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
Introduction:
The timing of umbilical cord clamping has been a topic of considerable debate in the medical community, particularly concerning preterm infants. A recent study aimed to shed light on this issue and understand how early or delayed cord clamping affects the health outcomes of these vulnerable newborns.
Methodology:
Researchers conducted a study involving 96 pregnant women eagerly awaiting the arrival of their babies. The participants were randomly assigned to one of two groups - early cord clamping (ECC) or delayed cord clamping (DCC). The researchers closely monitored hematological and cardiac changes in the preterm infants, focusing on gestational periods between 24 and 34 weeks, and evaluated the stability of key blood parameters within the first week after birth.
Key Findings:
The study revealed interesting insights into the impact of cord clamping timing. Infants in the DCC group showed higher levels of hemoglobin and hematocrit upon admission, indicating improved oxygen-carrying capacity compared to those in the ECC group. Similarly, by the seventh day of life, the DCC group maintained higher hemoglobin and hematocrit levels, suggesting continued hematological advantages.
However, it should be noted that the DCC group also had a slightly higher incidence of phototherapy usage to treat jaundice compared to the ECC group.
Cardiac parameters and maternal blood tests did not differ significantly between the two groups.
Conclusion:
The study suggests that delayed cord clamping may have certain benefits for preterm infants in terms of hematological outcomes, as evidenced by higher hemoglobin and hematocrit levels. However, it is important to consider that other factors, such as a slightly increased need for phototherapy, should be taken into account.
This study adds valuable insights to the ongoing discussion regarding the optimal timing for cord clamping in preterm births. Further research is warranted to better understand the long-term implications and overall health outcomes associated with cord clamping practices.
Reference: García, C., Prieto, M.T., Escudero, F., Bosh-Giménez, V., Quesada, L., Lewanczyk, M., Pertegal, M., Delgado, J.L., Blanco-Carnero, J.E., De Paco Matallana, C., 2023. The impact of early versus delayed cord clamping on hematological and cardiovascular changes in preterm newborns between 24 and 34 weeks’ gestation: a randomized clinical trial. Archives of Gynecology and Obstetrics.. https://doi.org/10.1007/s00404-023-07119-0
The timing of umbilical cord clamping has been a topic of considerable debate in the medical community, particularly concerning preterm infants. A recent study aimed to shed light on this issue and understand how early or delayed cord clamping affects the health outcomes of these vulnerable newborns.
Methodology:
Researchers conducted a study involving 96 pregnant women eagerly awaiting the arrival of their babies. The participants were randomly assigned to one of two groups - early cord clamping (ECC) or delayed cord clamping (DCC). The researchers closely monitored hematological and cardiac changes in the preterm infants, focusing on gestational periods between 24 and 34 weeks, and evaluated the stability of key blood parameters within the first week after birth.
Key Findings:
The study revealed interesting insights into the impact of cord clamping timing. Infants in the DCC group showed higher levels of hemoglobin and hematocrit upon admission, indicating improved oxygen-carrying capacity compared to those in the ECC group. Similarly, by the seventh day of life, the DCC group maintained higher hemoglobin and hematocrit levels, suggesting continued hematological advantages.
However, it should be noted that the DCC group also had a slightly higher incidence of phototherapy usage to treat jaundice compared to the ECC group.
Cardiac parameters and maternal blood tests did not differ significantly between the two groups.
Conclusion:
The study suggests that delayed cord clamping may have certain benefits for preterm infants in terms of hematological outcomes, as evidenced by higher hemoglobin and hematocrit levels. However, it is important to consider that other factors, such as a slightly increased need for phototherapy, should be taken into account.
This study adds valuable insights to the ongoing discussion regarding the optimal timing for cord clamping in preterm births. Further research is warranted to better understand the long-term implications and overall health outcomes associated with cord clamping practices.
Reference: García, C., Prieto, M.T., Escudero, F., Bosh-Giménez, V., Quesada, L., Lewanczyk, M., Pertegal, M., Delgado, J.L., Blanco-Carnero, J.E., De Paco Matallana, C., 2023. The impact of early versus delayed cord clamping on hematological and cardiovascular changes in preterm newborns between 24 and 34 weeks’ gestation: a randomized clinical trial. Archives of Gynecology and Obstetrics.. https://doi.org/10.1007/s00404-023-07119-0
Understanding the Dynamics of Umbilical Cord Circulation and Placental Transfusion: Debunking Common
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Comparing the safety and effectiveness of various umbilical cord milking techniques and delayed cord clamping in full-term and preterm infants: A systematic review and meta-analysis
Afr J Reprod Health. 2023 Nov 30;27(11):99-125. doi: 10.29063/ajrh2023/v27i11.11.ABSTRACTWe compare the hematocrit, hemoglobin, need for transfusion, recurrent phototherapy, serum bilirubin level, and serum ferritin at different time frames for the umbilical cord milking (UCM) and delayed cord clamping (DCC) in both full-term and preterm infants. A comprehensive search through various databases aimed to compare UCM and DCC studies until May 2nd, 2023. Cochrane and NIH tools assessed RCTs and cohorts, respectively. Meta-analysis employed Review Manager 5.4 software, calculating MD and RR with 95% CIs for continuous and dichotomous data. We included 20 studies with a total of 5189 infants. Regarding preterm infants, hematocrit level showed no significant difference between intact Umbilical Cord Milking (iUCM) compared to DCC (MD = -0.24, 95% CI [-1.11, 0.64]). Moreover, Neonatal death incidence was significantly higher with the UCM technique in comparison to DCC (RR = 1.28, 95% CI [1.01 to 1.62]). Regarding term and late preterm infants, Hematocrit level showed no significant difference between the iUCM or cUCM techniques compared to DCC (MD = 0.21, 95% CI [-1.28 to 1.69]), (MD = 0.96, 95% CI [-1.02 to 2.95]), respectively. UCM led to a higher risk of neonatal death in preterm infants compared to DCC. However, the incidence of polycythemia was lower in the UCM group. Additionally, UCM was associated with higher rates of severe IVH events. Based on these findings, DCC may be preferred due to its lower incidence of severe IVH and neonatal death.PMID:38053339 | DOI:10.29063/ajrh2023/v27i11.11… -
Effect of delayed cord clamping on cerebral hemodynamics in preterm infants
Heliyon. 2023 Nov 19;9(11):e22525. doi: 10.1016/j.heliyon.2023.e22525. eCollection 2023 Nov.ABSTRACTBACKGROUND: Unstable cerebral hemodynamics is an important cause of intracranial hemorrhage in premature infants. The increased blood flow of delayed cord clamping (DCC) compared to immediate cord clamping (ICC) is equivalent to 1/3-1/4 of newborn blood volume. Our objective was to assess whether the increased blood flow causes fluctuations in cerebral blood flow and how.METHODS: This experiment was a prospective, observational study. Neonatologists selected preterm infants eligible for inclusion and exclusion, and divided them into DCC group and ICC group according to the way of umbilical cord ligation performed by obstetrics department, and matched them 1:1 according to gestational age. The peak systolic velocity （PSV) ，end diastolic velocity (EDV)，and resistance index (RI) of middle cerebral artery was measured by Mindray M9 color ultrasonic diagnostic instrument within 1 h, 24±1 h, 48±1 h, 72±1 h, respectively.RESULTS: There was no significant difference in PSV, EDV and RI in middle cerebral artery between DCC group and ICC group (P > 0.05). There were no significant differences between groups and time (P > 0.05). The hemoglobin and hematocrit in DCC group were higher than those in ICC group within 2 h after birth (P < 0.05). (P > 0.05).CONCLUSION: DCC can increase hemoglobin and hematocrit in preterm infants, but does not cause cerebral blood flow fluctuation within a certain range. DCC is a safe method of placental transfusion.PMID:38034701 | PMC:PMC10687287 | DOI:10.1016/j.heliyon.2023.e22525… -
Effectiveness and safety of umbilical cord milking in premature infants: A randomized controlled trial
Medicine (Baltimore). 2023 Nov 24;102(47):e36121. doi: 10.1097/MD.0000000000036121.ABSTRACTINTRODUCTION: Both UCM and DCC are used to treat preterm infants, but there is no uniform standard for the length of UCM. The aim of this work was to explore the effectiveness and safety of different umbilical cord milking (UCM) lengths versus delayed cord clamping (DCC).METHODS: We enrolled premature infants from the Affiliated Hospital of Zunyi Medical University between September 2019 and October 2020 with random allocation (1:1:1:1) to the UCM 10 cm, UCM 20 cm, UCM 30 cm, and DCC groups. The primary outcome was hemoglobin at birth.RESULTS: Ultimately, 143 participants completed the trial (UCM 10 cm, n = 35; UCM 20 cm, n = 35; UCM 30 cm, n = 38; DCC, n = 35). The hemoglobin levels were significantly lower at birth in the UCM 10 cm group than in the UCM 20 and 30 cm and DCC groups (182.29 ± 22.15 vs 202.83 ± 21.46, 208.82 ± 20.72, and 198.46 ± 24.92, P = .001, .001, and .003, respectively). The systolic blood pressure and diastolic pressures in the UCM 30 cm group were higher than those in the UCM 10 and 20 cm and DCC groups at birth, postnatal day 3 and postnatal day 7 (P < .05). The occurrence rates of anemia were significantly higher in the UCM 10 cm group than in the UCM 20 and 30 cm and DCC groups (42.9% vs 14.3%, 10.5%, and 14.3%, all P < .0083). There were no significant differences in heart rate or complications among the 4 groups.CONCLUSIONS: A UCM of 20 or 30 cm is a safe, effective operation for preterm infants and could improve blood pressure and hemoglobin levels and reduce anemia.PMID:38013298 | PMC:PMC10681450 | DOI:10.1097/MD.0000000000036121… -
Alternatives to neonatal intubation
Semin Fetal Neonatal Med. 2023 Nov 18:101488. doi: 10.1016/j.siny.2023.101488. Online ahead of print.ABSTRACTOpportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in intubation, alternative strategies are critical. Most preterm infants breathe spontaneously, and require stabilisation rather than resuscitation at birth. Use of tactile stimulation, deferred cord clamping, and avoidance of hypoxia can help optimise breathing for these infants. Nasal devices appear a promising alternative to the face mask for early provision of respiratory support. In term and near-term infants, supraglottic airways may be the most effective initial approach to resuscitation. Use of supraglottic airways during resuscitation can be taught to a range of providers, and may reduce need for intubation. While face mask ventilation is an important skill, it is challenging to perform effectively. Identification of the best approach to training the use of these devices during neonatal resuscitation remains an important priority.PMID:38000926 | DOI:10.1016/j.siny.2023.101488… -
Thermoregulation-Focused Implementation of Delayed Cord Clamping among <34 Weeks' Gestational Age Neonates
Am J Perinatol. 2023 Nov 21. doi: 10.1055/s-0043-1776916. Online ahead of print.ABSTRACTOBJECTIVE: Delayed cord clamping (DCC) is recommended for all neonates; however, adapting such practice can be slow or unsustainable, especially among preterm neonates. During DCC neonates are exposed to a cool environment, raising concerns for neonatal hypothermia. Moderate hypothermia may induce morbidities that counteract the potential benefits of DCC. A quality improvement project on a thermoregulation-focused DCC protocol was implemented for neonates less than 34 weeks' gestational age (GA). The aim was to increase the compliance rate of DCC while maintaining normothermia.STUDY DESIGN: The DCC protocol was implemented on October 1, 2020 in a large Level III neonatal intensive care unit. The thermoregulation measures included increasing delivery room temperature and using heat conservation supplies (sterile polyethylene suit, warm towels, and thermal pads). Baseline characteristics, the compliance rate of DCC, and admission temperatures were compared 4 months' preimplementation and 26 months' postimplementation RESULTS: The rate of DCC increased from 20% (11/54) in preimplementation to 57% (240/425) in postimplementation (p < 0.001). The balancing measure of admission normothermia remained unchanged. In a postimplementation subgroup analysis, the DCC cohort had less tendency to experience admission moderate hypothermia (<36°C; 9.2 vs. 14.1%, p = 0.11). The DCC cohort had more favorable secondary outcomes including higher admission hematocrit, less blood transfusions, less intraventricular hemorrhage, and lower mortality. Improving the process measure of accurate documentation could help to identify implementation barriers.CONCLUSION: Performing DCC in preterm neonates was feasible and beneficial without increasing admission hypothermia.KEY POINTS: · Thermoregulation-focused DCC protocol was implemented to increase DCC while maintaining normothermia.. · DCC rate increased from 20 to 57% while admission normothermia rate remained the same.. · DCC practice on preterm neonates is safe and feasible while maintaining normothermia..PMID:37989208 | DOI:10.1055/s-0043-1776916… -
2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Circulation. 2023 Nov 16. doi: 10.1161/CIR.0000000000001181. Online ahead of print.ABSTRACTThis 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.PMID:37970724 | DOI:10.1161/CIR.0000000000001181… -
Umbilical Cord Milking Versus Delayed Cord Clamping in Infants 28 to 32 Weeks: A Randomized Trial
Pediatrics. 2023 Dec 1;152(6):e2023063113. doi: 10.1542/peds.2023-063113.ABSTRACTOBJECTIVES: To determine whether rate of severe intraventricular hemorrhage (IVH) or death among preterm infants receiving placental transfusion with UCM is noninferior to delayed cord clamping (DCC).METHODS: Noninferiority randomized controlled trial comparing UCM versus DCC in preterm infants born 28 to 32 weeks recruited between June 2017 through September 2022 from 19 university and private medical centers in 4 countries. The primary outcome was Grade III/IV IVH or death evaluated at a 1% noninferiority margin.RESULTS: Among 1019 infants (UCM n = 511 and DCC n = 508), all completed the trial from birth through initial hospitalization (mean gestational age 31 weeks, 44% female). For the primary outcome, 7 of 511 (1.4%) infants randomized to UCM developed severe IVH or died compared to 7 of 508 (1.4%) infants randomized to DCC (rate difference 0.01%, 95% confidence interval: (-1.4% to 1.4%), P = .99).CONCLUSIONS: In this randomized controlled trial of UCM versus DCC among preterm infants born between 28 and 32 weeks' gestation, there was no difference in the rates of severe IVH or death. UCM may be a safe alternative to DCC in premature infants born at 28 to 32 weeks who require resuscitation.PMID:37941523 | DOI:10.1542/peds.2023-063113… -
Placental Perfusion Rather Than Placental Transfusion-Key to Umbilical Cord Management at Birth?
JAMA Netw Open. 2023 Nov 1;6(11):e2340490. doi: 10.1001/jamanetworkopen.2023.40490.NO ABSTRACTPMID:37921775 | DOI:10.1001/jamanetworkopen.2023.40490… -
Extrauterine Placental Perfusion and Oxygenation in Infants With Very Low Birth Weight: A Randomized Clinical Trial
JAMA Netw Open. 2023 Nov 1;6(11):e2340597. doi: 10.1001/jamanetworkopen.2023.40597.ABSTRACTIMPORTANCE: An extrauterine placental perfusion (EPP) approach for physiological-based cord clamping (PBCC) may support infants with very low birth weight (VLBW) during transition without delaying measures of support.OBJECTIVE: To test whether EPP in resuscitation of infants with VLBW results in higher hematocrit levels, better oxygenation, or improved infant outcomes compared with delayed cord clamping (DCC).DESIGN, SETTING, AND PARTICIPANTS: This nonblinded, single-center randomized clinical trial was conducted at a tertiary care neonatal intensive care unit. Infants with a gestational age greater than 23 weeks and birth weight less than 1500 g born by cesarean delivery between May 2019 and June 2021 were included. Data were analyzed from October through December 2021.INTERVENTION: Prior to cesarean delivery, participants were allocated to receive EPP or DCC. In the EPP group, infant and placenta, connected by an intact umbilical cord, were detached from the uterus and transferred to the resuscitation unit. Respiratory support was initiated while holding the placenta over the infant. The umbilical cord was clamped when infants showed regular spontaneous breathing, stable heart rates greater than 100 beats/min, and adequate oxygen saturations. In the DCC group, cords were clamped 30 to 60 seconds after birth before infants were transferred to the resuscitation unit, where respiratory support was started.MAIN OUTCOMES AND MEASURE: The primary outcome was the mean hematocrit level in the first 24 hours after birth. Secondary prespecified outcome parameters comprised oxygenation during transition and short-term neonatal outcome.RESULTS: Among 60 infants randomized and included, 1 infant was excluded after randomization; there were 29 infants in the EPP group (mean [SD] gestational age, 27 weeks 6 days [15.0 days]; 14 females [48.3%]) and 30 infants in the DCC group (mean [SD] gestational age, 28 weeks 1 day [17.1 days]; 17 females [56.7%]). The mean (SD) birth weight was 982.8 (276.6) g and 970.2 (323.0) g in the EPP and DCC group, respectively. Intention-to-treat analysis revealed no significant difference in mean hematocrit level (mean difference [MD], 2.1 percentage points; [95% CI, -2.2 to 6.4 percentage points]). During transition, infants in the EPP group had significantly higher peripheral oxygen saturation as measured by pulse oximetry (adjusted MD at 5 minutes, 15.3 percentage points [95% CI, 2.0 to 28.6 percentage points]) and regional cerebral oxygen saturation (adjusted MD at 5 minutes, 11.3 percentage points [95% CI, 2.0 to 20.6 percentage points]). Neonatal outcome parameters were similar in the 2 groups.CONCLUSIONS AND RELEVANCE: This study found that EPP resulted in similar hematocrit levels as DCC, with improved cerebral and peripheral oxygenation during transition. These findings suggest that EPP may be an alternative procedure for PBCC in infants with VLBW.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03916159.PMID:37921769 | PMC:PMC10625045 | DOI:10.1001/jamanetworkopen.2023.40597… -
Iron Deficiency Prior to Discharge in Very Low Birth Weight Infants: Screening with Reticulocyte Hemoglobin Content
Am J Perinatol. 2023 Nov 28. doi: 10.1055/a-2200-3285. Online ahead of print.ABSTRACTOBJECTIVE: This study aimed to assess the iron status prior to discharge in very low birth weight (VLBW) infants utilizing reticulocyte hemoglobin content (CHr) and evaluate the impact of delayed cord clamping (DCC) on iron status.STUDY DESIGN: This is a retrospective analysis of VLBW infants from two tertiary level of care Neonatal Intensive Care Units. The primary outcome was the proportion of VLBW infants with low CHr (<29 pg) prior to discharge. Hematologic parameters were also compared between infants who received or did not receive DCC. Infants with a positive newborn screen for hemoglobin Bart's were excluded.RESULTS: Among the 315 infants included, 99 infants (31.4%) had low CHr prior to discharge. The median (interquartile range) CHr prior to discharge was 30.8 pg (28.4-39 pg). DCC was performed in 46.7% of infants. Hemoglobin at birth, discharge, and CHr prior to discharge were higher and the need for blood transfusion and the number of infants with low CHr prior to discharge were lower in the DCC group.CONCLUSION: Approximately 31.4% of VLBW infants had low CHr near the time of discharge suggesting they were iron deficient. DCC improved hematological parameters prior to discharge in VLBW infants. CHr content can be used to guide iron supplementation in VLBW infants to potentially improve their iron status and long-term neurocognitive outcomes.KEY POINTS: · DCC was associated with an improved hemoglobin and iron status at discharge in VLBW infants.. · CHr is an early and reliable marker for iron deficiency.. · Approximately one in three VLBW infants can be iron deficient at the time of discharge..PMID:37890510 | DOI:10.1055/a-2200-3285… -
Respiratory patterns in spontaneously breathing near-term lambs delivered by caesarean section under spinal anaesthesia
Front Pediatr. 2023 Oct 9;11:1273136. doi: 10.3389/fped.2023.1273136. eCollection 2023.ABSTRACTINTRODUCTION: The transition to newborn life has typically been studied in intubated and mechanically ventilated newborn lambs delivered via caesarean section (CS) under general anaesthesia. As a result, little is known of the spontaneous breathing patterns in lambs at birth, particularly those at risk of developing respiratory distress (RD). We have developed a method for delivering spontaneously breathing near-term lambs to characterise their breathing patterns in the immediate newborn period.METHODS: At 137-8 days gestation (2-3 days prior to delivery; term ∼147 days), fetal lambs (n = 7) were partially exteriorised for instrumentation (insertion of catheters and flow probes) before they were returned to the uterus. At 140 days, lambs were delivered via CS under light maternal sedation and spinal anaesthesia. Lambs were physically stimulated and when continuous breathing was established, the umbilical cord was clamped. Breathing patterns were assessed by measuring intrapleural and upper-tracheal pressures during the first four hours after birth.RESULTS: Newborn lambs display significant heterogeneity in respiratory patterns in the immediate newborn period that change with time after birth. Seven distinct breathing patterns were identified including: (i) quiet (tidal) breathing, (ii) breathing during active periods, (iii) breathing during oral feeding, (iv) tachypnoea, (v) expiratory braking manoeuvres, (vi) expiratory pauses or holding, and (vii) step changes in ventilation.CONCLUSIONS: We have described normal respiratory behaviour in newborn lambs, in order to identify respiratory behaviours that are indicative of RD in term newborn infants.PMID:37876521 | PMC:PMC10590898 | DOI:10.3389/fped.2023.1273136… -
'It must be right, I saw it on TV!': An observational study of third stage birth practices in popular television programmes
JRSM Open. 2023 Oct 19;14(10):20542704231205385. doi: 10.1177/20542704231205385. eCollection 2023 Oct.ABSTRACTOBJECTIVES: To examine modern media depictions of the third stage of birth in a selection of UK television representations.DESIGN: Observational study of a sample of televised fictional and real births, audited against current National Institute of Health and Social Care Excellence (NICE) guidance.SETTING: UK television channels BBC (Call The Midwife and This Is Going To Hurt) and Channel 4 (One Born Every Minute).PARTICIPANTS: 87 births from 48 episodes, sampled from the three shows.MAIN OUTCOME MEASURES: The primary outcome was the number of births where the cord was clamped at more than 1 min after birth. Secondary outcomes included place and type of birth, measures of dignity and paternal involvement.RESULTS: Overall, the timing of cord clamping was clearly shown in 25/87 (29%) of births, of which only 4/25 (16%) occurred at more than 1 min in screen time. The place of birth and caesarean section (CS) rate changed according to the series perspective and era; graphic explicit images were shown, but these related to CS detail.CONCLUSIONS: UK television shows have accurately depicted changes in place, culture and type of birth over the last century. They provide the public with a view of new rituals but an inaccurate picture of good quality care. Early cord clamping was shown in most births, even those set after 2014. No programme informed viewers about the safety aspects. When showing outdated practices, broadcasters have a public health duty to inform viewers that this is no longer recommended.PMID:37869445 | PMC:PMC10588410 | DOI:10.1177/20542704231205385… -
Umbilical cord clamping in the early phases of the COVID-19 era - a systematic review and meta-analysis of reported practice and recommendations in guidelines
Int J Infect Dis. 2023 Dec;137:63-70. doi: 10.1016/j.ijid.2023.10.010. Epub 2023 Oct 13.ABSTRACTOBJECTIVES: At the beginning of the COVID-19 pandemic, delayed umbilical cord clamping (CC) at birth may have been commonly discouraged despite a lack of convincing evidence of mother-to-neonate SARS-CoV-2 transmission. We aimed to systematically review guidelines, and reports of practice and to analyze associations between timing of CC and mother-to-neonate SARS-CoV-2 transmission during the early phases of the pandemic.METHODS: Major databases were searched from December 1, 2019, to July 20, 2021.INCLUSION: studies and guidelines describing CC practice in women with SARS-CoV-2 infection during pregnancy until 2 postnatal days, giving birth to live-born neonates.EXCLUSION: no extractable data. Two reviewers independently screened studies for eligibility and assessed study quality. Pooled prevalence rates were calculated.RESULTS: Forty-eight studies (1476 neonates) and 40 guidelines were included. Delayed CC was recommended in 70.0% of the guidelines. Nevertheless, delayed CC was reported less often than early CC: 262/1476 (17.8%) vs 511/1476 (34.6%). Neonatal SARS-CoV-2 positivity rates were similar following delayed (1.2%) and early CC (1.3%). Most SARS-CoV-2 transmissions (93.3%) occurred in utero.CONCLUSION: Delayed CC did not seem to increase mother-to-neonate SARS-CoV-2 transmission. Due to its benefits, it should be encouraged even in births where the mother has a SARS-CoV-2 infection.SYSTEMATIC REVIEW REGISTRATION: Prospero CRD42020199500.PMID:37839504 | DOI:10.1016/j.ijid.2023.10.010… -
Effect of delayed cord clamping on maternal and neonatal outcome in twin pregnancies: a retrospective cohort study
Sci Rep. 2023 Oct 13;13(1):17339. doi: 10.1038/s41598-023-44575-9.ABSTRACTThe objective of this study was to compare the maternal and neonatal outcomes following delayed cord clamping (DCC) versus immediate cord clamping (ICC) in twin pregnancies. This was a retrospective cohort study of 705 twin pregnancies who delivered at ≥ 24 weeks of gestation. Maternal and neonatal hemoglobin levels, blood transfusion, and neonatal outcomes were compared between DCC (n = 225) and ICC (n = 480) groups. Mean maternal predelivery and postpartum hemoglobin levels and the rate of postpartum hemoglobin drop ≥ 20% or maternal blood transfusion were comparable between the two groups. The DCC group had a significantly higher mean neonatal hemoglobin level (DCC vs. ICC: 17.4 ± 3.5 vs. 16.6 ± 2.7 g/dl, P = 0.010) but significantly lower rates of neonatal blood transfusion (DCC vs. ICC: 3.3% vs. 8.8%, P < 0.001) and respiratory distress syndrome (DCC vs. ICC: 6.7% vs. 15.2%, P < 0.001) than the ICC group. In conclusion, DCC compared with ICC in twin pregnancy was not associated with an increase of maternal postpartum bleeding complications, but it was associated with higher neonatal hemoglobin level and lower risks of neonatal blood transfusion and respiratory distress syndrome.PMID:37833351 | PMC:PMC10575853 | DOI:10.1038/s41598-023-44575-9… -
Outcomes of Neonatal Resuscitation With and Without an Intact Umbilical Cord: A Meta-Analysis
Cureus. 2023 Aug 31;15(8):e44449. doi: 10.7759/cureus.44449. eCollection 2023 Aug.ABSTRACTAround the world, very few babies require a more intensive resuscitative effort for stabilization. The optimal timing of an intact umbilical cord to help with resuscitation is controversial. Our objective in the review is to compare the outcomes of neonatal resuscitation with and without an intact umbilical cord. A search of six electronic database libraries was explored for data released between 2014 and 2023. A manual search of secondary references in relevant studies was also performed. Studies focused only on randomized controlled trials comparing the outcomes of neonatal resuscitation with and without an intact umbilical cord at any gestational age. Two reviewers retrieved data for relevant outcomes and independently evaluated trial quality and eligibility. Mortality rate and APGAR (appearance, pulse, grimace, activity, and respiration) scores were noted as common in the two studies. Four randomized control trials were assessed for the impact of delayed cord clamping on neonates. One study focused on neurodevelopmental outcomes and noted significant improvement. Other studies noted delayed clamping as beneficial for improving oxygen saturation, APGAR score, and mortality rate. The meta-analysis included three controlled trials with a total of 528 babies and tested the effects of clamping the umbilical cord either late (n = 264) or early (n = 264). The heterogeneity of mortality and APGAR score at 5 minutes were not significant, which may be because only two studies of each case were available to compare. We concluded that very few studies are available to identify a significant impact of delayed cord clamping in neonates. However, delayed clamping for up to 5 minutes is noted as beneficial to the newborn.PMID:37791162 | PMC:PMC10544125 | DOI:10.7759/cureus.44449… -
Stabilisation and resuscitation with intact cord circulation is feasible using a wide variety of approaches; a scoping review
Acta Paediatr. 2023 Dec;112(12):2468-2477. doi: 10.1111/apa.16985. Epub 2023 Sep 28.ABSTRACTAIM: This scoping review identified studies on approaches to intact cord resuscitation and/or stabilisation (ICR/S) for neonates delivered by Caesarean section (C-section).METHODS: A systematic literature search was carried out using the PubMed, Web of Science, Scopus, Cochrane and CINAHL databases to identify papers published in English from inception to 14 November 2022.RESULTS: We assessed 2613 studies and included 18 from 10 countries, covering 1-125 C-sections: the United States, the United Kingdom, Australia, India, Italy, China, France, The Netherlands, New Zealand and Taiwan. The papers were published from 2014 to 2023, and the majority were randomised controlled trials and observational studies. Different platforms, equipment and staff positions in relation to the operating table were described. Options for resuscitation and stabilisation included different bedding and trolley approaches, and maintaining aseptic conditions was mainly addressed by the neonatal team scrubbing in. Hypothermia was prevented by using warm surfaces, polythene bags and radiant heaters. Equipment was kept easily accessible by mounting it on a trolley or a separate mobile pole.CONCLUSION: We could not reach definitive conclusions on the optimal method for performing ICR/S during a C-section, due to study variations. However, a number of equipment and management options appeared to be feasible approaches.PMID:37767916 | DOI:10.1111/apa.16985… -
Significance of Neonatal Heart Rate in the Delivery Room-A Review
Children (Basel). 2023 Sep 14;10(9):1551. doi: 10.3390/children10091551.ABSTRACTBACKGROUND: Heart rate (HR) is considered the main vital sign in newborns during perinatal transition, with a threshold of 100 beats per minute (bpm), below which, intervention is recommended. However, recent changes in delivery room management, including delayed cord clamping, are likely to have influenced normal HR transition.OBJECTIVE: To summarize the updated knowledge about the factors, including measurement methods, that influence HR in newborn infants immediately after birth. Additionally, this paper provides an overview of delivery room HR as a prognostic indicator in different subgroups of newborns.METHODS: We searched PubMed, EMBASE, and Google Scholar with the terms infant, heart rate, delivery room, resuscitation, pulse oximetry, and electrocardiogram.RESULTS: Seven studies that described HR values in newborn infants immediately after birth were included. Pulse oximetry-derived HR percentiles after immediate cord clamping may not be applicable to the current practice of delayed cord clamping and the increasing use of delivery room electrocardiograms. Mask ventilation may adversely affect HR, particularly in premature and non-asphyxiated infants. Prolonged bradycardia is a negative prognostic factor, especially if combined with hypoxemia in infants <32 weeks of gestation.CONCLUSIONS: HR assessment in the delivery room remains important. However, the cardiopulmonary transition is affected by delayed cord clamping, gestational age, and underlying conditions.PMID:37761512 | PMC:PMC10528538 | DOI:10.3390/children10091551… -
Effect of delayed cord clamping on red blood cell alloimmunization: a retrospective cohort study
Am J Obstet Gynecol MFM. 2023 Nov;5(11):101165. doi: 10.1016/j.ajogmf.2023.101165. Epub 2023 Sep 20.ABSTRACTBACKGROUND: Although delayed cord clamping has well-known benefits for preterm and term neonates, it has been inadequately assessed in alloimmunized neonates.OBJECTIVE: This study aimed to evaluate the benefits and risks of delayed cord clamping in alloimmunized neonates.STUDY DESIGN: This was a retrospective comparative pre-post cohort study conducted from 2003 to 2018 in a tertiary care center in France. All living singleton neonates whose mothers were followed up for red blood cell alloimmunization during gestation and confirmed at birth (N=224) were included. Neonates were either exposed to immediate (n=125) or delayed cord clamping (n=99). Our main outcome was the time from birth to first exchange transfusions and/or transfusions. Secondary outcomes were hemoglobin level at birth, rate of exchange transfusion, number of postnatal transfusions, maximum bilirubin level, and number of phototherapy hours.RESULTS: Hemoglobin at birth was significantly higher in case of delayed cord clamping (mean difference, 1.7 g/dL; 95% confidence interval, 0.7-2.8). Among infants treated with exchange transfusion or transfusion, the time to initial treatment was higher in case of delayed cord clamping (median difference, 8 days; rate ratio, 1.51; 95% confidence interval, 1.09-2.10). There were no significant differences in the need for exchange transfusion, the number of transfusions, the maximum total bilirubin level, nor the number of phototherapy hours. In the subgroup analysis of neonates needing intrauterine transfusion during pregnancy (ie, severe alloimmunization), neonates had a lower rate of exchange transfusion in case of delayed cord clamping (odds ratio, 0.36; 95% confidence interval, 0.15-0.82).CONCLUSION: Our results indicate a benefit of delayed cord clamping in alloimmunization, regardless of pathology severity, without increased risk of jaundice.PMID:37734659 | DOI:10.1016/j.ajogmf.2023.101165… -
Supine versus Prone Position during Delayed Cord Clamping in Infants ≥36 Weeks: A Randomized Trial
Am J Perinatol. 2023 Sep 19. doi: 10.1055/s-0043-1775563. Online ahead of print.ABSTRACTOBJECTIVE: There is no recommendation in the literature on optimal positioning of the newborn immediately at birth during delayed cord clamping. To evaluate if prone positioning on the mother's chest at birth during delayed cord clamping leads to a higher hematocrit at 30 hours of life compared to supine positioning.STUDY DESIGN: A randomized unblinded trial comparing prone and supine position of the newborn before umbilical cord clamping. Healthy newborns ≥36 weeks gestational age and born vaginally with cephalic presentation were included. The newborn was randomized to prone or supine position. Umbilical cord clamping was delayed in both groups to 1 minute after birth. The primary outcome was hematocrit at 30 hours of life. As a secondary outcome, cerebral tissue oxygenation (CrSO2) values were compared between both groups by near infrared spectroscopy.RESULTS: There was no difference in hematocrit at 30 hours of life between supine and prone positions with a mean at 52 and 53.1, respectively, mean difference -1.1 (95% confidence interval:-2.7, 0.5), p = 0.17. Newborns in supine and prone positions had comparable level of CrSO2 at 30 hours of life with a mean at 84.1 and 82.2, respectively, mean difference 1.9 (-0.2, 4.0), p = 0.07. There was no correlation between hematocrit and CrSO2 at 30 hours of life (r = 0.14).CONCLUSION: There was no difference between prone and supine positioning immediately after birth during delayed cord clamping on hematocrit at 30 hours of life. In the absence of clear findings, further studies with assessment of the effect of position on breastfeeding success in the case room, on maternal satisfaction and outcome beyond 30 hours are needed to make adequate recommendations on positioning.KEY POINTS: · Delayed cord clamping at 60 seconds is recommended at birth, but optimal positioning is unknown.. · A randomized trial was conducted to compare hematocrit at 36 hours of life of prone versus supine position.. · No difference in hematocrit was found in prone versus supine position during delayed cord clamping..PMID:37726014 | DOI:10.1055/s-0043-1775563… -
Low-Dose Remifentanil in Preterm Cesarean Section with General Anesthesia: A Randomized Controlled Trial
Paediatr Drugs. 2023 Sep 15. doi: 10.1007/s40272-023-00591-w. Online ahead of print.ABSTRACTBACKGROUND AND OBJECTIVE: The conventional technique of general anesthesia induction during a Cesarean section involves the use of opioids only after cord clamping. We hypothesized that the use of remifentanil before cord clamping might reduce the use of maternal supplemental anesthetic agents and improve the maternal hemodynamics status and neonatal adaptation of the preterm neonate.METHODS: A phase III, double-blind, randomized, placebo-controlled, hospital-based trial enrolled parturients undergoing a Cesarean section under general anesthesia before 37 weeks of gestation. Block randomization allocated pregnant women to remifentanil or placebo. The primary outcome was the rate of newborns with Apgar scores < 7 at 5 min. Secondary outcomes were maternal hemodynamic parameters, complications of anesthetic induction, use of adjuvant anesthetic agents, neonatal respiratory distress, umbilical cord pH, and lactate levels.RESULTS: A total of 52/55 participants were analyzed, comprising 27 women in the remifentanil group and 25 in the placebo group. Nine of 27 (33.3%) neonates had an Apgar score < 7 at 5 min in the remifentanil group versus 11/25 (44.0%) in the placebo group (p = 0.45, odds ratio = 0.66, 95 confidence interval 0.20-2.18). The blood cord gases, cognitive, behavior, sensory, sleeping, and feeding scores at 1 and 2 years of corrected age were not different. For the mothers, hemodynamic parameters, anesthesia duration, and the cumulative treatment dose until cord clamping did not differ between the groups.CONCLUSIONS: The use of a low dose of remifentanil before cord clamping for a Cesarean section appears to be safe both for the mother and the preterm newborn, but it does not improve maternal or neonatal outcomes.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT02029898.PMID:37713021 | DOI:10.1007/s40272-023-00591-w… -
SGLT2 and SGLT1 inhibitors suppress the activities of the RVLM neurons in newborn Wistar rats
Hypertens Res. 2023 Sep 15. doi: 10.1038/s41440-023-01417-5. Online ahead of print.ABSTRACTHypertension is well-known to often coexist with diabetes mellitus (DM) in humans. Treatment with sodium-glucose cotransporter 2 (SGLT2) inhibitors has been shown to decrease both the blood glucose and the blood pressure (BP) in such patients. Some reports show that SGLT2 inhibitors improve the BP by decreasing the activities of the sympathetic nervous system. Therefore, we hypothesized that SGLT2 inhibitors might alleviate hypertension via attenuating sympathetic nervous activity. Combined SGLT2/SGLT1 inhibitor therapy is also reported as being rather effective for decreasing the BP. In this study, we examined the effects of SGLT2 and SGLT1 inhibitors on the bulbospinal neurons of the rostral ventrolateral medulla (RVLM). To investigate whether bulbospinal RVLM neurons are sensitive to SGLT2 and SGLT1 inhibitors, we examined the changes in the neuronal membrane potentials (MPs) of these neurons using the whole-cell patch-clamp technique during superfusion of the cells with the SGLT2 and SGLT1 inhibitors. A brainstem-spinal cord preparation was used for the experiments. Our results showed that superfusion of the RVLM neurons with SGLT2 and SGLT1 inhibitor solutions induced hyperpolarization of the neurons. Histological examination revealed the presence of SGLT2s and SGLT1s in the RVLM neurons, and also colocalization of SGLT2s with SGLT1s. These results suggest the involvement of SGLT2s and SGLT1s in regulating the activities of the RVLM neurons, so that SGLT2 and SGLT1 inhibitors may inactivate the RVLM neurons hyperpolarized by empagliflozin. SGLT2 and SGLT1 inhibitors suppressed the activities of the bulbospinal RVLM neurons in the brainstem-spinal preparations, suggesting the possibilities of lowering BP by decreasing the sympathetic nerve activities. RVLM, rostral ventrolateral medulla. IML, intralateral cell column. aCSF, artificial cerebrospinal fluid.PMID:37710035 | DOI:10.1038/s41440-023-01417-5… -
Timing of umbilical cord occlusion, delayed vs early, in preterm babies: A randomized controlled trial (CODE-P Trial)
Eur J Obstet Gynecol Reprod Biol. 2023 Oct;289:203-207. doi: 10.1016/j.ejogrb.2023.08.376. Epub 2023 Aug 23.ABSTRACTINTRODUCTION: Our hypothesis was that delayed cord clamping (DCC) (not earlier than 30 s; at 30-60 s) in premature neonates (born between 26.0 and 32.6 weeks of gestation), as compared with the usual early cord clamping (ECC), significantly reduces the need for blood transfusions and incidence of intraventricular haemorrhage (IVH) without an increased rate of maternal postpartum haemorrhage.MATERIAL AND METHODS: A prospective, open-label, randomized, controlled trial was conducted at Vall d'Hebron Hospital from July 2014 to December 2018. All pregnant women at risk of impending preterm birth (≥26.0-<33.0 weeks of gestation) who were admitted to the obstetrics emergency department were evaluated for eligibility. If they met the eligibility criteria, they were invited to participate in the study and, if they agreed, they signed an informed consent. Patients were randomly assigned to one of two groups: ECC group and DCC group.RESULTS: Our study included a total of 57 patients: 30 in the ECC group and 27 in the DCC group. Due to a lack of funding and low recruitment rates, the study was discontinued in 2018. Maternal characteristics and obstetric outcomes were similar between both groups. The intention-to-treat analysis did not reveal any differences between groups for neonatal red blood cell transfusions, neonatal IVH or maternal postpartum haemorrhage. There were no differences for secondary outcomes. Similarly, no differences were observed in the as-treated analysis.CONCLUSION: The primary and secondary outcomes of our study were not achieved. Therefore, more meta-analysis and trials are needed to evaluate the appropriate timing of cord clamping in preterm birth.PMID:37696147 | DOI:10.1016/j.ejogrb.2023.08.376… -
Cardiovascular responses to mild perinatal asphyxia in growth-restricted preterm lambs
Am J Physiol Heart Circ Physiol. 2023 Nov 1;325(5):H1081-H1087. doi: 10.1152/ajpheart.00485.2023. Epub 2023 Sep 1.ABSTRACTGrowth-restricted neonates have worse outcomes after perinatal asphyxia, with more severe metabolic acidosis than appropriately grown neonates. The cardiovascular physiology associated with fetal growth restriction (FGR) may alter their response to asphyxia. However, research on asphyxia in FGR is limited. Here we compared cardiovascular hemodynamics in preterm FGR and control lambs during mild perinatal asphyxia. We induced FGR in one twin at 89 days gestation (term 148 days), while the other served as a control. At 126 days gestation, lambs were instrumented to allow arterial blood pressure and regional blood flow recording, and then mild perinatal asphyxia was induced by umbilical cord clamping, and resuscitation followed neonatal guidelines. FGR lambs maintained carotid blood flow (CBF) for 7 min, while control lambs rapidly decreased CBF (P < 0.05). Fewer growth-restricted lambs needed chest compressions for return of spontaneous circulation (ROSC) (17 vs. 83%, P = 0.02). The extent of blood pressure overshoot after ROSC was similar, but it took longer for MAP to return to baseline in FGR lambs (18.83 ± 0.00 vs. 47.67 ± 0.00 min, P = 0.003). Growth-restricted lambs had higher CBF after ROSC (P < 0.05) and displayed CBF overshoot, unlike control lambs (P < 0.03). In conclusion, preterm growth-restricted lambs show resilience during perinatal asphyxia based on prolonged CBF maintenance and reduced need for chest compressions during resuscitation. However, CBF overshoot after ROSC may increase the risk of cerebrovascular injury in FGR.NEW & NOTEWORTHY Preterm growth-restricted lambs maintain carotid blood flow for longer than control lambs during asphyxia and have a lower requirement for chest compressions than control lambs during resuscitation. Preterm growth-restricted, but not control, lambs displayed an overshoot in carotid blood flow following return of spontaneous circulation.PMID:37656131 | DOI:10.1152/ajpheart.00485.2023… -
Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya
Sex Reprod Healthc. 2023 Sep;37:100893. doi: 10.1016/j.srhc.2023.100893. Epub 2023 Jul 24.ABSTRACTBACKGROUND: Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability.METHODS: We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD).RESULTS: At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD.CONCLUSION: Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.PMID:37586305 | DOI:10.1016/j.srhc.2023.100893… -
Heart Rate Changes following Facemask Placement in Infants Born at ≥32+0 Weeks of Gestation
Neonatology. 2023;120(5):624-632. doi: 10.1159/000531739. Epub 2023 Aug 2.ABSTRACTINTRODUCTION: Recent reports have raised concerns of cardiorespiratory deterioration in some infants receiving respiratory support at birth. We aimed to independently determine whether respiratory support with a facemask is associated with a decrease in heart rate (HR) in some late-preterm and term infants.METHODS: Secondary analysis of data from infants born at ≥32+0 weeks of gestation at 2 perinatal centres in Melbourne, Australia. Change in HR up to 120 s after facemask placement, measured using 3-lead electrocardiography, was assessed every 3 s until 60 s and every 5 s thereafter from video recordings.RESULTS: In the 15 s after facemask placement, 10/68 (15%) infants had a decrease in mean HR by >10 beats per minute (bpm) compared with their individual baseline mean HR in the 15 s before facemask placement. In 4 (6%) infants, HR decreased to <100 bpm. Nine out of 68 (13%) infants had an increase in mean HR by >10 bpm; 7 of these infants had a baseline HR <120 bpm. In univariable comparisons, the following characteristics were found not to be risk factors for a decrease in HR by >10 bpm: prematurity; type of respiratory support; hypoxaemia; early cord clamping; mode of birth; HR <120 bpm before mask placement. Six out of 63 infants (10%) who had HR ≥120 bpm after facemask placement had a late decrease in HR to <100 bpm between 30 and 120 s after facemask placement.CONCLUSION: Facemask respiratory support at birth is temporally associated with a decrease in HR in a subset of late-preterm and term infants.PMID:37531947 | DOI:10.1159/000531739… -
Waiting with cord clamping: not only placental transfusion, also physiological benefit
Ned Tijdschr Geneeskd. 2023 Jun 22;167:D7179.ABSTRACTWaiting with cord clamping after birth has been shown to be beneficial for term and preterm infants without increasing the risk for postpartum maternal hemorrhage. While the benefits have been attributed to the placental transfusion that can take place, there is probably another, perhaps even larger, physiological benefit. Waiting with cord clamping until the lungs of the infant have been aerated and pulmonary blood flow has increased leads to a more gentle and stable hemodynamic transition. This raises the question whether the moment of clamping should be defined by a fixed time point or by the moment the infant is ready for clamping, and this can vary.PMID:37493293… -
The impact of early versus delayed cord clamping on hematological and cardiovascular changes in preterm newborns between 24 and 34 weeks' gestation: a randomized clinical trial
Arch Gynecol Obstet. 2023 Jul 12. doi: 10.1007/s00404-023-07119-0. Online ahead of print.ABSTRACTPURPOSE: This study aimed to investigate hematological and cardiac changes after early (ECC) versus delayed cord clamping (DCC) in preterm infants at 24-34 weeks of gestation.METHODS: Ninety-six healthy pregnant women were assigned randomly to the ECC (< 10 s postpartum, n = 49) or DCC (45-60 s postpartum, n = 47). Primary endpoint was evaluation of neonatal hemoglobin, hematocrit and bilirrubin levels within the first 7 days after birth. A postpartum blood test was performed in the mother and a neonatal echocardiography in the first week of life.RESULTS: We found differences in hematological parameters during the first week of life. On admission, the DCC group had higher hemoglobin levels than the ECC group (18.7 ± 3.0 vs. 16.8 ± 2.4, p < 0.0014) and higher hematocrit values (53.9 ± 8.0 vs. 48.8 ± 6.4, p < 0.0011). Around day 7 of life, hemoglobin levels were also higher in the DCC group compared with the ECC group (16.4 ± 3.8 vs 13.9 ± 2.5, p < 0.005), as was the hematocrit (49.3 ± 12.7 vs 41.2 ± 8.4, p < 0.0087). The need of transfusion was lower in the DCC compared to the ECC (8.5% vs 24.5%; OR: 0.29, 95% CI: 0.09-0.97, p < 0.036). The need for phototherapy was also higher in the DCC (80.9% vs 63.3%; OR: 0.23, 95% CI: 0.06-0.84, p < 0.026). No differences in cardiac parameters or maternal blood tests.CONCLUSION: DCC improved neonatal hematological parameters. No changes in cardiac function were found and maternal blood loss did not increase to require transfusion.PMID:37436461 | DOI:10.1007/s00404-023-07119-0… -
To guide future practice, perinatal trials should be much larger, simpler and less fragile with close to 100% ascertainment of mortality and other key outcomes
Semin Perinatol. 2023 Aug;47(5):151789. doi: 10.1016/j.semperi.2023.151789. Epub 2023 Jun 11.ABSTRACTThe Australian Placental Transfusion Study (APTS) randomised 1,634 fetuses to delayed (≥60 s) versus immediate (≤10 s) clamping of the umbilical cord. Systematic reviews with meta-analyses, including this and similar trials, show that delaying clamping in preterm infants reduces mortality and need for blood transfusions. Amongst 1,531 infants in APTS followed up at two years, aiming to delay clamping for 60 s or more reduced the relative risk of the primary composite outcome of death or disability by 17% (p = 0.01). However, this result is fragile because nominal statistical significance (p < 0.05) would be abolished by only 2 patients switching from a non-event to an event, and the primary composite outcome was missing in 112 patients (7%). To achieve more robust evidence, any future trials should emulate the large, simple trials co-ordinated from Oxford which reliably identified moderate, incremental improvements in mortality in tens of thousands of participants, with <1% missing data. Those who fund, regulate, and conduct trials that aim to change practice should repay the trust of those who consent to participate by doing everything possible to minimise missing data for key outcomes.PMID:37422415 | DOI:10.1016/j.semperi.2023.151789… -
Optimizing transition: Providing oxygen during intact cord resuscitation
Semin Perinatol. 2023 Aug;47(5):151787. doi: 10.1016/j.semperi.2023.151787. Epub 2023 Jun 10.ABSTRACTDelayed clamping and cutting of the umbilical cord at birth is standard practice for management for all newborns. Preterm infants may additionally benefit from a combination of ventilation and oxygen provision during intact cord resuscitation. This review highlights both the potential benefits of such a combined approach and the need for further rigorous studies, including randomized controlled trials, of delivery room management in this population.PMID:37380527 | PMC:PMC10529853 | DOI:10.1016/j.semperi.2023.151787… -
Prevention of Chronic Morbidities in Extremely Premature Newborns with LISA-nCPAP Respiratory Therapy and Adjuvant Perinatal Strategies
Antioxidants (Basel). 2023 May 24;12(6):1149. doi: 10.3390/antiox12061149.ABSTRACTLess invasive surfactant administration techniques, together with nasal continuous airway pressure (LISA-nCPAP) ventilation, an emerging noninvasive ventilation (NIV) technique in neonatology, are gaining more significance, even in extremely premature newborns (ELBW), under 27 weeks of gestational age. In this review, studies on LISA-nCPAP are compiled with an emphasis on short- and long-term morbidities associated with prematurity. Several perinatal preventative and therapeutic investigations are also discussed in order to start integrated therapies as numerous organ-saving techniques in addition to lung-protective ventilations. Two thirds of immature newborns can start their lives on NIV, and one third of them never need mechanical ventilation. With adjuvant intervention, these ratios are expected to be increased, resulting in better outcomes. Optimized cardiopulmonary transition, especially physiologic cord clamping, could have an additively beneficial effect on patient outcomes gained from NIV. Organ development and angiogenesis are strictly linked not only in the immature lung and retina, but also possibly in the kidney, and optimized interventions using angiogenic growth factors could lead to better morbidity-free survival. Corticosteroids, caffeine, insulin, thyroid hormones, antioxidants, N-acetylcysteine, and, moreover, the immunomodulatory components of mother's milk are also discussed as adjuvant treatments, since immature newborns deserve more complex neonatal interventions.PMID:37371878 | PMC:PMC10294858 | DOI:10.3390/antiox12061149… -
Thermal care for preterm infants in the delivery room has not been compromised since the routine adoption of delayed cord clamping in our unit
Arch Dis Child Fetal Neonatal Ed. 2023 Nov;108(6):662. doi: 10.1136/archdischild-2023-325861. Epub 2023 Jun 27.NO ABSTRACTPMID:37369600 | DOI:10.1136/archdischild-2023-325861… -
Contemporary controversies in umbilical cord clamping practices
Semin Perinatol. 2023 Aug;47(5):151782. doi: 10.1016/j.semperi.2023.151782. Epub 2023 Jun 11.NO ABSTRACTPMID:37357044 | DOI:10.1016/j.semperi.2023.151782… -
Knowledge gaps in optimal umbilical cord management at birth
Semin Perinatol. 2023 Aug;47(5):151791. doi: 10.1016/j.semperi.2023.151791. Epub 2023 Jun 11.ABSTRACTIn 2014 the World Health Organisation recommended providing placental blood to all newborn infants by waiting for at least one minute before clamping the umbilical cord. Mounting evidence supports providing a placental transfusion at the time of birth for all infants. The optimal time before clamping and cutting the umbilical cord is still not yet known, and debate exists around other cord management issues. The newborn's transition phase from intra- to extra-uterine life and the effects of blood volume on the many necessary adaptations are understudied. How best to support these adaptations guides our suggested research questions. Parents' perceptions of enrolling their unborn infant into a study play important parts in the conduct of such trials. This article aims to address these topics and suggest research questions for further studies.PMID:37357042 | DOI:10.1016/j.semperi.2023.151791… -
Editorial: Umbilical cord milking-benefits and potential harmful effects
Front Pediatr. 2023 Jun 7;11:1210388. doi: 10.3389/fped.2023.1210388. eCollection 2023.NO ABSTRACTPMID:37351313 | PMC:PMC10283007 | DOI:10.3389/fped.2023.1210388… -
Deferred cord clamping and cord milking: Certainty and quality of the evidence in meta-analyses, and systematic reviews of randomized control trials, guidelines, and implementation studies
Semin Perinatol. 2023 Aug;47(5):151790. doi: 10.1016/j.semperi.2023.151790. Epub 2023 Jun 13.ABSTRACTDeferred1 cord clamping (DCC) saves lives, so why is it not implemented more routinely? Despite neonatal benefits, DCC is under-utilized, particularly in preterm births. Umbilical cord milking (UCM) also improves some outcomes for preterm infants such as decreasing the need for transfusions. At term, DCC and UCM improve hematological indices.OBJECTIVE: The objective of this chapter is to examine the quality of evidence for both preterm and term DCC (and UCM), clinical practice guidelines and implementation issues.METHODS: Key evidence, primarily from network meta-analyses, meta-analyses and systematic reviews on both preterm and term DCC (and UCM) from randomized clinical trials, clinical practice guidelines and implementation studies, are summarized through a lens of the certainty and quality of the evidence. Regarding the certainty of evidence, for network meta-analysis the Confidence in Network Meta-analysis tool was used, and for meta-analyses the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used. Guideline quality was appraised with two tools: Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) and AGREE-Recommendation EXcellence (AGREE-REX). Implementation study quality was evaluated using The Mixed Method Appraisal tool.RESULTS: In a network meta-analysis of 56 RCTs of cord management strategies, DCC reduced the odds of mortality in preterm infants by 30% compared to immediate cord clamping (ICC), including in the subgroup of infants born before 33 weeks', both with a moderate confidence assessment using the Confidence in Network Meta-analysis tool. DCC reduced the odds of any intraventricular hemorrhage (IVH) by 30%, and the odds of red blood cell transfusion by more than 50%, both with high ratings on the Confidence in Network Meta-analysis. Umbilical Cord Milking (UCM) did not reduce mortality compared to ICC. In contrast to the benefits shown in preterm birth with DCC, a systematic review showed that at term, there were no mortality benefits and few benefits at all except for improved hematological indices. A systematic review of clinical practice guidelines demonstrated that all of them endorsed DCC for uncompromised preterm infants, and 11 more cautiously noted that cord milking might be considered when DCC was not feasible. However, only half (49%) of the recommendations in the guidelines on the optimal duration of DCC were supported by high-quality evidence per AGREE-II and AGREE-REX. Fewer than one in 10 statements (8%) cited a mortality benefit with DCC for preterm infants. Regarding the uptake of DCC, a systematic review of 18 studies on facilitators and barriers to implementation found that almost all (12 of the 14 studies) focused on strategies such as protocols, policy, or toolkits; additionally, 8 of 14 studies used didactic teaching sessions. Only 8 of 18 studies scored high on all four domains of the Mixed Method Appraisal tool.CONCLUSIONS: Compared to ICC, DCC in preterm infants conferred significant benefits for mortality, IVH and red blood cell transfusion, with confidence ratings of moderate (mortality) or high. Although guidelines worldwide encouraged preterm (and term) DCC, the quality of the clinical practice guidelines had room for improvement; only half of the recommendations on the optimal duration of preterm DCC were supported by high-quality evidence. Most guidelines did not mention a mortality benefit with preterm DCC and lacked details on practical aspects of implementation. Among implementation studies, which have focused mainly on protocols, policies, toolkits or didactic teaching, quality also demonstrated an opportunity for improvement.PMID:37349189 | DOI:10.1016/j.semperi.2023.151790… -
Comparing delayed cord clamping and umbilical cord milking during elective cesarean section for the neonatal outcome
Eur J Obstet Gynecol Reprod Biol X. 2023 May 26;18:100200. doi: 10.1016/j.eurox.2023.100200. eCollection 2023 Jun.ABSTRACTOBJECTIVES: to compare between immediate cord clamping, delayed cord clamping, and umbilical cord milking and their effects on hemoglobin and bilirubin level in term infants in cesarean section.STUDY DESIGN: A randomized clinical trial was conducted from November 2021 to June 2022, including 162 full term pregnant women undergoing elective cesarean section at EL-Shatby Maternity University Hospital. They were randomly assigned (1:1:1 ratio) either to immediate cord clamping just after delivery (Group 1) or delayed cord clamping for 30 s (Group 2) or umbilical cord milking 10 times for 10-15 s (Group 3). The primary outcome measures included hemoglobin and hematocrit levels of the newborn at birth and the secondary outcome was bilirubin level measurement at 72 h of life.RESULTS: one hundred sixty- two newborns were randomized into 3 groups, fifty-four cases in each, and were investigated on hemoglobin and hematocrit levels; five were lost to follow-up and one hundred fifty-seven were tested for bilirubin. Participants among groups had no significant difference regarding demographic and clinical characteristics, regarding the hemoglobin at birth it was significant higher in the umbilical cord milking group (Group 3) through all groups (14.91 ± 0.91 g/dl vs15.38 ± 0.74 g/dl vs 16.56 ± 1.03 g/dl, p value <0.001), regarding hematocrit level at birth it was significant in the umbilical cord milking group (Group 3) through all groups (44.71 ± 2.94 vs 46.48 ± 2.61 vs 49.74 ± 3.26, p value <0.001). On the other hand, bilirubin level after 72 h had no significant different through the 3 groups (8.80(IQR 4.50-17.20), vs 9.70(IQR3.50-14.70), vs 8.50(IQR 3.20-19.50), respectively p value= 0.348).CONCLUSION: this study showed that umbilical cord milking 10 times for 10-15 s is more effective than delayed cord clamping for 30 s in enhancing hemoglobin and hematocrit levels in newborn delivered by cesarean section with no significant difference on bilirubin level in the newborn.PMID:37305179 | PMC:PMC10250567 | DOI:10.1016/j.eurox.2023.100200… -
An Indian perspective for umbilical cord blood haematological parameters reference interval
BMC Pediatr. 2023 Jun 8;23(1):287. doi: 10.1186/s12887-023-04090-2.ABSTRACTBACKGROUND: The Haematological Reference Intervals (RIs) are prone to vary on the basis of various factors such as altitude, age, sex, socioeconomic status, etc. These values play a major role in laboratory data interpretation and determine the necessary clinical treatment. Currently, India has no well-established RI for cord blood haematological parameters of newborns. This study aims to establish these intervals from Mumbai, India.METHOD: A cross sectional study was conducted in a tertiary care hospital of India from October 2022 to December 2022 on healthy and term neonates having normal birth weight and born to healthy pregnant mothers. About 2 - 3 mL of cord blood was collected from the clamped cord into EDTA tubes from 127 term neonates. The samples were analysed in the haematology laboratory of the institute and the data was analysed. The upper and lower limits were determined using non-parametric method. The Mann-Whitney U test was used to compare the distribution of the parameters between sex of infant, modes of deliveries, maternal age and obstetric history. P value less than 0.05 was considered to declare statistical significance.RESULT: The median values and 95% RI for umbilical cord blood haematological parameters of newborns were as follows: WBC = 12.35 [2.56-21.19] × 109/L, RBC = 4.34 [2.45-6.27] × 1012/L, HGB = 14.7 [8.08-21.44] g/dL, HCT = 48 [29-67]%, MCV = 109.6 [59.04-159.1] fL, MCH = 34.5 [30.54-37.79] pg, MCHC = 31.3 [29.87-32.75] %, PLT = 249 [16.97-479.46] × 109/L,LYM = 38 [17-62] %, NEU = 50 [26-74] %, EOS = 2.3 [0.1-4.8] %, MON = 7.3 [3.1-11.4], BAS = 0 [0-1]. This study found no statistically significant difference between sex of infants, except MCHC, and obstetric history. A significant difference was observed in WBC, EOS% and absolute NEU, LYM, MON and BAS by delivery type. A higher platelet count and absolute LYM was observed in the cord blood compared to venous blood.CONCLUSIONS: For the first time, haematological reference intervals in cord blood were established for newborns in Mumbai, India. The values are applicable for newborns from this area. Larger study throughout the country is required.PMID:37291518 | PMC:PMC10249286 | DOI:10.1186/s12887-023-04090-2… -
Midwifery care providers' childbirth and immediate newborn care competencies: A cross-sectional study in Benin, Malawi, Tanzania and Uganda
PLOS Glob Public Health. 2023 Jun 6;3(6):e0001399. doi: 10.1371/journal.pgph.0001399. eCollection 2023.ABSTRACTEvidence-based quality care is essential for reducing sub-Saharan Africa's high burden of maternal and newborn mortality and morbidity. Provision of quality care results from interaction between several components of the health system including competent midwifery care providers and the working environment. We assessed midwifery care providers' ability to provide quality intrapartum and newborn care and selected aspects of the working environment as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) project in Benin, Malawi, Tanzania, and Uganda. We used a self-administered questionnaire to assess provider knowledge and their working environment and skills drills simulations to assess skills and behaviours. All midwifery care providers including doctors providing midwifery care in the maternity units were invited to take part in the knowledge assessment and one third of the midwifery care providers who took part in the knowledge assessment were randomly selected and invited to take part in the skills and behaviour simulation assessment. Descriptive statistics of interest were calculated. A total of 302 participants took part in the knowledge assessment and 113 skills drills simulations were conducted. The assessments revealed knowledge gaps in frequency of fetal heart rate monitoring and timing of umbilical cord clamping. Over half of the participants scored poorly on aspects related to routine admission tasks, clinical history-taking and rapid and initial assessment of the newborn, while higher scores were achieved in active management of the third stage of labour. The assessment also identified a lack of involvement of women in clinical decision-making. Inadequate competency level of the midwifery care providers may be due to gaps in pre-service training but possibly related to the structural and operational facility characteristics including continuing professional development. Investment and action on these findings are needed when developing and designing pre-service and in-service training. Trial registration: PACTR202006793783148-June 17th, 2020.PMID:37279204 | PMC:PMC10243614 | DOI:10.1371/journal.pgph.0001399… -
Effects of delayed cord clamping at different time intervals in late preterm and term neonates: a randomized controlled trial
Eur J Pediatr. 2023 Aug;182(8):3701-3711. doi: 10.1007/s00431-023-05053-6. Epub 2023 Jun 6.ABSTRACTDelayed cord clamping (DCC) at delivery has well-recognized benefits; however, current scientific guidelines lack uniformity in its definition. This parallel-group, three-arm assessor-blinded randomized controlled trial compared the effects of three different timings of DCC at 30, 60, and 120 s on venous hematocrit and serum ferritin levels in late preterm and term neonates not requiring resuscitation. Eligible newborns (n = 204) were randomized to DCC 30 (n = 65), DCC 60 (n = 70), and DCC 120 (n = 69) groups immediately after delivery. The primary outcome variable was venous hematocrit at 24 ± 2 h. Secondary outcome variables were respiratory support, axillary temperature, vital parameters, incidences of polycythemia, neonatal hyperbilirubinemia (NNH), need and duration of phototherapy, and postpartum hemorrhage (PPH). Additionally, serum ferritin levels, the incidence of iron deficiency, exclusive breastfeeding (EBF) rate, and anthropometric parameters were assessed during post-discharge follow-up at 12 ± 2 weeks. Over one-third of the included mothers were anemic. DCC 120 was associated with a significant increase in the mean hematocrit by 2%, incidence of polycythemia, and duration of phototherapy, compared to DCC30 and DCC60; though the incidence of NNH and need for phototherapy was similar. No other serious neonatal or maternal adverse events including PPH were observed. No significant difference was documented in serum ferritin, incidences of iron deficiency, and growth parameters at 3 months even in the presence of a high EBF rate. Conclusion: The standard recommendation of DCC at 30-60 s may be considered a safe and effective intervention in the busy settings of low-middle-income countries with a high prevalence of maternal anemia. Trial registration: Clinical trial registry of India (CTRI/2021/10/037070). What is Known: • The benefits of delayed cord clamping (DCC) makes it an increasingly well-accepted practice in the delivery room. • However, uncertainty continues regarding the optimal timing of clamping; this may be of concern both in the neonate and the mother. What is New: • DCC at 120 s led to higher hematocrit, polycythemia and longer duration of phototherapy, without any difference in serum ferritin, and incidence of iron deficiency. • DCC at 30-60 s may be considered a safe and effective intervention in LMICs.PMID:37278737 | PMC:PMC10243262 | DOI:10.1007/s00431-023-05053-6… -
Respiratory and cardiovascular stabilisation prior to deferred umbilical cord clamping in premature infants: a feasibility and safety study
Arch Dis Child Fetal Neonatal Ed. 2023 Sep;108(5):548-549. doi: 10.1136/archdischild-2023-325360. Epub 2023 May 12.NO ABSTRACTPMID:37173120 | DOI:10.1136/archdischild-2023-325360… -
Evidence-based antenatal interventions to reduce the incidence of small vulnerable newborns and their associated poor outcomes
Lancet. 2023 May 20;401(10389):1733-1744. doi: 10.1016/S0140-6736(23)00355-0. Epub 2023 May 8.ABSTRACTA package of care for all pregnant women within eight scheduled antenatal care contacts is recommended by WHO. Some interventions for reducing and managing the outcomes for small vulnerable newborns (SVNs) exist within the WHO package and need to be more fully implemented, but additional effective measures are needed. We summarise evidence-based antenatal and intrapartum interventions (up to and including clamping the umbilical cord) to prevent vulnerable births or improve outcomes, informed by systematic reviews. We estimate, using the Lives Saved Tool, that eight proven preventive interventions (multiple micronutrient supplementation, balanced protein and energy supplementation, low-dose aspirin, progesterone provided vaginally, education for smoking cessation, malaria prevention, treatment of asymptomatic bacteriuria, and treatment of syphilis), if fully implemented in 81 low-income and middle-income countries, could prevent 5·202 million SVN births (sensitivity bounds 2·398-7·903) and 0·566 million stillbirths (0·208-0·754) per year. These interventions, along with two that can reduce the complications of preterm (<37 weeks' gestation) births (antenatal corticosteroids and delayed cord clamping), could avert 0·476 million neonatal deaths (0·181-0·676) per year. If further research substantiates the preventive effect of three additional interventions (supplementation with omega-3 fatty acids, calcium, and zinc) on SVN births, about 8·369 million SVN births (2·398-13·857) and 0·652 million neonatal deaths (0·181-0·917) could be avoided per year. Scaling up the eight proven interventions and two intrapartum interventions would cost about US$1·1 billion in 2030 and the potential interventions would cost an additional $3·0 billion. Implementation of antenatal care recommendations is urgent and should include all interventions that have proven effects on SVN babies, within the context of access to family planning services and addressing social determinants of health. Attaining high effective coverage with these interventions will be necessary to achieve global targets for the reduction of low birthweight births and neonatal mortality, and long-term benefits on growth and human capital.PMID:37167988 | DOI:10.1016/S0140-6736(23)00355-0… -
Umbilical cord pH, blood gases, and lactate at birth: normal values, interpretation, and clinical utility
Am J Obstet Gynecol. 2023 May;228(5S):S1222-S1240. doi: 10.1016/j.ajog.2022.07.001. Epub 2023 Mar 19.ABSTRACTNormal birth is a eustress reaction, a beneficial hedonic stress with extremely high catecholamines that protects us from intrauterine hypoxia and assists in the rapid shift to extrauterine life. Occasionally the cellular O2 requirement becomes critical and an O2 deficit in blood (hypoxemia) may evolve to a tissue deficit (hypoxia) and finally a risk of organ damage (asphyxia). An increase in H+ concentration is reflected in a decrease in pH, which together with increased base deficit is a proxy for the level of fetal O2 deficit. Base deficit (or its negative value, base excess) was introduced to reflect the metabolic component of a low pH and to distinguish from the respiratory cause of a low pH, which is a high CO2 concentration. Base deficit is a theoretical estimate and not a measured parameter, calculated by the blood gas analyzer from values of pH, the partial pressure of CO2, and hemoglobin. Different brands of analyzers use different calculation equations, and base deficit values can thus differ by multiples. This could influence the diagnosis of metabolic acidosis, which is commonly defined as a pH <7.00 combined with a base deficit ≥12.0 mmol/L in umbilical cord arterial blood. Base deficit can be calculated as base deficit in blood (or actual base deficit) or base deficit in extracellular fluid (or standard base deficit). The extracellular fluid compartment represents the blood volume diluted with the interstitial fluid. Base deficit in extracellular fluid is advocated for fetal blood because a high partial pressure of CO2 (hypercapnia) is common in newborns without concomitant hypoxia, and hypercapnia has a strong influence on the pH value, then termed respiratory acidosis. An increase in partial pressure of CO2 causes less increase in base deficit in extracellular fluid than in base deficit in blood, thus base deficit in extracellular fluid better represents the metabolic component of acidosis. The different types of base deficit for defining metabolic acidosis in cord blood have unfortunately not been noticed by many obstetrical experts and organizations. In addition to an increase in H+ concentration, the lactate production is accelerated during hypoxia and anaerobic metabolism. There is no global consensus on definitions of normal cord blood gases and lactate, and different cutoff values for abnormality are used. At a pH <7.20, 7% to 9% of newborns are deemed academic; at <7.10, 1% to 3%; and at <7.00, 0.26% to 1.3%. From numerous studies of different eras and sizes, it can firmly be concluded that in the cord artery, the statistically defined lower pH limit (mean -2 standard deviations) is 7.10. Given that the pH for optimal enzyme activity differs between different cell types and organs, it seems difficult to establish a general biologically critical pH limit. The blood gases and lactate in cord blood change with the progression of pregnancy toward a mixed metabolic and respiratory acidemia because of increased metabolism and CO2 production in the growing fetus. Gestational age-adjusted normal reference values have accordingly been published for pH and lactate, and they associate with Apgar score slightly better than stationary cutoffs, but they are not widely used in clinical practice. On the basis of good-quality data, it is reasonable to set a cord artery lactate cutoff (mean +2 standard deviations) at 10 mmol/L at 39 to 40 weeks' gestation. For base deficit, it is not possible to establish statistically defined reference values because base deficit is calculated with different equations, and there is no consensus on which to use. Arterial cord blood represents the fetus better than venous blood, and samples from both vessels are needed to validate the arterial origin. A venoarterial pH gradient of <0.02 is commonly used to differentiate arterial from venous samples. Reference values for pH in cord venous blood have been determined, but venous blood comes from the placenta after clearance of a surplus of arterial CO2, and base deficit in venous blood then overestimates the metabolic component of fetal acidosis. The ambition to increase neonatal hemoglobin and iron depots by delaying cord clamping after birth results in falsely acidic blood gas and lactate values if the blood sampling is also delayed. Within seconds after birth, sour metabolites accumulated in peripheral tissues and organs will flood into the central circulation and further to the cord arteries when the newborn starts to breathe, move, and cry. This influence of "hidden acidosis" can be avoided by needle puncture of unclamped cord vessels and blood collection immediately after birth. Because of a continuing anaerobic glycolysis in the collected blood, it should be analyzed within 5 minutes to not result in a falsely high lactate value. If the syringe is placed in ice slurry, the time limit is 20 minutes. For pH, it is reasonable to wait no longer than 15 minutes if not in ice. Routine analyses of cord blood gases enable perinatal audits to gain the wisdom of hindsight, to maintain quality assurance at a maternity unit over years by following the rate of neonatal acidosis, to compare results between hospitals on regional or national bases, and to obtain an objective outcome measure in clinical research. Given that the intrapartum cardiotocogram is an uncertain proxy for fetal hypoxia, and there is no strong correlation between pathologic cardiotocograms and fetal acidosis, a cord artery pH may help rather than hurt a staff person subjected to a malpractice suit based on undesirable cardiotocogram patterns. Contrary to common beliefs and assumptions, up to 90% of cases of cerebral palsy do not originate from intrapartum events. Future research will elucidate whether cell injury markers with point-of-care analysis will become valuable in improving the dating of perinatal injuries and differentiating hypoxic from nonhypoxic injuries.PMID:37164495 | DOI:10.1016/j.ajog.2022.07.001… -
The effect of delayed umbilical cord clamping on the infant's beta-endorphin level, mother-infant attachment and breastfeeding
Eur J Obstet Gynecol Reprod Biol. 2023 Jun;285:187-192. doi: 10.1016/j.ejogrb.2023.04.025. Epub 2023 May 2.ABSTRACTOBJECTIVES: To examine the effect of delayed umbilical cord clamping on the infant's betaendorphin level, mother-infant attachment and breastfeeding.STUDY DESIGN: This study had an experimental design with a control group. The study was undertaken between October and December 2017 in a maternity hospital in the east of Turkey. In total, 107 pregnant women [55 in the experimental group (delayed cord clamping) and 52 in the control group (early cord clamping)] participated in the study.RESULTS: The beta-endorphin level in the umbilical cord was 775.80 ± 229.35 in the experimental group and 547.91 ± 290.01 in the control group, and the difference was significant (t = 4.492, p = 0.000). Similarly, the prolactin level in the umbilical cord was 174.26 ± 47.20 in the experimental group and 119.06 ± 47.74 in the control group, and the difference was significant (t = 6.012, p = 0.000). Mother-infant attachment and breastfeeding success were higher in the experimental group.CONCLUSIONS: Beta-endorphin and prolactin levels in the umbilical cord, mother-infant attachment and breastfeeding success were higher in the group which underwent delayed cord clamping.PMID:37148645 | DOI:10.1016/j.ejogrb.2023.04.025… -
Umbilical cord milking-benefits and risks
Front Pediatr. 2023 Apr 18;11:1146057. doi: 10.3389/fped.2023.1146057. eCollection 2023.ABSTRACTThe most common methods for providing additional placental blood to a newborn are delayed cord clamping (DCC) and umbilical cord milking (UCM). However, DCC carries the potential risk of hypothermia due to extended exposure to the cold environment in the operating room or delivery room, as well as a delay in performing resuscitation. As an alternative, umbilical cord milking (UCM) and delayed cord clamping with resuscitation (DCC-R) have been studied, as they allow for immediate resuscitation after birth. Given the relative ease of performing UCM compared to DCC-R, UCM is being strongly considered as a practical option in non-vigorous term and near-term neonates, as well as preterm neonates requiring immediate respiratory support. However, the safety profile of UCM, particularly in premature newborns, remains a concern. This review will highlight the currently known benefits and risks of umbilical cord milking and explore ongoing studies.PMID:37144151 | PMC:PMC10151786 | DOI:10.3389/fped.2023.1146057… -
Timing of Intravenous Prophylactic Antibiotic Agents for Cesarean Delivery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Surg Infect (Larchmt). 2023 May;24(4):303-310. doi: 10.1089/sur.2022.389.ABSTRACTBackground: Prophylactic antibiotic administration has been used to reduce infectious morbidities in cesarean deliveries. However, no consensus on the timing has been reached. We performed this review to compare maternal and neonatal infectious morbidities of antibiotic administration before skin incision and after cord clamping. Methods: PubMed, EMBASE, MEDLINE, Cochrane Library, and Web of Science databases were searched. Only randomized controlled trials (RCTs) comparing the use of antibiotic agents pre-operatively and after cord clamping were included. Characteristics and results of the included studies were extracted, and risks of bias were assessed. A fixed-effect model was applied to estimate the relative risks (RRs) for outcomes. Results: Sixteen RCTs, including 8,027 women and 7,131 newborns, met the selection criteria. Pre-operative administration of antibiotic agents was associated with a reduction in the risk of endometritis (RR, 0.52; 95% confidence interval [CI], 0.37-0.72) and wound complications (RR, 0.54; 95% CI, 0.42-0.69), compared with administration after cord clamping. No differences were observed in the rate of febrile illness (RR, 0.79; 95% CI, 0.59-1.05), urinary tract infection (RR, 0.92; 95% CI, 0.64-1.32), neonatal intensive care unit (NICU) admission (RR, 0.94; 95% CI, 0.79-1.12), and neonatal sepsis (RR, 0.83; 95% CI, 0.61-1.14). Conclusions: The present study showed that prophylactic antibiotic agent administration before skin incision can reduce the risk of endometritis and wound complications while not increasing that of NICU admission and neonatal sepsis compared with administration after cord clamping.PMID:37126077 | DOI:10.1089/sur.2022.389… -
Delayed versus immediate cord clamping in dichorionic twins <32 weeks: a retrospective study
J Matern Fetal Neonatal Med. 2023 Dec;36(1):2203300. doi: 10.1080/14767058.2023.2203300.ABSTRACTOBJECTIVES: Strong evidence imply that delayed cord clamping (DCC) provides significant benefits for singleton neonates. However, there is little information about the safety or efficacy of DCC in twins to recommend for or against DCC in twins in guidelines. We aimed to determine the effect of DCC on dichorionic twins born at <32 weeks of gestation.STUDY DESIGN: This is a retrospective cohort study comparing the neonatal and maternal outcomes of immediate cord clamping (ICC) [<15 second (s)] versus DCC (at 60 s). Generalized estimating equations models were performed accounting for twin correlation.RESULTS: A total of 82 pairs of twins (DCC: 41; ICC: 41) were included in analysis. The primary outcome of death before discharge occurred in 3.66% of twins in the DCC group and 7.32% in the ICC group, without a significant difference between the groups. Compared to ICC group, DCC was associated with increased hemoglobin levels [β1 coefficient 6.51; 95% confidence interval (CI) 0.69-12.32. β2 coefficient 5.80; 95% CI 0.07-11.54] at 12-24 h of life. There were no significant differences between the groups in neonatal death, neonatal major morbidities and maternal bleeding complications, although DCC was associated with higher estimated maternal blood loss in the cesarean section group (p = .005).CONCLUSIONS: DCC for 60 s in dichorionic twins born at <32 weeks of gestation was associated with increased neonatal hemoglobin levels, when compared with ICC. The finding of a higher estimated maternal blood loss by cesarean section in the DCC group calls for further trials to assess maternal safety of this procedure in this patient population.PMID:37120713 | DOI:10.1080/14767058.2023.2203300… -
Maternal implications of placental transfusion
Semin Perinatol. 2023 Jun;47(4):151733. doi: 10.1016/j.semperi.2023.151733. Epub 2023 Mar 17.ABSTRACTPlacental transfusion for 30-60 s after delivery is recommended by numerous professional societies and is now a common practice. Numerous studies document neonatal benefit with minimal maternal risk when routine neonatal stabilization and active management of the third stage of labor are undertaken during the period of delayed cord clamping. Maternal outcomes do not show any increased incidence of postpartum hemorrhage, or need for blood product transfusion in the case of vaginal delivery or cesarean section. Fetomaternal hemorrhage is also likely decreased with delayed cord clamping. In the case of fetal anomalies, cord management should be individualized according to each special circumstance, but is unlikely to lead to increased maternal morbidity. While few studies have investigated maternal outcomes with umbilical cord milking, this practice has not been as widely adopted. With careful monitoring of maternal and fetal well-being, a period of placental transfusion following delivery is advised for benefit of the neonate without significant maternal risk.PMID:37068968 | DOI:10.1016/j.semperi.2023.151733… -
Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates: A Systematic Review and Meta-analysis
JAMA Netw Open. 2023 Apr 3;6(4):e237473. doi: 10.1001/jamanetworkopen.2023.7473.ABSTRACTIMPORTANCE: Interventions to reduce severe brain injury risk are the prime focus in neonatal clinical trials.OBJECTIVE: To evaluate multiple perinatal interventions across clinical settings for reducing the risk of severe intraventricular hemorrhage (sIVH) and cystic periventricular leukomalacia (cPVL) in preterm neonates.DATA SOURCES: MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception until September 8, 2022, using prespecified search terms and no language restrictions.STUDY SELECTION: Randomized clinical trials (RCTs) that evaluated perinatal interventions, chosen a priori, and reported 1 or more outcomes (sIVH, cPVL, and severe brain injury) were included.DATA EXTRACTION AND SYNTHESIS: Two co-authors independently extracted the data, assessed the quality of the trials, and evaluated the certainty of the evidence using the Cochrane GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Fixed-effects pairwise meta-analysis was used for data synthesis.MAIN OUTCOMES AND MEASURES: The 3 prespecified outcomes were sIVH, cPVL, and severe brain injury.RESULTS: A total of 221 RCTs that assessed 44 perinatal interventions (6 antenatal, 6 delivery room, and 32 neonatal) were included. Meta-analysis showed with moderate certainty that antenatal corticosteroids were associated with small reduction in sIVH risk (risk ratio [RR], 0.54 [95% CI, 0.35-0.82]; absolute risk difference [ARD], -1% [95% CI, -2% to 0%]; number needed to treat [NNT], 80 [95% CI, 48-232]), whereas indomethacin prophylaxis was associated with moderate reduction in sIVH risk (RR, 0.64 [95% CI, 0.52-0.79]; ARD, -5% [95% CI, -8% to -3%]; NNT, 20 [95% CI, 13-39]). Similarly, the meta-analysis showed with low certainty that volume-targeted ventilation was associated with large reduction in risk of sIVH (RR, 0.51 [95% CI, 0.36-0.72]; ARD, -9% [95% CI, -13% to -5%]; NNT, 11 [95% CI, 7-23]). Additionally, early erythropoiesis-stimulating agents (RR, 0.68 [95% CI, 0.57-0.83]; ARD, -3% [95% CI, -4% to -1%]; NNT, 34 [95% CI, 22-67]) and prophylactic ethamsylate (RR, 0.68 [95% CI, 0.48-0.97]; ARD, -4% [95% CI, -7% to 0%]; NNT, 26 [95% CI, 13-372]) were associated with moderate reduction in sIVH risk (low certainty). The meta-analysis also showed with low certainty that compared with delayed cord clamping, umbilical cord milking was associated with a moderate increase in sIVH risk (RR, 1.82 [95% CI, 1.03-3.21]; ARD, 3% [95% CI, 0%-6%]; NNT, -30 [95% CI, -368 to -16]).CONCLUSIONS AND RELEVANCE: Results of this study suggest that a few interventions, including antenatal corticosteroids and indomethacin prophylaxis, were associated with reduction in sIVH risk (moderate certainty), and volume-targeted ventilation, early erythropoiesis-stimulating agents, and prophylactic ethamsylate were associated with reduction in sIVH risk (low certainty) in preterm neonates. However, clinicians should carefully consider all of the critical factors that may affect applicability in these interventions, including certainty of the evidence, before applying them to clinical practice.PMID:37052920 | PMC:PMC10102877 | DOI:10.1001/jamanetworkopen.2023.7473… -
Midwifery and nursing: Considerations on cord management at birth
Semin Perinatol. 2023 Jun;47(4):151738. doi: 10.1016/j.semperi.2023.151738. Epub 2023 Mar 17.ABSTRACTMounting evidence overwhelmingly supports the practice of the return of an infant's placental blood volume at the time of birth. Waiting just a few minutes before clamping the umbilical cord can provide health benefits to infants of all gestational ages. Despite the robust evidence, uptake of delayed cord clamping (DCC) into mainstream obstetrical practice is moving slowly. The practice of DCC is influenced by various factors that include the setting in which the birth takes place, the use of evidence-informed guidelines and other influences that facilitate or hinder the practice of DCC. Through communication, collaboration, and unique disciplinary perspectives, midwives and nurses work with other members of their respective care team to develop strategies for best practice to improve an infant's well-being through optimal cord management. Midwifery has been practiced for centuries throughout the world and midwives have supported DCC since the beginning of recorded history. An important tenet of midwifery philosophy is watchful waiting and non-intervention in normal processes. Nurses are vital to care of birthing families in- and out-of-hospitals as well as in prenatal and postpartum ambulatory care. Nurses and midwives are positioned to be involved in the process of adapting to the mounting evidence for DCC. Strategies to increase better utilization of the practice of DCC have been proposed. For all, teamwork and collaboration among disciplines participating in maternity care are essential for adapting to the new evidence. Involving midwives and nurses as partners in an interdisciplinary approach to plan, implement and sustain DCC at birth increases success.PMID:37032272 | DOI:10.1016/j.semperi.2023.151738… -
Physiology, Neonatal
2023 Apr 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–.ABSTRACTThe neonatal period is the period of the most dramatic physiologic changes that occur during human life. While the respiratory and cardiovascular systems change immediately at birth, other organ systems evolve slowly with time until the transition from intrauterine to adult physiology is complete. The transitional period of the newborn is a critical time for humans to adapt to life outside the womb. There are distinct physiologic changes during this period, especially regarding the respiratory and cardiovascular systems. The loss of the low-pressure placenta and its ability to facilitate gas exchange, circulation, and waste management for the fetus creates a need for physiologic adaptation.Premature birth can significantly thwart these physiologic changes from occurring as they should. The endocrine system, specifically the release of cortisol via the hypothalamus, is responsible for lung maturation of the fetus and the neonate. There is a “cortisol surge” that begins with cortisol levels of 5 to 10 mcg/ml at 30 weeks gestational age, 20 mcg/ml at 36 weeks, 46 mcg/ml at 40 weeks, and 200mcg/ml during labor. Cortisol is responsible for lung maturation, thyroid hormone secretion, hepatic gluconeogenesis, catecholamine secretion, and the production of digestive enzymes. Mature thyroid function appears to help prepare the neonatal cardiovascular system and aid in the regulation of temperature. Following clamping of the umbilical cord and the first breath of life, arterial oxygen tension increases, and pulmonary vascular resistance decreases, facilitating gas exchange in the lungs. Subsequent pulmonary blood flow will cause an increase in left atrial pressure and a reduction in right atrial pressure. Changes in the PO2, PCO2, and pH are contributing factors to these physiologic changes in the newborn. Lung surfactant plays a critical role in these changes allowing the lungs to mature upon delivery. Remnants of fetal circulation (ductus arteriosus, foramen ovale, ductus venosus) will also gradually recede during this neonatal period, defined as up to 44 weeks postconceptual age.PMID:30969662 | Bookshelf:NBK539840…
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