Intérêt du clampage retardé du cordon ombilical chez le nouveau-né

Outcomes of Neonatal Resuscitation With and Without an Intact Umbilical Cord: A Meta-Analysis

Around 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.

Respectful and evidence-based birth care in Mexico (or lack thereof): An observational study

PROBLEM

In Mexico, women are often disrespected and abused during birth, evidence-based practices are seldom used, while outdated and dangerous procedures linger.

BACKGROUND

Disrespectful and abusive practices in Mexico have been reported but are not necessarily well-documented; none of the reports so far have relied on direct observation of births.

AIM

To describe birth practices and factors associated with respectful and evidence-based care at 15 referral hospitals in Mexico.

METHODS

We observed 401 births from 2010-2016. We analysed woman, provider, and hospital characteristics and their association with the performance of 14 evidence-based and 15 respectful birth practices via descriptive statistics and multiple logistic regression models.

FINDINGS

Only in four births were all the analysed evidence-based and respectful-birth practices performed. Essential interventions like uterine massage was only given to 46.1% of women and the administration of a uterotonic soon after birth only occurred in 58.3% of births. Professionals who were trained in respectful birth care were more likely to address women by their name (Odds Ratio=3.34, p<0.05), allow consumption of liquids during labour (Odds Ratio=31.6, p<0.05), encourage skin-to-skin contact (Odds Ratio=31.82, p<0.05), and examine the placenta after birth (Odds Ratio=16.55, p<0.01); they were less likely to perform episiotomies (Odds Ratio=0.27, p<0.05).

DISCUSSION

This study reveals low rates of evidence-based practices and respectful maternity care but shows training in the topic can have a considerable positive impact. Our results call for further efforts to improve the quality of maternal healthcare, a universal right.

The effects of umblical cord clamping time on lymphocyte subgroups in term and late preterm infants

Aim

To evaluate the effect of umblical cord clamping time on lymphocyte subgroups in term and late preterm infants.

Material and Methods

Seventy-four infants between 34 and 41 weeks of gestation were included in the study. Of these, 37 were umbilical cord clamped immediately after birth and the remaining 37 were clamped after waiting one minute. Babies were divided into two groups as term and preterm. The prenatal, natal, postnatal characteristics of the infants were recorded. Hematologic and lymphocyte subgroups were investigated in cord blood and venous blood at day 7. Lymphocyte subgroups were evaluated using flow cytometry.

Results

With the delay of cord clamping, the leucocytes count and the percentage of CD3+T lymphocytes in cord blood of preterm infants decreased and this decrease continued at day 7. On the contrary, CD19+B lymphocyte levels in the cord blood of preterm infants increased, and this increase continued at day 7. Also, the percentage of CD4+T lymphocytes of preterm infants decreased with the delay of cord clamping at day 7. There was no difference between groups for the rate of sepsis development.

Conclusion

With the delay of cord clamping, the leucocytes count, the percentage of CD3+T, and CD4+T lymphocytes decreased, and the percentage of CD19+B lymphocytes increased in preterm infants. The delay in cord clamping time in term and preterm infants seems to have no impact on the rate of sepsis development. Larger series of studies are needed to assess the effect of these findings on the development of infection in late preterm infants who have delayed cord clamping.

Evaluation of umbilical cord pulsatility after vaginal delivery in singleton pregnancies at term

OBJECTIVES

To define the duration of umbilical cord pulsatility (UCP) after vaginal delivery and to evaluate its possible association with maternal characteristics and obstetric and neonatal variables.

STUDY DESIGN

Prospective observational study on women with a singleton pregnancy at term who had a vaginal delivery and cord clamping at the cessation of pulsations. The collection of UCP duration was performed through a stopwatch and by manual palpation of the umbilical cord. Maternal (age, BMI, parity, antepartum hemoglobin), obstetric (pregnancy characteristics, gestational age at delivery, induction of labor, duration of the first, the second and the third stage of labor, post-partum blood loss, umbilical cord length) and neonatal (birthweight, Apgar score, hematocrit, hemoglobin) variables were then compared between two groups: long-term vs. short-term UCP.

RESULTS

A total of 102 women were identified. The median duration of UCP after birth was 213 s (IQR 120, 420), corresponding to 3 min and 33 s. The long-term UCP group (n = 51) had a significantly longer duration of third stage of labor (median 12 vs. 8 min, p < 0.001) and a significantly higher birthweight (median 3530 g vs. 3250 g, p = 0.005) compared with the short-term UCP group (n = 51). No differences in the other variables were found between groups.

CONCLUSION

For the first time we have reported the duration of UCP after vaginal delivery. An increased duration of UCP is associated with a prolonged duration of third stage of labor and a higher birthweight.

[Influence of obstetric factors on characteristics of umbilical cord blood transplants]

OBJECTIVES

There is a correlation between the success of the cord blood transplant and the numbers of HSC found in the unit of cord blood donation. The purpose of this analysis is to identify obstetric factors that may influence the quality of a cord blood unit taken during delivery.

METHODS

A retrospective study was carried out at the Liège cord blood bank on a sample of 7.463 cord blood units collected between 2000 and 2016. Eight obstetric factors were analyzed in relation to two dependent variables; the total nucleated cells (TNC) and the volume of one unit of cord blood. The Welch test, the percentiles 25 and 75 and the non-parametric Mann-Whitney Wilcoxon test were used.

RESULTS

Several obstetric parameters were found to influence (P<0.05) the quality of the cord blood unit are: cord clamping (>15 seconds), the use of oxytocin during labor, a more advanced gestational age (38-41 weeks), a higher birth weight (>3300 gr), and a higher weight of the placenta (>500 gr). A female newborn and the use of epidural, influence (P<0.05) the number of TNC but not the volume of the cord blood unit.

CONCLUSION

We can conclude that the birth weight, the weight of the placenta, the gestational age and cord clamping are parameters that could be used by maternity hospitals to identify births that enable more voluminous grafts which are richer in total nucleated cells.

[Anemia, a new severity factor in young infants with acute viral bronchiolitis?]

INTRODUCTION

The role of anemia is raised as a risk of low respiratory infection of the child, but there are no data on anemia as a severity factor in acute viral bronchiolitis (AVB) in infants.

METHODS

All infants less than 16 weeks old admitted to Montpellier University Hospital from 2015/10/01 to 2016/04/01 for AVB were included in a retrospective observational study. The primary objective was to determine whether the hemoglobin (Hb) concentration on admission was an independent factor of clinical severity, judged by the modified Wood's clinical asthma score (m-WCAS). The secondary objective was to assess the impact of Hb level on the characteristics of hospitalization, including the type and duration of respiratory support.

RESULTS

The m-WCAS was used at least once during hospitalization in 180 out of 220 patients (82%), making it possible to distinguish patients with mild AVB (maximum m-WCAS<2, n=81) from patients with severe AVB (maximum m-WCAS>2, n=99). A logistic regression model indicated that the Hb concentration, for every 1g/dL decrement, was an independent factor of AVB severity (OR 1.16 [1.03-1.29], P=0.026). A level under 10g/dL on admission was associated with a higher use of continuous positive airway pressure (P<0.001), as well as a longer duration of respiratory support (P=0.01).

CONCLUSION

This study suggested that anemia may influence the clinical expression of AVB in young infants.

Management of red blood cell alloimmunization in pregnancy

The main cause of fetal anemia is maternal red blood cell alloimmunization (AI). The search of maternal antibodies by indirect antiglobulin test allows screening for AI during pregnancy. In case of AI, fetal genotyping (for Rh-D, Rh-c, Rh-E and Kell), quantification (for anti-rhesus antibodies) and antibody titration, as well as ultrasound monitoring, are performed. This surveillance aims at screening for severe anemia before hydrops fetalis occurs. Management of severe anemia is based on intrauterine transfusion (IUT) or labor induction depending on gestational age. After intrauterine transfusion, follow-up will focus on detecting recurrence of anemia and detecting fetal brain injury. With IUT, survival of fetuses with alloimmunization is greater than 90% but 4.8% of children with at least one IUT have neurodevelopmental impairment.

Can a simulation-based training program impact the use of evidence based routine practices at birth? Results of a hospital-based cluster randomized trial in Mexico

Background

In Mexico, although the majority of births are attended in hospitals, reports have emerged of obstetric violence, use of unsafe practices, and failure to employ evidence-based practices (EBP). Recent attention has refocused global efforts towards provision of quality care that is both patient-centered and evidence-based. Scaling up of local interventions should rely on strong evidence of effectiveness.

Objective

To perform a secondary analysis to evaluate the impact of a simulation and team-training program (PRONTO) on the performance of EBP in normal births.

Methods

A pair-matched cluster randomized controlled trial of the intervention was designed to measure the impact of the program (PRONTO intervention) on a sample of 24 hospitals (12 hospitals received the PRONTO training and 12 served as controls) in the states of Chiapas, Guerrero, and Mexico. We estimated the impact of receiving the intervention on the probability of birth practices performance in a sample of 641 observed births of which 318 occurred in the treated hospitals and 323 occurred in control hospitals. Data was collected at 4 time points (baseline, 4^th, 8^th and 12^th months after the training). Women were blinded to treatment allocation but observers and providers were not. Estimates were obtained by fitting difference-in-differences logistic regression models considering confounding variables. The trial is registered at clinicaltrials.gov: # NCT01477554.

Results

Significant changes were found following the intervention. At 4 months post-intervention an increase of 20 percentage points (p.p.) for complete Active Management of Third Stage of Labor (AMTSL) (p = 0.044), and 16 p.p. increase for Skin-to-Skin Contact (p = 0.067); at 12 months a 25 p.p. increase of the 1st step of AMTSL (p = 0.026) and a 42 p.p. increase of Delayed Cord Clamping (p = 0.004); at 4 months a 30 (p = 0.001) and at 8 months a 22 (p = 0.010) p.p. decrease for Uterine Sweeping.

Conclusions

The intervention has an impact on adopting EBP at birth, contributing to an increased quality of care. Long lasting impacts on these practices are possible if there were to be a widespread adoption of the training techniques including simulation, team-training and facilitated discussions regarding routine care.