j.jpeds.2022.11.029. Online ahead of print.NO ABSTRACTPMID:36463936 | DOI:10.1016/j.jpeds.2022.11.029… -
A Review on Umbilical Cord Milking and Its Implications in Neonatal Health
Cureus. 2022 Oct 23;14(10):e30610. doi: 10.7759/cureus.30610. eCollection 2022 Oct.ABSTRACTIn India, there is an extreme lack of advancement in techniques concerning the care of infants during labor and post-pregnancy, i.e., the postnatal period. India projected an Infant Mortality Rate of 28.771 deaths per 1000 live births for the year 2021. Such a high death rate in infants arises a dire need to discover and launch new techniques and increase the application of the existing lesser-known techniques. One less well-known technique is the milking of the infant's umbilical cord. Transfusion of placental blood has recently been considered definitive in the care of newborns with the boon to the infant of declined death rate in preterm neonates and the enhanced consequences of growth in term infants. The chief goal of this descriptive review article is to examine all the studies relating to umbilical cord milking (UCM) in late-preterm and term infants and to evaluate every achievable outcome and restriction of a given process in clinical application, mainly when compared to rapid and late umbilical cord clamping. Application of milking of the umbilical cord can be seen to improve the health of hypoxic neonates, weight parameters, blood volume, hematocrit, hemoglobin, iron levels in the blood, red blood cell count, blood pressure, right ventricular output, left ventricular functions, cerebral oxygenation, urine output regulation, cognitive abilities, antioxidant levels, better outcomes in the resuscitation of infant and above all helps in lowering Infant Mortality Rates.PMID:36426307 | PMC:PMC9681015 | DOI:10.7759/cureus.30610… -
Maternal bleeding complications and neonatal outcomes following early versus delayed umbilical cord clamping in cesarean deliveries for very low birthweight infants
J Perinatol. 2023 Jan;43(1):39-43. doi: 10.1038/s41372-022-01558-4. Epub 2022 Nov 10.ABSTRACTOBJECTIVE: Determine effect of at least 60 s delayed cord clamping (DCC) on postpartum hemorrhage and maternal estimated blood loss (EBL) in very low birth weight (VLBW) cesarean deliveries when compared to early cord clamping (ECC).STUDY DESIGN: Retrospective study of VLBW infants at birth. Maternal pre- and post-operative hemoglobin, EBL, and neonatal outcomes were collected.RESULTS: In total, 620 VLBW infants (DCC = 166, ECC = 454) born to 545 mothers (DCC = 155, ECC = 390) were included. Maternal PPH between DCC was 8% versus ECC was 10% p = 0.52. There were no differences in estimated blood loss or rate of maternal blood transfusion between groups. The post-operative hemoglobin was lower in infants receiving ECC compared to DCC (10.4 [9.4-11.5] versus 10.8 [10.1-11.9] g/dl, p = 0.01). In comparing pre-operative to post-operative hemoglobin there was no difference between DCC and ECC (-1.2 [-2.0 to -0.3] versus -1.2 [-2.1 to -0.6] g/dl, p = 0.46).CONCLUSION: DCC of at least 60 s did not increase maternal bleeding complications during VLBW cesarean delivery. To our knowledge, this retrospective study is the largest sample size to date of preterm cesarean deliveries to support maternal safety regarding bleeding complications after delayed cord clamping.PMID:36357575 | DOI:10.1038/s41372-022-01558-4… -
Delayed Cord Clamping Uptake and Outcomes for Infants Born Very Preterm in California
Am J Perinatol. 2022 Dec 30. doi: 10.1055/a-1975-4607. Online ahead of print.ABSTRACTOBJECTIVE: The aim of this study is to investigate whether the purported benefits of delayed cord clamping (DCC) translate into a reduction in mortality and intraventricular hemorrhage (IVH) among preterm neonates in practice.STUDY DESIGN: This was a prospective cohort study of very preterm infants constructed from data from the California Perinatal Quality Care Collaborative for infants admitted into 130 California neonatal intensive care units (NICUs) within the first 28 days of life from 2016 through 2020. Individual-level analyses were conducted using log-binomial regression models controlling for confounders and allowing for correlation within hospitals to examine the relationship of DCC to the outcomes of mortality and IVH. Hospital-level analyses were conducted using Poisson regression models with robust variance controlling for confounders.RESULTS: Among 13,094 very preterm infants included (5,856 with DCC and 7,220 without), DCC was associated with a 43% lower risk of mortality (adjusted risk ratio [aRR]: 0.57; 95% confidence interval [CI]: 0.47-0.66). Furthermore, every 10% increase in the hospital rate of DCC among preterm infants was associated with a 4% lower hospital mortality rate among preterm infants (aRR: 0.96; 95% CI: 0.96-0.99). DCC was associated with severe IVH at the individual level, but not at the hospital level.CONCLUSION: At the individual level and hospital level, the use of DCC was associated with lower mortality among preterm infants admitted to NICUs in California. These findings are consistent with clinical trial results, suggesting that the effects of DCC seen in clinical trials are translating to improved survival in practice.KEY POINTS: · DCC was associated with lower mortality among very preterm newborns in California.. · Hospitals using DCC more often had lower very preterm mortality.. · DCC was not associated with IVH at the hospital level..PMID:36351446 | DOI:10.1055/a-1975-4607… -
Every treasured drop! Blood transfusion requirements in very preterm neonates after implementation of blood conservation strategies: an observational analytical study
J Trop Pediatr. 2022 Oct 6;68(6):fmac093. doi: 10.1093/tropej/fmac093.ABSTRACTBACKGROUND: Certain morbidities are inevitable in preterm infants; the challenge lies in minimizing them. Anemia of prematurity is multifactorial. Therapy largely depends on adult red blood cell transfusions (RBCT); which inherently, are not without problems. Most literature in this respect are retrospective or evaluate individual stratagems to reduce RBCT.METHODS: This observational analytical study was planned to compare need for RBCT, before and after institution of blood conservation strategies (BCS). All those ≤30 weeks gestation at birth during two-time epochs were included (Before BCS: retrospective; After BCS: prospective). BCS constituted of delayed cord clamping (DCC), strict sampling indications, micro-sampling with point-of-care testing (MS-POCT) and adherence to RBCT thresholds.RESULTS: Of 45 enrolled neonates in each group, proportion of those requiring even 1 RBCT was significantly reduced after BCS [51.1% vs. 26.7%, p = 0.02, OR 0.35, 95%CI (0.14, 0.84)]. Calculated cumulative blood volume losses (35.3 ml vs. 21.9 ml) and loss per kilogram birth weight (35.3 ml/kg vs. 20.12 ml/kg) were significantly lower after BCS (p = 0.0036). Need for >1 RBCT, mean lowest Hb, mean maximum-hemoglobin drop, need for arterial lines were reduced. Adherence to RBCT thresholds were acceptably good in both time epochs. However, the compliance to DCC was low in both groups, identifying one area of focus with scope for massive improvement.CONCLUSIONS: Need for RBCT transfusions largely attributable to reduced blood losses for lab analysis were reduced after BCS. Installation of in-house MS-POCT seemed to be the pivotal factor. Units that care for very preterm infants must make attempts to procure MS-POCT equipment.PMID:36306125 | DOI:10.1093/tropej/fmac093… -
Manually Controlled, Continuous Infusion of Phenylephrine or Norepinephrine for Maintenance of Blood Pressure and Cardiac Output During Spinal Anesthesia for Cesarean Delivery: A Double-Blinded Randomized Study
Anesth Analg. 2023 Mar 1;136(3):540-550. doi: 10.1213/ANE.0000000000006244. Epub 2022 Oct 24.ABSTRACTBACKGROUND: To counteract the vasoplegia induced by spinal anesthesia (SA) and maintain blood pressure (BP) during cesarean delivery, phenylephrine is currently recommended, but norepinephrine might offer superior preservation of cardiac output. We aimed to compare the hemodynamic effects of phenylephrine and norepinephrine administered by manually adjusted continuous infusion during elective cesarean delivery.METHODS: In this pragmatic, parallel-group, double-blind randomized controlled trial, 124 parturients scheduled for elective cesarean delivery under SA in a tertiary maternity in France, between February 2019 and December 2020, were randomized to receive norepinephrine at a starting rate of 0.05 μg·kg -1 ·min -1 (n = 62) or phenylephrine at a starting rate of 0.5 μg·kg -1 ·min -1 (n = 62). In both groups, the vasopressor infusion rate was then manually adjusted to maintain maternal systolic BP above 90% of the baseline value. The primary outcome, the change in cardiac index (CI) measured by thoracic bioreactance from SA to umbilical cord clamping, was analyzed through repeated measures analysis of variance and post hoc t tests. Secondary outcomes included maternal BP and neonatal outcomes.RESULTS: In the norepinephrine group, cardiac index was maintained between 90% and 100% of baseline from SA to umbilical cord clamping, whereas it was maintained at significantly lower values (81%-88%) in the phenylephrine group ( P = .001). The percentage of elapsed time with a mean maternal BP <65 mm Hg and with systolic BP <80% of the baseline value was higher in the phenylephrine group: 2.9% (7.3) vs 0.5% (1.8) (absolute risk difference [ARD], -2.4%; 95% confidence interval, -4.4 to -0.5; P = .012) and 8.5% (16.6) vs 2.3% (5.2) (ARD, -6.2%; 95% confidence interval, -10.6 to -1.8; P = .006). Excluding parturients with gestational diabetes, severe neonatal hypoglycemia was more common in the phenylephrine group at 19.6% (9/46) vs 4.1% (2/49) ( P = .02). The other neonatal outcomes did not differ significantly between the groups.CONCLUSIONS: When administered by manually adjusted infusion during SA for cesarean delivery, norepinephrine was associated with a higher CI; both infusions were effective for maintaining BP.PMID:36279409 | DOI:10.1213/ANE.0000000000006244… -
Resuscitation with Intact Cord Versus Clamped Cord in Late Preterm and Term Neonates: A Randomized Controlled Trial
J Pediatr. 2023 Mar;254:54-60.e4. doi: 10.1016/j.jpeds.2022.08.061. Epub 2022 Oct 18.ABSTRACTOBJECTIVE: To compare the effect of intact cord versus clamped cord resuscitation on the physiologic transition of neonates receiving positive-pressure ventilation (PPV) at birth.STUDY DESIGN: This open-label, parallel-group, randomized controlled superiority trial was conducted in a tertiary care hospital in India. Neonates born at ≥34 weeks of gestation after a complicated pregnancy or labor were randomized just before birth to receive resuscitation according to the Neonatal Resuscitation Program algorithm with either an intact cord (intact cord resuscitation group) or after early cord clamping (early cord clamping resuscitation group). The allocated study intervention was administered if the neonate needed PPV at birth. The primary outcome was expanded Apgar score at 5 minutes after birth.RESULTS: Birth weight, gestational age, and the incidence of pregnancy complications were similar in the 2 study groups. The proportion of neonates who received PPV was lower in the intact cord resuscitation group (28.7% vs 36.5%, P = .05; relative risk, 0.79; 95% CI, 0.61-1.01). Among neonates who received PPV, the expanded Apgar score at 5 minutes was significantly higher in the intact cord resuscitation group (median, 15 [IQR, 14-15] vs 14 [IQR, 13-15]; P < .001). The expanded Apgar score at 10 minutes, Apgar scores at 5 and 10 minutes, and oxygen saturation at 1, 5, and 10 minutes were also higher in the intact cord resuscitation group.CONCLUSION: In late preterm and term neonates, resuscitation with an intact cord results in better postnatal physiologic transition than the standard practice of resuscitation after immediate cord clamping.TRIAL REGISTRATION: Clinical Trial Registry of India (www.ctri.nic.in); trial registration no. CTRI/2020/02/023379.PMID:36265571 | DOI:10.1016/j.jpeds.2022.08.061… -
The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists
Gynecol Obstet Fertil Senol. 2023 Jan;51(1):7-34. doi: 10.1016/j.gofs.2022.10.002. Epub 2022 Oct 11.ABSTRACTOBJECTIVE: To identify procedures to reduce maternal morbidity during cesarean.MATERIAL AND METHODS: The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.RESULTS: Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.CONCLUSION: In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.PMID:36228999 | DOI:10.1016/j.gofs.2022.10.002… -
Neurodevelopmental outcomes of very preterm infants who received cord milking at birth: a randomized controlled trial
Eur J Pediatr. 2022 Dec;181(12):4215-4220. doi: 10.1007/s00431-022-04638-x. Epub 2022 Oct 4.ABSTRACTUmbilical cord milking improves postnatal adaptation and short-term outcomes of very preterm infants compared to early cord clamping. Little is known about the impact of umbilical cord milking on long-term neurodevelopmental outcomes. The objective of this study is to compare the effects of intact umbilical cord milking (UCM) vs. early cord clamping (ECC) at birth on neurodevelopmental outcomes at 36 months' corrected age. Preterm infants < 31 weeks' gestation who were randomized at birth to receive three time milking of their attached cord or ECC (< 10 s) were evaluated at 36 months' corrected age. Neurodevelopmental outcomes were assessed by blinded examiners using Bayley Scales of Infant and Toddler Development (version III). Analysis was by intention to treat. Out of the 73 infants included in the original trial, 2 died and 65 (92%) infants were evaluated at 36 months' corrected age. Patient characteristics and short-term outcomes were similar in both study groups. There were no significant differences in the median cognitive, motor or language scores or in the rates of cerebral palsy, developmental impairment, deafness, or blindness between study groups.CONCLUSION: Neurodevelopmental outcomes at 36 months' corrected age of very preterm infants who received UCM were not shown to be significantly different from those who received ECC at birth.TRIAL REGISTRATION: ClinicalTrials.gov: NCT01487187 What is Known: • Compared to early cord clamping, umbilical cord milking improves postnatal adaptation and short-term outcomes of very preterm infants compared to early cord clamping. • Little is known about the impact of umbilical cord milking on neurodevelopmental outcomes.WHAT IS NEW: • Neurodevelopmental outcomes at 3 years of age were not significantly different in very preterm infants who received cord milking vs. those who received early cord clamping at birth.PMID:36194256 | DOI:10.1007/s00431-022-04638-x… -
Physiological-based cord clamping in very preterm infants: the Aeration, Breathing, Clamping 3 (ABC3) trial-study protocol for a multicentre randomised controlled trial
Trials. 2022 Oct 1;23(1):838. doi: 10.1186/s13063-022-06789-6.ABSTRACTBACKGROUND: International guidelines recommend delayed umbilical cord clamping (DCC) up to 1 min in preterm infants, unless the condition of the infant requires immediate resuscitation. However, clamping the cord prior to lung aeration may severely limit circulatory adaptation resulting in a reduction in cardiac output and hypoxia. Delaying cord clamping until lung aeration and ventilation have been established (physiological-based cord clamping, PBCC) allows for an adequately established pulmonary circulation and results in a more stable circulatory transition. The decline in cardiac output following time-based delayed cord clamping (TBCC) may thus be avoided. We hypothesise that PBCC, compared to TBCC, results in a more stable transition in very preterm infants, leading to improved clinical outcomes. The primary objective is to compare the effect of PBCC on intact survival with TBCC.METHODS: The Aeriation, Breathing, Clamping 3 (ABC3) trial is a multicentre randomised controlled clinical trial. In the interventional PBCC group, the umbilical cord is clamped after the infant is stabilised, defined as reaching heart rate > 100 bpm and SpO2 > 85% while using supplemental oxygen < 40%. In the control TBCC group, cord clamping is time based at 30-60 s. The primary outcome is survival without major cerebral and/or intestinal injury. Preterm infants born before 30 weeks of gestation are included after prenatal parental informed consent. The required sample size is 660 infants.DISCUSSION: The findings of this trial will provide evidence for future clinical guidelines on optimal cord clamping management in very preterm infants at birth.TRIAL REGISTRATION: ClinicalTrials.gov NCT03808051. First registered on January 17, 2019.PMID:36183143 | PMC:PMC9526936 | DOI:10.1186/s13063-022-06789-6… -
Effect of Breathing Support in Very Preterm Infants Not Breathing During Deferred Cord Clamping: A Randomized Controlled Trial (The ABC Study)
J Pediatr. 2023 Feb;253:94-100.e1. doi: 10.1016/j.jpeds.2022.09.025. Epub 2022 Sep 22.ABSTRACTOBJECTIVE: To determine if providing respiratory support to very preterm infants who fail to breathe regularly during deferred cord clamping (DCC) decreased red cell transfusion.STUDY DESIGN: Infants less than 31 weeks of gestation undergoing DCC who were apneic or not breathing regularly at 15 seconds underwent stratified randomization. Pale, limp, and nonresponsive infants were excluded. The standard group received gentle stimulation in a neutral position for 50 seconds; the intervention group received intermittent positive pressure ventilation via face mask and T piece from 20 to 50 seconds of age with a fractional inspired oxygen of 0.3. The primary outcome was the proportion transfused, with a secondary composite outcome of death, severe intraventricular hemorrhage, or chronic lung disease.RESULTS: Of 311 assessed infants, 113 met the inclusion criteria and were studied; 57 received the intervention and 56 standard treatment. Patient characteristics were similar. Overall, 105 infants (93%) received the intended 50 seconds DCC (54 in the intervention group and 51 in the standard group). Rates of transfusion were similar (28% vs 30% in the intervention vs control groups), as were rates of the composite outcome (46% vs 38% in the intervention vs the control arms; P = .45).CONCLUSIONS: Providing breathing support during 50 seconds of DCC in this single-center cohort seemed to be safe and feasible, but did not decrease the transfusion rates or improve outcomes.TRIAL REGISTRATION: http://www.anzctr.org.au/ACTRN12615001026516.aspx.PMID:36152686 | DOI:10.1016/j.jpeds.2022.09.025… -
Intrinsic and synaptic properties of adult mouse spinoperiaqueductal gray neurons and the influence of neonatal tissue damage
Pain. 2023 Apr 1;164(4):905-917. doi: 10.1097/j.pain.0000000000002787. Epub 2022 Sep 23.ABSTRACTThe periaqueductal gray (PAG) represents a key target of projection neurons residing in the spinal dorsal horn. In comparison to lamina I spinoparabrachial neurons, little is known about the intrinsic and synaptic properties governing the firing of spino-PAG neurons, or whether such activity is modulated by neonatal injury. In this study, this issue was addressed using ex vivo whole-cell patch clamp recordings from lamina I spino-PAG neurons in adult male and female FVB mice after hindpaw incision at postnatal day (P)3. Spino-PAG neurons were classified as high output, medium output, or low output based on their action potential discharge after dorsal root stimulation. The high-output subgroup exhibited prevalent spontaneous burst firing and displayed initial burst or tonic patterns of intrinsic firing, whereas low-output neurons showed little spontaneous activity. Interestingly, the level of dorsal root-evoked firing significantly correlated with the resting potential and membrane resistance but not with the strength of primary afferent-mediated glutamatergic drive. Neonatal incision failed to alter the pattern of monosynaptic sensory input, with most spino-PAG neurons receiving direct connections from low-threshold C-fibers. Furthermore, primary afferent-evoked glutamatergic input and action potential discharge in adult spino-PAG neurons were unaltered by neonatal surgical injury. Finally, Hebbian long-term potentiation at sensory synapses, which significantly increased afferent-evoked firing, was similar between P3-incised and naive littermates. Collectively, these data suggest that the functional response of lamina I spino-PAG neurons to sensory input is largely governed by their intrinsic membrane properties and appears resistant to the persistent influence of neonatal tissue damage.PMID:36149785 | PMC:PMC10033328 | DOI:10.1097/j.pain.0000000000002787… -
The Novel Use of Umbilical Cord Blood to Obtain Complete Blood Counts for Critical Neonatal Assessment
Cureus. 2022 Aug 14;14(8):e28009. doi: 10.7759/cureus.28009. eCollection 2022 Aug.ABSTRACTBACKGROUND: Neonates undergoing clinical evaluations are often subjected to potentially painful phlebotomy for laboratory tests. The use of cord blood laboratory values for admission has been suggested as a means to decrease the risk of painful venipuncture and anemia.METHODS: Peripheral and umbilical cord blood complete blood count (CBC) results were obtained from infants who required a CBC. Results were compared using the Sysmex XN heme analyzer (Sysmex, Kobe, Japan).RESULTS: White blood cell (WBC) and hemoglobin (HgB) values were significantly higher in peripheral samples than in cord samples. The mean cord WBC count was 14.1 × 103/mm3 versus 15.6 × 103/mm3 peripherally (p < 0.001). The mean cord HgB was 15.8 g/dL versus 16.8 g/dL peripherally (p < 0.001). Cord platelet (Plt) counts were, conversely, lower in peripheral samples than in cord samples (264.8 × 103/mm3 versus 242.3 × 103/mm3, respectively; p < 0.001). Although statistically different, the mean CBC values from both samples were within the reference ranges. Delayed cord clamping (DCC) increased peripheral versus cord HgB difference nearly threefold (0.6-1.7 g/dL; p = 0.01).CONCLUSIONS: Cord blood is an acceptable source for CBC blood sampling in newborn infants and can be used for clinical decisions. CBC laboratory values for cord blood remained within the peripheral blood reference range, with slight variability between the two samples.PMID:36134078 | PMC:PMC9470209 | DOI:10.7759/cureus.28009… -
The effect of placental transfusion on hemodynamics in premature newborns: a randomized controlled trial
Eur J Pediatr. 2022 Dec;181(12):4121-4133. doi: 10.1007/s00431-022-04619-0. Epub 2022 Sep 21.ABSTRACTDespite of growing evidence of the beneficial effects of placental transfusion techniques, there is no available sufficient data about their effects on vulnerable hemodynamics and myocardium of premature infants. The purpose of this work is to study ventricular functions and hemodynamics after applying different placental transfusion techniques, delayed cord clamping (DCC), cut cord milking (C-UCM), and intact cord milking (I-UCM). Sixty-four infants delivered whether by C-section or vaginal delivery were randomly assigned to undergo C-UCM (20-30 cm), I-UCM (3-4 strippings), and DCC (30-60 s). Functional echocardiography was done on day 1 and day 3 of life for 57 infants. Primary outcome variable was superior vena cava flow measurement in infants having placental transfusion in the first 24 h of life and between 64 and 72 h. Secondary outcomes were other echocardiographic and clinical hemodynamic parameters, and biventricular functions in those infants. Of a total 196 preterm infants ≤ 32 weeks delivered in the study period, from January 2021 to August 2021, 57 infants were eligible and survived till the second examination. They were randomly assigned to the three groups. Neonates randomly assigned to DCC had significantly higher superior vena cava flow and lower right ventricular systolic function in the first 24 h of life. This finding vanished at day 3. Neonates undergone different methods of placental transfusions had similar hemoglobin, admission temperature, and mean blood pressure in the first 24 h of life.CONCLUSION: Despite their potential benefits, placental transfusions have shown to alter the hemodynamics and adversely affect myocardial function of premature neonates.TRIAL REGISTRATION: This trial was registered in the clinical trial gov NCT04811872.WHAT IS KNOWN: • Placental transfusion techniques might have benefits regarding prematurity- related morbidities and mortality.WHAT IS NEW: • Placental transfusion might adversely affect the myocardium and alter hemodynamics in premature infants.PMID:36129535 | PMC:PMC9649456 | DOI:10.1007/s00431-022-04619-0… -
Umbilical cord clamping time and maternal satisfaction
Midwifery. 2022 Dec;115:103487. doi: 10.1016/j.midw.2022.103487. Epub 2022 Sep 13.ABSTRACTOBJECTIVE: Clamping of the umbilical cord is part of the third stage of delivery. Delayed cord clamping (DCC) is recommended due to its contribution to prevention of anaemia. There is no evidence on the effect of DCC on maternal satisfaction. The aim of this study is to evaluate the effect of different sociodemographic and obstetric factors, including the timing of cord clamping, on maternal satisfaction with the birth experience in our healthcare system.DESIGN: Pragmatic non-drug intervention study with simple random assignment of participating mothers (Clinical Trials N°: NCT03624335).SETTING: A public, university-level hospital in Villarreal city, eastern Spain.PARTICIPANTS: Childbearing woman, gestation week between 35 and 42 weeks, with regular medical pregnancy checks, single pregnancy and vaginal delivery (N = 198, 80% of the women recruited).INTERVENTIONS: umbilical cord clamping within 60 seconds of the birth (Early cord clamping, ECC) versus umbilical cord clamping after pulsation had been ceased (Delayed cord clamping, DCC).MEASUREMENTS: Birth satisfaction was measured using the Mackey Childbirth Satisfaction Rating Scale (MCSRS). Additionally, sociodemographic data, degree of knowledge about the moment of clamping and type of breastfeeding data were recorded. The Mann-Whitney and Kruskal-Wallis tests for comparison of the mean of two, three, or more groups, respectively, and Chi-square and Spearman for comparison of two qualitative and quantitative variables, respectively, were used. To determine the weight of each factor of MCSRS, an exploratory factor analysis was carried out using the maximum likelihood method for factor extraction and the varimax method for factor rotation. The adequacy of the factor analysis was checked by mean of Kaiser-Meyer-Olkin test and Bartlett sphericity test. The level of significance was set at a p-value of < 0.05.FINDINGS: The average degree of satisfaction was 4.55/5 (SD: 0.37). No statistically significant difference was observed between mothers' satisfaction according to mother level of study or mother's place of birth, while it changed significantly with age (p = 0.0398). Within the obstetric variables, satisfaction was significantly associated with spontaneous amniorrhexis, the duration of the second stage of delivery, and the Apgar value of the newborn at the first minute of life, and was independent of the number of previous pregnancies and deliveries, use of intrapartum oxytocin, epidural analgesia, episiotomy, the weight of the child at birth and type of breastfeeding. Furthermore, there was no relationship between the time of clamping and satisfaction (p = 0.5178).KEY CONCLUSIONS: Maternal satisfaction with the birth experience varies with the age of the childbearing woman, and some intrapartum factors and the result is not influenced by the time of clamping of the umbilical cord. Therefore, this component of the physiological management of childbirth provides additional benefits for the health of the neonate, without negative consequences on the final perception of the maternal health care received.IMPLICATIONS FOR PRACTICE: If there are no reasons that justify an early umbilical cord clamping, delaying it brings benefits to the neonate, without negatively affecting the maternal assessment of the experience of childbirth.PMID:36126369 | DOI:10.1016/j.midw.2022.103487… -
The hematological impact of umbilical cord milking versus delayed cord clamping in premature neonates: a randomized controlled trial
BMC Pregnancy Childbirth. 2022 Sep 19;22(1):714. doi: 10.1186/s12884-022-05046-7.ABSTRACTBACKGROUND: The hematological impact of umbilical cord milking (UCM) was compared to that of delayed cord clamping (DCC) as a faster placental transfusion technique for preterm neonates (between 24 and 34 + 6 weeks gestation). A comparison of important neonatal morbidities was also made.METHODS: This was an open-label randomized trial conducted from June 8, 2017, to April 22, 2019. Two hundred patients with preterm deliveries (24 and 34 + 6 weeks gestation) were assigned to the DCC or UCM group at random at a ratio of 1:1. The study power was 80% for a difference in the hematocrit value of 3% and Hb value of one gram, and an alpha error of 0.05.RESULTS: The following variables were analyzed in the comparison of UCM vs. DCC: first draw hemoglobin: 17.0 ± 1.9 vs. 16.8 ± 1.8 gm/dl (95% CI -0.75-0.29, P 0.383); first draw hematocrit: 55.6 ± 6.4 vs. 55.2 ± 6.4% (95% CI -2.18-1.38, P 0.659); peak hematocrit: 56.9 ± 6.4 vs. 56.3 ± 6.7% (95% CI -2.41-1.26, P 0.537); the need for respiratory assistance (47% vs. 30%, P 0.020), inotropes (16% vs. 6%, P 0.040), and blood transfusion (26% vs. 12%, P 0.018); and the occurrence of intraventricular hemorrhage (9% vs. 5%, P 0.407), necrotizing enterocolitis (6% vs. 2%, P 0.279), sepsis (25% vs. 15%, P 0.111), and neonatal death (13% vs. 4%, P 0.40).CONCLUSION: UCM facilitated a rapid transfer of placental blood equivalent to that of DCC for premature neonates. However, it resulted in increased rates of interventions and morbidities, especially in extremely preterm neonates.TRIAL REGISTRATION: The clinical trial was registered on May 10, 2017, with registration number (NCT03147846).PMID:36123638 | PMC:PMC9484179 | DOI:10.1186/s12884-022-05046-7… -
Midwives' decision-making process when a non-vigorous neonate is born - a Swedish qualitative interview study
Midwifery. 2022 Nov;114:103455. doi: 10.1016/j.midw.2022.103455. Epub 2022 Aug 18.ABSTRACTOBJECTIVE: Midwives are often the first ones to make decisions when a neonate is unexpectedly born non-vigorous. This study aimed to understand how midwives reason and what they experience when deciding what to do when a non-vigorous neonate is born. In present practice, the decision to cut the umbilical cord early is strongly affected bythe decision that the neonate needs resuscitation. To better understand the decisions taken during the first minutes of the non-vigorous neonate’s life, this study focused on the midwives’ decision to cut the umbilical cord.DESIGN: A qualitative study with an inductive and descriptive design using the Critical Incident Technique was chosen to gain a more in-depth understanding of the factors influencing the midwife’s decision-making process concerning cutting the umbilical cord in a critical situation. Semi-structured interviews were conducted, and thematic analysis, as described by Braun and Clarke, was performed.SETTING AND PARTICIPANTS: Eligible study participants were midwives currently working in labour wards in Sweden.FINDINGS: In total, 14 midwives were interviewed between November 2019 and March 2020. The interviews rendered an understanding about midwives' decision-making on the timing of cord clamping in the non-vigorous neonates. An overarching theme was generated: "The balancing act of clamping the umbilical cord" which consisted of three themes, "Assessing the neonate in need of resuscitation", "Valuing own knowledge and experience" and "Influencing decision-making", and seven sub-themes. Many factors in addition to clinical reasoning influenced the midwives' decision-making processes. Feelings, intuition, and experience also had an effect to varying degrees.PMID:36103771 | DOI:10.1016/j.midw.2022.103455… -
Delayed cord clamping practice at birth: A narrative review of literature
Eur J Obstet Gynecol Reprod Biol. 2022 Oct;277:116-121. doi: 10.1016/j.ejogrb.2022.08.024. Epub 2022 Sep 5.ABSTRACTBACKGROUND: Anaemia in infants is a major public health concern particularly in low and middle-income countries. Delayed cord clamping (DCC) has been advocated as a strategy to decrease iron deficiency anaemia in infants because of the benefits that come with placental transfusion. Despite the documented benefits of delayed cord clamping in preventing anaemia the current practices of delayed cord clamping by midwives and obstetricians across countries and in different contexts is unclear. This narrative review assesses the literature on delayed cord clamping practices published from 2013 to February 2022, in order to examine current practice in birth units globally, and with a focus in low and middle-income countries (LMICs).METHOD: A search of four bibliographic databases Medline, Scopus (Elsevier), ProQuest, CINAHL and two network and search engines, Wiley and Google Scholar, was undertaken from 2013 to February 2022 using key terms related to delayed cord clamping and immediate cord clamping. A snowball method as well as backward and forward reference checking was also undertaken.RESULTS: The search strategy identified 10 studies on umbilical cord clamping practices by midwives and obstetricians. Only two studies were conducted in low and middle-income countries.CONCLUSION: Despite the potential benefits of DCC in reducing anaemia, particularly in low and middle-income countries where the burden of anaemia is a public health concern, there is a paucity of literature on current DCC practices by obstetricians and midwives. Research to establish current DCC practices in these countries is needed to address this gap in the literature.PMID:36084387 | DOI:10.1016/j.ejogrb.2022.08.024… -
Protocol for a Nested, Retrospective Study of the Australian Placental Transfusion Study Cohort
Cureus. 2022 Aug 4;14(8):e27693. doi: 10.7759/cureus.27693. eCollection 2022 Aug.ABSTRACTBackground Neonates, particularly if born preterm or with congenital anomalies, are among the pediatric patients most likely to need blood transfusion. However, they are also particularly vulnerable to adverse consequences of blood transfusion. Aiming to clamp the umbilical cord for at least a minute after birth is a simple safe procedure that is being increasingly adopted worldwide, although may be associated with increased rates of polycythemia and jaundice. It may also reduce the proportion of preterm babies who need a blood transfusion. The mechanisms for this are not fully understood. Potential mechanisms could include an increased volume of blood transfusion from the placenta to the baby after birth, and an overall reduction in the severity of illness in the first weeks after birth, which could lead to fewer blood tests and greater tolerance of anemia, or enhanced erythropoiesis. Objectives To investigate the mechanism behind the reduced need for blood transfusions after deferral of cord clamping. Methodology This protocol outlines the methods and data analysis plan for a study using nested retrospective data from a large randomized trial combined with additional data collected from patient medical and pathology records. The additional data items to be collected all relate to the receipt of transfusion and the factors that affect the risk for transfusion in preterm babies. The analysis will include all randomized babies from Australia and New Zealand for whom data are available. Causal mediation analysis is planned to estimate the effects of mediators on the relationship between the timing of cord clamping and the need for blood transfusion. The analysis is designed to discern whether initial severity of illness or the magnitude of placental transfusion mediates red blood cell transfusion dependence. Anticipated outcomes and dissemination We expect the study will identify potential strategies for reducing blood transfusions and associated negative outcomes in preterm infants. This will be relevant to researchers, clinicians, and parents. The results will be disseminated through publications, presentations, and inclusion in evidence-based guidelines.PMID:36081962 | PMC:PMC9440991 | DOI:10.7759/cureus.27693… -
The effect of delayed umbilical cord clamping on Newborn's oxygen saturation and sucking success in primiparous pregnant
J Obstet Gynaecol Res. 2022 Nov;48(11):2821-2829. doi: 10.1111/jog.15417. Epub 2022 Sep 5.ABSTRACTAIM: The objective of this study was to examine the effect of delayed umbilical cord clamping on the newborn's oxygen saturation and sucking success in primiparas.METHODS: The study was conducted based on the experimental model with a control group, between March 15-November 10, 2020. The sample of the study consisted of 101 primiparous pregnant (48 primiparous with delayed cord clamping within 1-3 min and 53 primiparous with early cord clamping within 1 min) (having no high-risk pregnancy, 38-42 weeks, vaginal birth) in Turkey. The data were collected using a personal information form, the LATCH breastfeeding tool and the pulse oximetry. Statistical analyses were conducted using percentage distribution, arithmetic means, chi-square testing, and independent samples t-testing.RESULTS: Oxygen saturation values of newborns with delayed umbilical cord clamping were higher than those of newborns with early cord clamping. The saturation was first minute 66.43 versus 74.37, fifth minute 81.90 versus 88.60, tenth minute 91.77 versus 94.50 (p < 0.05). When compared to the group with early cord clamping, oxygen saturation is higher in the first by 11.95%, in the fifth by 8.18%, and in the tenth minute by 2.97% in the group with delayed cord clamping. The LATCH breastfeeding scores were found to be higher in the group with delayed cord clamping compared to the group with early cord clamping.CONCLUSION: It was determined that delayed cord clamping positively affected oxygen saturation values and sucking success in neonatal babies. Delayed umbilical cord clamping is an important issue that needs to be addressed in its different dimensions.PMID:36065164 | DOI:10.1111/jog.15417… -
Neonatal breast-suckling skills in the context of lactation and peripartum hormonal changes and additional factors-a pilot study
Int Breastfeed J. 2022 Sep 1;17(1):66. doi: 10.1186/s13006-022-00508-2.ABSTRACTBACKGROUND: Childbirth and lactation are intricate processes, involving several hormones, the most important of which are prolactin (a protein hormone) and cortisol (one of the glucocorticoids). The early postpartum period is crucial for both mother and newborn and has an impact on the lactation and breastfeeding process.METHODS: The study included 78 patients who were admitted to the Gynecology-Obstetrics Clinical Hospital in Poznań for labor induction and/or in the active phase of the first labor stage. The levels of cortisol and prolactin in serum were assessed in these women during admission in labor, during the third labor stage, and on the second day postpartum. The levels of cortisol and prolactin in the umbilical cord serum were assessed immediately after cord clamping. The "Protocol for the assessment of breast-suckling skills" was used to assess the neonatal breast-suckling skills on the second day postpartum. Some additional parameters were evaluated in mothers via a telephone interview at three and six months postpartum. The study was conducted from January to August 2020, however the study was suspended during April-July 2020 due to the SARS-CoV-2 pandemic, which led to restrictions in the hospital limiting access to the hospital wards unless necessary.RESULTS: Early breastfeeding with skin-to-skin contact was associated with low levels of hormones, cortisol levels were lower in serum (p = 0.0108) and umbilical vein (p = 0.0273) in mothers who breastfed immediately after childbirth. At three months postpartum, 88% of the mothers who did not offer a pacifier to the child during the first few days of life breastfed the child naturally (p = 0.037), and at six months, 96% of those who did not offer a pacifier continued to breastfeed (p = 0.0008). Multiple, statistically significant correlations were observed between the variables assessed according to the "Protocol for the assessment of breast-suckling skills" and breastfeeding after three months.CONCLUSIONS: Breastfeeding immediately after childbirth, appropriate assessment of the breast-suckling skills of newborns, avoiding pacifiers and infant formula feeding, and offering support to new mothers in the early days after childbirth seem to be important factors for sustaining breastfeeding after three and six months of childbirth.PMID:36050767 | PMC:PMC9436720 | DOI:10.1186/s13006-022-00508-2… -
Early essential newborn care for cesarean section newborns in China: study protocol for a multi-centered randomized controlled trial
Trials. 2022 Aug 19;23(1):696. doi: 10.1186/s13063-022-06615-z.ABSTRACTBACKGROUND: Early essential newborn care (EENC) is a package of evidence-based and cost-effective interventions delivered around birth mainly including delayed cord clamping, immediate and sustained skin-to-skin contact, and early initiation of exclusive breastfeeding. EENC is proven effective in promoting breastfeeding and improving women's and newborns' health. However, there is little evidence on implementation of EENC on newborns born by cesarean section in China. Therefore, the objective of this study is to assess the effectiveness of EENC intervention on rates of exclusive breastfeeding and early initiation of breastfeeding for cesarean section newborns in China.METHODS: This is a multi-centered, randomized controlled trial conducted in 4 tertiary hospitals in China. A total of 720 eligible women who will receive cesarean section are being randomized into four groups: control group (n=180), intervention group 1 (skin-to-skin contact for 30 min, n=180), intervention group 2 (skin-to-skin contact for 60 min, n=180), and intervention group 3 (skin-to-skin contact for 90 min, n=180). The control group will receive routine care, whereas the intervention groups will receive EENC with different duration of skin-to-skin contact. Demographic characteristics, clinical information, and breastfeeding outcomes will be collected. The primary outcome is rates of exclusive breastfeeding and early initiation of breastfeeding, and the secondary outcomes include maternal and neonatal morbidity and admissions.DISCUSSION: This study will provide evidence of the impact of EENC on improvement of breastfeeding outcomes and maternal and neonatal health for cesarean section newborns in China, and evidence-based recommendation to inform optimal duration of skin-to-skin contact for cesarean deliveries. The results of this study have potential to inform national-level guidelines and policy-making for optimizing EENC implementation for cesarean section newborns.TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2100048997. Retrospectively registered on 19 July 2021.PMID:35986372 | PMC:PMC9389737 | DOI:10.1186/s13063-022-06615-z… -
Umbilical cord milking in nonvigorous infants: a cluster-randomized crossover trial
Am J Obstet Gynecol. 2023 Feb;228(2):217.e1-217.e14. doi: 10.1016/j.ajog.2022.08.015. Epub 2022 Aug 13.ABSTRACTBACKGROUND: Delayed cord clamping and umbilical cord milking provide placental transfusion to vigorous newborns. Delayed cord clamping in nonvigorous newborns may not be provided owing to a perceived need for immediate resuscitation. Umbilical cord milking is an alternative, as it can be performed more quickly than delayed cord clamping and may confer similar benefits.OBJECTIVE: We hypothesized that umbilical cord milking would reduce admission to the neonatal intensive care unit compared with early cord clamping in nonvigorous newborns born between 35 and 42 weeks' gestation.STUDY DESIGN: This was a pragmatic cluster-randomized crossover trial of infants born at 35 to 42 weeks' gestation in 10 medical centers in 3 countries between January 2019 and May 2021. The centers were randomized to umbilical cord milking or early cord clamping for approximately 1 year and then crossed over for an additional year or until the required number of consented subjects was reached. Waiver of consent as obtained in all centers to implement the intervention. Infants were eligible if nonvigorous at birth (poor tone, pale color, or lack of breathing in the first 15 seconds after birth) and were assigned to umbilical cord milking or early cord clamping according to their birth hospital randomization assignment. The baseline characteristics and outcomes were collected following deferred informed consent. The primary outcome was admission to the neonatal intensive care unit for predefined criteria. The main safety outcome was hypoxic-ischemic encephalopathy. Data were analyzed by the intention-to-treat concept.RESULTS: Among 16,234 screened newborns, 1780 were eligible (905 umbilical cord milking, 875 early cord clamping), and 1730 had primary outcome data for analysis (97% of eligible; 872 umbilical cord milking, 858 early cord clamping) either via informed consent (606 umbilical cord milking, 601 early cord clamping) or waiver of informed consent (266 umbilical cord milking, 257 early cord clamping). The difference in the frequency of neonatal intensive care unit admission using predefined criteria between the umbilical cord milking (23%) and early cord clamping (28%) groups did not reach statistical significance (modeled odds ratio, 0.69; 95% confidence interval, 0.41-1.14). Umbilical cord milking was associated with predefined secondary outcomes, including higher hemoglobin (modeled mean difference between umbilical cord milking and early cord clamping groups 0.68 g/dL, 95% confidence interval, 0.31-1.05), lower odds of abnormal 1-minute Apgar scores (Apgar ≤3, 30% vs 34%, crude odds ratio, 0.72; 95% confidence interval, 0.56-0.92); cardiorespiratory support at delivery (61% vs 71%, modeled odds ratio, 0.57; 95% confidence interval, 0.33-0.99), and therapeutic hypothermia (3% vs 4%, crude odds ratio, 0.57; 95% confidence interval, 0.33-0.99). Moderate-to-severe hypoxic-ischemic encephalopathy was significantly less common with umbilical cord milking (1% vs 3%, crude odds ratio, 0.48; 95% confidence interval, 0.24-0.96). No significant differences were observed for normal saline bolus, phototherapy, abnormal 5-minute Apgar scores (Apgar ≤6, 15.7% vs 18.8%, crude odds ratio, 0.81; 95% confidence interval, 0.62-1.06), or a serious adverse event composite of death before discharge.CONCLUSION: Among nonvigorous infants born at 35 to 42 weeks' gestation, umbilical cord milking did not reduce neonatal intensive care unit admission for predefined criteria. However, infants in the umbilical cord milking arm had higher hemoglobin, received less delivery room cardiorespiratory support, had a lower incidence of moderate-to-severe hypoxic-ischemic encephalopathy, and received less therapeutic hypothermia. These data may provide the first randomized controlled trial evidence that umbilical cord milking in nonvigorous infants is feasible, safe and, superior to early cord clamping.PMID:35970202 | PMC:PMC9877105 | DOI:10.1016/j.ajog.2022.08.015… -
Hemoglobin differences in twins are related to the time of cord clamping, not intertwin transfusion - a prospective cohort study
BMC Pregnancy Childbirth. 2022 Aug 5;22(1):619. doi: 10.1186/s12884-022-04942-2.ABSTRACTBACKGROUND: Delayed cord clamping increases placental transfusion. In vaginal deliveries higher hemoglobin concentrations are found in the second-born twin. We hypothesized it is unrelated to intertwin transfusion but to the time of cord clamping.METHODS: It was a prospective cohort study of 202 women delivering twins > 32 weeks of gestation. Monoamniotic pregnancy, antenatal intertwin transfusions, fetal demise or major abnormalities were excluded from the study. The time of cord clamping depended on the obstetrician's decision. Hemoglobin, hematocrit, and reticulocyte count were measured at birth and during the second day of life.RESULTS: At birth, hemoglobin and hematocrit levels were significantly higher in the first-born twins delivered with delayed than with early cord clamping. Higher hemoglobin and hematocrit levels were observed during the second day of life in all twins delivered with delayed cord clamping. The lowest levels were observed in twins delivered with early cord clamping. Infants delivered with delayed cord clamping were at a lower risk of respiratory disorders and NICU hospitalization.CONCLUSION: The observed differences in Hgb concentrations between the infants in a twin pregnancy are related to cord clamping time.PMID:35931974 | PMC:PMC9354348 | DOI:10.1186/s12884-022-04942-2…
ALtimetric score
Measure of how our paper in JAMA Pediatrics 2017 on anemia is spread by media
Measure of how our paper in JAMA Pediatrics 2015 on neurodevelopment is spread by media