A randomized clinical trial of the Leboyer approach to childbirth

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Umbilical Cord Management at Term and Late Preterm Birth: A Meta-analysis

CONTEXT

The International Liaison Committee on Resuscitation prioritized scientific review of umbilical cord management at term and late preterm birth.

OBJECTIVE

To assess effects of umbilical cord management strategies (clamping timing and cord milking) in infants ≥34 weeks' gestational age.

DATA SOURCES

Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and trial registries searched July 2019.

STUDY SELECTION

Two authors independently assessed eligibility of randomized controlled trials.

DATA EXTRACTION

Two authors independently extracted data and assessed evidence certainty (Grading of Recommendations Assessment, Development and Evaluations).

RESULTS

We identified 46 studies (9159 women and their infants) investigating 7 comparisons. Compared with early cord clamping (ECC) <30 seconds, delayed cord clamping (DCC) ≥30 seconds (33 studies), intact-cord milking (1 study), and cut-cord milking (2 studies) probably improve hematologic measures but may not affect survival without neurodisability, anemia in early infancy, or maternal postpartum hemorrhage. No differences in major neonatal morbidities are seen in studies comparing methods of optimizing placental transfusion (DCC versus cut-cord milking [3 studies], longer delays in clamping [7 studies], or physiologic parameters [3 studies]). Strategies that promote increased placental transfusion may be associated with greater phototherapy use. Evidence for all outcomes was low or very low certainty.

LIMITATIONS

Incompleteness and low certainty of findings limit applicability.

CONCLUSIONS

Compared with ECC, DCC or cord milking increases hemoglobin and hematocrit immediately after birth in infants ≥34 weeks' gestational age. The uncertain effects of DCC and cord milking compared with ECC on major morbidities limit usefulness of available evidence for policy and practice.

Prevalence and risk factors for hyperbilirubinemia among newborns from a low-risk birth setting using delayed cord clamping in Japan

AIM

Neonatal jaundice is a common problem among infants. Among the several risk factors are East Asian race and delayed cord clamping. Birth centers manage low-risk term deliveries using physiological management, which may include delayed cord clamping. This study aimed to investigate the occurrence of hyperbilirubinemia, a pathological process of jaundice, and its risk factors among neonates born at a Japanese birth center.

METHODS

This was a retrospective cohort study. Data were collected from March 2006 to October 2014 from healthy mothers and neonates at a birth center in a metropolitan area of Japan. Demographic data and background factors of hyperbilirubinemia, including blood and transcutaneous values of jaundice, were collected and statistically analyzed.

RESULTS

Of the 1,211 neonates analyzed, 4.7% exceeded the standard transcutaneous bilirubin value, and 1.8% needed phototherapy. Multiple logistic regression with adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) was used to identify the risk factors of hyperbilirubinemia, which were found to be cephalohematoma (OR = 30.18, 95% CI 5.63-161.69), delay of meconium elimination (OR = 2.66, 95% CI 1.28-5.51), previous history of phototherapy of siblings (OR = 10.28, 95% CI 3.53-29.92), and primiparity (OR = 4.55, 95% CI 2.59-8.02).

CONCLUSIONS

In low-risk Japanese neonates delivered at a birth center expected to practice delayed cord clamping, the rate of neonates requiring phototherapy was not high compared to previous studies, and the identified risk factors of hyperbilirubinemia were related to bilirubin metabolism.

Effect of Delayed vs Immediate Umbilical Cord Clamping on Maternal Blood Loss in Term Cesarean Delivery: A Randomized Clinical Trial

IMPORTANCE

The American College of Obstetricians and Gynecologists recommends a delay in umbilical cord clamping in term neonates for at least 30 to 60 seconds after birth. Most literature supporting this practice is from low-risk vaginal deliveries. There are no published data specific to cesarean delivery.

OBJECTIVE

To compare maternal blood loss with immediate cord clamping vs delayed cord clamping in scheduled cesarean deliveries at term (≥37 weeks).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial performed at 2 hospitals within a tertiary academic medical center in New York City from October 2017 to February 2018 (follow-up completed March 15, 2018). A total of 113 women undergoing scheduled cesarean delivery of term singleton gestations were included.

INTERVENTIONS

In the immediate cord clamping group (n = 56), cord clamping was within 15 seconds after birth. In the delayed cord clamping group (n = 57), cord clamping was at 60 seconds after birth.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in maternal hemoglobin level from preoperative to postoperative day 1, which was used as a proxy for maternal blood loss. Secondary outcomes included neonatal hemoglobin level at 24 to 72 hours of life.

RESULTS

All of the 113 women who were randomized (mean [SD] age, 32.6 [5.2] years) completed the trial. The mean preoperative hemoglobin level was 12.0 g/dL in the delayed and 11.6 g/dL in the immediate cord clamping group. The mean postoperative day 1 hemoglobin level was 10.1 g/dL in the delayed group and 9.8 g/dL in the immediate group. There was no significant difference in the primary outcome, with a mean hemoglobin change of -1.90 g/dL (95% CI, -2.14 to -1.66) and -1.78 g/dL (95% CI, -2.03 to -1.54) in the delayed and immediate cord clamping groups, respectively (mean difference, 0.12 g/dL [95% CI, -0.22 to 0.46]; P = .49). Of 19 prespecified secondary outcomes analyzed, 15 showed no significant difference. The mean neonatal hemoglobin level, available for 90 neonates (79.6%), was significantly higher with delayed (18.1 g/dL [95% CI, 17.4 to 18.8]) compared with immediate (16.4 g/dL [95% CI, 15.9 to 17.0]) cord clamping (mean difference, 1.67 g/dL [95% CI, 0.75 to 2.59]; P < .001). There was 1 unplanned hysterectomy in each group.

CONCLUSIONS AND RELEVANCE

Among women undergoing scheduled cesarean delivery of term singleton pregnancies, delayed umbilical cord clamping, compared with immediate cord clamping, resulted in no significant difference in the change in maternal hemoglobin level at postoperative day 1.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03150641.

Effects of delayed cord clamping on infants after neonatal period: A systematic review and meta-analysis

BACKGROUND

The majority of current evidences simply showed the short-term benefits of delayed cord clamping, mainly focusing on the first week after birth. Without follow-up data, we can hardly come to the conclusion that delayed cord clamping may do more harm than good.

OBJECTIVE

To evaluate the long-term effects of delayed cord clamping compared with early cord clamping on infants after neonatal period.

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

DATA SOURCES

PubMed, EMBASE, and the Cochrane Library were systematically searched from inception date to June 22, 2018 for randomized clinical trials comparing early cord clamping with delayed cord clamping in infants beyond 1 month of age.

REVIEW METHODS

Two reviewers independently assessed trial eligibility and quality and extracted all infants' follow-up data after one month of age, which were divided into two groups for analysis, with follow-up periods of less than 6 months (<6 months) and beyond 6 months (≥6 months) respectively.

RESULTS

A total of twenty RCTs were identified and included in this study. All data of the twenty studies were pooled for final meta-analysis (3733 infants). Among preterm deliveries, delayed cord clamping slightly increased hematocrit (6-10 weeks) and serum ferritin (6-10 weeks). For term infants, delayed cord clamping reduced the incidence of anemia after six months of age (≥6 months), iron deficiency (< 6 months, ≥6 months) and iron deficiency anemia (4-12 months), while increased mean corpuscular volume before six months of age (< 6 months), hemoglobin after six months of age (≥6 months), serum iron (2-4 months), total body iron (4-6 months), serum ferritin (< 6 months, ≥6 months) and transferrin saturation (2-12 months). There were no significant differences between early versus late cord clamping groups for other variables.

CONCLUSION

Delayed cord clamping modestly improved hematological and iron status of both preterm and term infants after neonatal period. This affords cogent evidence on the practice of delayed cord clamping for medical staff, especially for countries and regions suffering from relatively higher prevalence rate of iron deficiency during infancy and childhood.

Effects of delayed cord clamping on residual placental blood volume, hemoglobin and bilirubin levels in term infants: a randomized controlled trial

OBJECTIVE

The objective of the study was to measure the effects of a 5-min delay (DCC) versus immediate cord clamping (ICC) on residual placental blood volume (RPBV) at birth, and hemoglobin and serum bilirubin at 24 to 48 h of age.

STUDY DESIGN

In this prospective randomized controlled trial, 73 women with term (37 to 41 weeks) singleton fetuses were randomized to DCC (⩾5 min; n=37) or ICC (<20 s; n=36).

RESULTS

Maternal and infant demographics were not different between the groups. Mean cord clamping time was 303±121 (DCC) versus 23±59 (ICC) s (P<0.001) with 10 protocol violations. Cord milking was the proxy for DCC (n=11) when the provider could not wait. Infants randomized to DCC compared with ICC had significantly less RPBV (20.0 versus 30.8 ml kg^-1, P<0.001), higher hemoglobin levels (19.4 versus 17.8 g dl^-1, P=0.002) at 24 to 48 h, with no difference in bilirubin levels.

CONCLUSION

Term infants had early hematological advantage of DCC without increases in hyperbilirubinemia or symptomatic polycythemia.

Current practice of cord clamping in the Netherlands: a questionnaire study

BACKGROUND

Recent meta-analyses recommend delayed cord clamping (DCC) after uncomplicated births as well as preterm births, but there is no clear definition of timing and uniform national guidelines are lacking.

OBJECTIVE

We aimed to investigate if guidelines for the timing of cord clamping (CC) are followed and what the national practice entails.

METHODS

A postal questionnaire concerning CC after uncomplicated vaginal, Caesarean term and preterm deliveries was sent to all midwifery practices (n = 526) and obstetrical departments (n = 94) in the Netherlands.

RESULTS

The response rate was 81% (500/620). CC protocols were present in 16 and 38% of midwifery and obstetric practices, respectively. Early cord clamping (ECC) was recommended in 54%, DCC in 33%, 6% indicated a specific time point and 7% did not specify. In current practice, DCC was applied after uncomplicated vaginal term deliveries in 90% and ECC in 6%, and no timing was specified in 4%. Midwives used DCC more often than obstetricians (97 vs. 75%). Cessation of cord pulsations was often (54%) used as a time point, 40% used a fixed time point, 2% waited for placental expulsion and 4% did not specify. ECC was preferred in obstetric practices after Caesarean deliveries (in 81%). In preterm births, ECC was practised by 36%, DCC by 54 and 10% did not specify.

CONCLUSION

In the Netherlands, although often not protocolized, DCC is widely used after uncomplicated vaginal term and preterm deliveries, but not after Caesareans. Cessation of cord pulsation is often used as the time point for CC.

Late umbilical cord-clamping as an intervention for reducing iron deficiency anaemia in term infants in developing and industrialised countries: a systematic review

This review evaluates the potential of delayed cord-clamping for improving iron status and reducing anaemia in term infants and for increasing the risk of polycythaemia and hyperbilirubinaemia. We applied a strict search protocol to identify controlled trials of early vs late cord-clamping. Four trials from developing and four from industrialised countries were finally assessed. Two of the four studies from developing countries found a significant difference in infant haemoglobin levels at 2-3 months of age in favour of delayed cord-clamping. This difference was more marked when mothers were anaemic. Three of four studies from industrialised countries showed a significant difference in haematocrit levels in favour of delayed clamping. Although meta-analysis showed an increased risk for hyperbilirubinaemia of 12%, no studies reported the need to apply phototherapy or perform exchange transfusion. We conclude that delayed cord-clamping in term infants, especially those with anaemic mothers, increases haemoglobin concentration in infants at 2-3 months of age and reduces the risk of anaemia, without an associated increased risk of perinatal complications. In developing countries where fetal anaemia is common, the advantages of delayed cord-clamping might be especially beneficial.

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes

BACKGROUND

Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord more than one minute after the birth or when cord pulsation has ceased. The benefits and potential harms of each policy are debated.

OBJECTIVES

To determine the effects of early cord clamping compared with late cord clamping after birth on maternal and neonatal outcomes

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013).

SELECTION CRITERIA

Randomised controlled trials comparing early and late cord clamping.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and quality and extracted data.

MAIN RESULTS

We included 15 trials involving a total of 3911 women and infant pairs. We judged the trials to have an overall moderate risk of bias. Maternal outcomes: No studies in this review reported on maternal death or on severe maternal morbidity. There were no significant differences between early versus late cord clamping groups for the primary outcome of severe postpartum haemorrhage (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.65 to 1.65; five trials with data for 2066 women with a late clamping event rate (LCER) of ~3.5%, I(2) 0%) or for postpartum haemorrhage of 500 mL or more (RR 1.17 95% CI 0.94 to 1.44; five trials, 2260 women with a LCER of ~12%, I(2) 0%). There were no significant differences between subgroups depending on the use of uterotonic drugs. Mean blood loss was reported in only two trials with data for 1345 women, with no significant differences seen between groups; or for maternal haemoglobin values (mean difference (MD) -0.12 g/dL; 95% CI -0.30 to 0.06, I(2) 0%) at 24 to 72 hours after the birth in three trials. Neonatal outcomes: There were no significant differences between early and late clamping for the primary outcome of neonatal mortality (RR 0.37, 95% CI 0.04 to 3.41, two trials, 381 infants with a LCER of ~1%), or for most other neonatal morbidity outcomes, such as Apgar score less than seven at five minutes or admission to the special care nursery or neonatal intensive care unit. Mean birthweight was significantly higher in the late, compared with early, cord clamping (101 g increase 95% CI 45 to 157, random-effects model, 12 trials, 3139 infants, I(2) 62%). Fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group (RR 0.62, 95% CI 0.41 to 0.96, data from seven trials, 2324 infants with a LCER of 4.36%, I(2) 0%). Haemoglobin concentration in infants at 24 to 48 hours was significantly lower in the early cord clamping group (MD -1.49 g/dL, 95% CI -1.78 to -1.21; 884 infants, I(2) 59%). This difference in haemoglobin concentration was not seen at subsequent assessments. However, improvement in iron stores appeared to persist, with infants in the early cord clamping over twice as likely to be iron deficient at three to six months compared with infants whose cord clamping was delayed (RR 2.65 95% CI 1.04 to 6.73, five trials, 1152 infants, I(2) 82%). In the only trial to report longer-term neurodevelopmental outcomes so far, no overall differences between early and late clamping were seen for Ages and Stages Questionnaire scores.

AUTHORS' CONCLUSIONS

A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.

Rethinking placental transfusion and cord clamping issues

A brief delay in clamping the umbilical cord results in a placental transfusion that supplies the infant with a major source of iron during the first few months of life. Cord circulation continues for several minutes after birth and placental transfusion results in approximately 30% more blood volume. Gravity influences the amount of placental transfusion that an infant receives. Placing the infant skin-to-skin requires a longer delay of cord clamping (DCC) than current recommendations. Uterotonics are not contraindicated with DCC. Cord milking is a safe alternative to DCC when one must cut the cord prematurely. Recent randomized controlled trials demonstrate benefits for term and preterm infants from DCC. The belief that DCC causes hyperbilirubinemia or symptomatic polycythemia is unsupported by the available research. Delay of cord clamping substantively increases iron stores in early infancy. Inadequate iron stores in infancy may have an irreversible impact on the developing brain despite oral iron supplementation. Iron deficiency in infancy can lead to neurologic issues in older children including poor school performance, decreased cognitive abilities, and behavioral problems. The management of the umbilical cord in complex situations is inconsistent between birth settings. A change in practice requires collaboration between all types of providers who attend births.

Timing of umbilical cord clamping: new thoughts on an old discussion

The optimal time to clamp the umbilical cord in preterm and full-term neonates after birth continues to be a matter of debate. A review of randomised controlled trials comparing the effects of early versus late cord clamping on maternal and infant outcomes was performed to assess data in favor of immediate or delayed clamping. Although there is no conclusive evidence, delayed cord clamping seems to be beneficial in preterm and full-term neonates without compromising the initial postpartum adaptation phase or affecting the mother in the short term. However, further randomised clinical studies are needed to confirm the benefits of delayed cord clamping.

Alternative positions for the baby at birth before clamping the umbilical cord

BACKGROUND

The third stage of labour is from birth of the baby until delivery of the placenta. Clamping the umbilical cord is one component of active management of the third stage. Deferring cord clamping allows blood flow between the baby and the placenta to continue; net transfer to the baby is called placental transfusion. If the cord is clamped immediately placental transfusion is restricted. Gravity is one of several factors that may influence the volume and duration of placental transfusion at both vaginal and caesarean births. Hence raising or lowering the baby whilst the cord is intact may influence placental transfusion, which in turn may affect outcome for the baby and the woman.

OBJECTIVES

To compare the effects of alternative positions for the baby between birth and cord clamping on outcome for the baby, outcome for the mother and on use of health service resources.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010).

SELECTION CRITERIA

Randomised trials comparing alternative positions for the baby at vaginal and caesarean birth, before clamping of the umbilical cord.

DATA COLLECTION AND ANALYSIS

We independently assessed trial eligibility and quality. When necessary, we contacted study authors for additional information.

MAIN RESULTS

Thirty-seven studies (7559 mother-infant pairs) were excluded: 33 (7296) because they did not compare alternative positions for the baby before clamping the umbilical cord and four (263) due to quasi-random allocation. No studies met the inclusion criteria. One additional trial is ongoing.

AUTHORS' CONCLUSIONS

No randomised trials have assessed the influence of gravity on placental transfusion. Large, well-designed randomised trials are needed to assess whether gravity influences placental transfusion at vaginal and caesarean births and, if so, whether this affects short-term and long-term outcome for the baby and for the mother.

Umbilical cord blood acid-base and gas analysis after early versus delayed cord clamping in neonates at term

OBJECTIVE

To compare umbilical cord acid-base status and blood gas analysis between umbilical cords clamped within 10 s and at 2 min of delivery.

METHODS

A total of 158 healthy full-term mothers were randomly assigned to an early clamping (<10 s post-delivery, n = 79) or delayed clamping (2 min post-delivery, n = 79) group. After application of inclusion criteria, umbilical vein blood acid-base status and gases were analyzed in 65 early clamped and 51 delayed clamped cords. Fewer cases could be examined in the umbilical artery: 55 cords in the early clamping group and 44 in the delayed one.

RESULTS

Acid-base and gas analysis results did not significantly differ between the groups in the umbilical vein or umbilical artery, with the exception of a higher (p < 0.001) mean umbilical artery pO(2) value in the delayed versus early clamping group. No significant differences in umbilical vein or artery pCO(2) or HCO(3) (-) values were observed between the early and delayed clamp groups.

CONCLUSIONS

A delay of 2 min before umbilical cord clamping does not significantly change acid-base and gas analysis results, with the exception of a higher mean umbilical artery pO(2) value in the delayed clamping group.

THIRD STAGE PRACTICES AND THE NEONATE

The third stage of labour is defined as the period following the completed delivery of the newborn until the completed delivery of the placenta and its attached membranes. Whilst to the exhausted labouring woman this stage may be an afterthought, it is a crucial time for fetal-to-neonatal transition. Major changes in anatomy and physiology occur in both mother and baby. It has also been described as ‘potentially the most hazardous part of childbirth, largely due to the risk of postpartum haemorrhage (PPH) on placental separation. Despite this, the current management guidelines are based on an ‘eclectic combination of historical, anecdotal, philosophical and research-based factors.

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes

BACKGROUND

Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord greater than one minute after the birth or when cord pulsation has ceased.

OBJECTIVES

To determine the effects of different policies of timing of cord clamping at delivery of the placenta on maternal and neonatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2007).

SELECTION CRITERIA

Randomised controlled trials comparing early and late cord clamping.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and quality and extracted data.

MAIN RESULTS

We included 11 trials of 2989 mothers and their babies. No significant differences between early and late cord clamping were seen for postpartum haemorrhage or severe postpartum haemorrhage in any of the five trials (2236 women) which measured this outcome (relative risk (RR) for postpartum haemorrhage 500 mls or more 1.22, 95% confidence interval (CI) 0.96 to 1.55). For neonatal outcomes, our review showed both benefits and harms for late cord clamping. Following birth, there was a significant increase in infants needing phototherapy for jaundice (RR 0.59, 95% CI 0.38 to 0.92; five trials of 1762 infants) in the late compared with early clamping group. This was accompanied by significant increases in newborn haemoglobin levels in the late cord clamping group compared with early cord clamping (weighted mean difference 2.17 g/dL; 95% CI 0.28 to 4.06; three trials of 671 infants), although this effect did not persist past six months. Infant ferritin levels remained higher in the late clamping group than the early clamping group at six months.

AUTHORS' CONCLUSIONS

One definition of active management includes directions to administer an uterotonic with birth of the anterior shoulder of the baby and to clamp the umbilical cord within 30-60 seconds of birth of the baby (which is not always feasible in practice). In this review delaying clamping of the cord for at least two to three minutes seems not to increase the risk of postpartum haemorrhage. In addition, late cord clamping can be advantageous for the infant by improving iron status which may be of clinical value particularly in infants where access to good nutrition is poor, although delaying clamping increases the risk of jaundice requiring phototherapy.

Early versus late cord clamping: effects on peripheral blood flow and cardiac function in term infants

BACKGROUND

In the debate on the best cord clamping time in newborn infants, we hypothesized that late cord clamping enables an increased volemia due to blood transfer to the newborn from the placenta.

AIM

To assess whether clamping time can affect limb perfusion and heart hemodynamics in a group of 22 healthy term newborn infants.

STUDY DESIGN

A case-control study.

SUBJECTS

Eleven early-clamped (at 30 s) vaginally-delivered newborn infants were compared with eleven late-clamped (at 4 min) newborns.

OUTCOME MEASURES

The two groups were studied using near-infrared spectroscopy and M-mode echocardiography.

RESULTS

Late cord clamping coincided with a higher hematocrit (median 62% versus 54%) and hemoglobin concentration (median 17.2 versus 15 g/dL), whilst there were no changes in bilirubin level. Echocardiography showed a larger end-diastolic left ventricle diameter (1.7 cm median value versus 1.5) coupled with unvaried shortening and ejection fraction values. There were no changes in calf blood flow, oxygen delivery, oxygen consumption or fractional oxygen extraction calculated from the NIRS measurements, or in foot perfusion index.

CONCLUSIONS

Our results demonstrated that late cord clamping coincides with an increased placental transfusion, expressed by higher hematocrit and hemoglobin values, and larger left ventricle diameter at the end of the diastole, with no changes in peripheral perfusion or oxygen metabolism.

The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial

BACKGROUND

The umbilical cord is usually clamped immediately after birth. There is no sound evidence to support this approach, which might deprive the newborn of some benefits such as an increase in iron storage.

OBJECTIVES

We sought to determine the effect of timing of cord clamping on neonatal venous hematocrit and clinical outcome in term newborns and maternal postpartum hemorrhage.

METHODS

This was a randomized, controlled trial performed in 2 obstetrical units in Argentina on neonates born at term without complications to mothers with uneventful pregnancies. After written parental consents were obtained, newborns were randomly assigned to cord clamping within the first 15 seconds (group 1), at 1 minute (group 2), or at 3 minutes (group 3) after birth. The infants' venous hematocrit value was measured 6 hours after birth.

RESULTS

Two hundred seventy-six newborns were recruited. Mean venous hematocrit values at 6 hours of life were 53.5% (group 1), 57.0% (group 2), and 59.4% (group 3). Statistical analyses were performed, and results were equivalent among groups because the hematocrit increase in neonates with late clamping was within the prespecified physiologic range. The prevalence of hematocrit at <45% (anemia) was significantly lower in groups 2 and 3 than in group 1. The prevalence of hematocrit at >65% was similar in groups 1 and 2 (4.4% and 5.9%, respectively) but significantly higher in group 3 (14.1%) versus group 1 (4.4%). There were no significant differences in other neonatal outcomes and in maternal postpartum hemorrhage.

CONCLUSIONS

Delayed cord clamping at birth increases neonatal mean venous hematocrit within a physiologic range. Neither significant differences nor harmful effects were observed among groups. Furthermore, this intervention seems to reduce the rate of neonatal anemia. This practice has been shown to be safe and should be implemented to increase neonatal iron storage at birth.

¿Pinzamiento precoz o tardío del cordón umbilical? Una revisión sistemática de la literatura médica

INTRODUCTION

There is wide variability in clinical practice in the moment of clamping the umbilical cord. Opinions in the medical community differ on the harm and/or benefits, both for the mother and for the newborn, of early versus late cord clamping. Currently, the debate among those who defend and/or criticize one or other of these practices continues. The aim of this study was to evaluate the effects of early versus late clamping of the umbilical cord in full-term newborns on maternal and neonatal outcomes.

MATERIAL AND METHODS

A literature search of randomized clinical trials was carried out in the Cochrane Library, MEDLINE and Lilacs. It was completed with a hand search of references in relevant articles. All randomized controlled clinical trials of good methodological quality that compared early versus late cord clamping in term newborns were selected.

RESULTS

Of seven identified studies, four had the required characteristics for inclusion in this systematic review. Comparison of early versus late clamping in these studies revealed that late clamping could diminish the prevalence of children with low iron reserves at 3 months of age by 50%, but this result comes from a study that lost more than 40% of the patients during follow-up. The results concerning anemia at 3 months of age showed statistical heterogeneity since the two studies that analyzed this outcome had opposite results. For other outcomes such as birth weight, Apgar < 5, and tachypnea the studies were too small for significant differences to be detected.

CONCLUSIONS

This review shows that there is no clear evidence for defending any of the modalities of cord clamping in full-term newborns. Further research is needed to identify the best moment for cord clamping.

Assessing psychosocial risk in pregnant/postpartum women using the Contextual Assessment of Maternity Experience (CAME)--recent life adversity, social support and maternal feelings

BACKGROUND

The Contextual Assessment of Maternity Experience (CAME) interview was developed to characterise the psychosocial context relevant to the maternity experience by providing a detailed picture of women's lives during the transition to motherhood. More specifically, it was designed to enable the assessment of major risk factors for emotional disturbances in pregnant and postpartum women, especially depression, within the same instrument and using a coherent methodological framework.

METHOD

The CAME assesses three domains relevant to motherhood: 1) recent life adversity or stressors; 2) the quality of social support and key relationships including partner relationship; and 3) maternal feelings towards pregnancy, motherhood and the baby. Two high-risk samples of inner-city London women were used to test the psychometric qualities of the CAME components.

RESULTS

Overall, the internal consistencies of the relevant components were high in both samples examined. The validity of the three components of the measure was evidenced by their association with either maternal characteristics or parenting assessments.

CONCLUSION

It was concluded that the CAME shows promise as a measure of the psychosocial risk factors involved in the maternity experience for future research in this field.

The Effect of Bather and Location of First Bath on Maintaining Thermal Stability in Newborns

OBJECTIVE

To compare thermal stability during the first bath of newborns bathed by maternal-child nurses in a newborn nursery with thermal stability of newborns bathed by parents at the maternal bedside.

DESIGN

A randomized clinical controlled trial.

SETTING

A tertiary care hospital in western Canada.

PARTICIPANTS

Participants (N = 111) were full-term newborns born vaginally.

INTERVENTIONS

The experimental treatment was the parent bathing the newborn under nursing supervision at the bedside in the first few hours of birth; the standard treatment was a nurse bathing the newborn in an admission nursery.

MAIN OUTCOME MEASURES

The main outcome measure was newborn heat loss occurring from bathing as assessed by changes in aural temperatures, which were taken before, during, and following bathing.

RESULTS

There was no difference in temperature change between newborns bathed by a nurse and those bathed by a parent (F = 0.595, df = 1, p = .442). A return to normal thermal ranges takes approximately an hour.

CONCLUSION

Heat loss experienced by newborns during bathing is significant and is not associated with who bathes the newborn or where the bath takes place.

Current best evidence: a review of the literature on umbilical cord clamping

Immediate clamping of the umbilical cord can reduce the red blood cells an infant receives at birth by more than 50%, resulting in potential short-term and long-term neonatal problems. Cord clamping studies from 1980 to 2001 were reviewed. Five hundred thirty-one term infants in the nine identified randomized and nonrandomized studies experienced late clamping, ranging from 3 minutes to cessation of pulsations, without symptoms of polycythemia or significant hyperbilirubinemia. Higher red blood cell flow to vital organs in the first week was noted, and term infants had less anemia at 2 months and increased duration of early breastfeeding. In seven randomized trials of preterm infants, benefits associated with delayed clamping in these infants included higher hematocrit and hemoglobin levels, blood pressure, and blood volume, with better cardiopulmonary adaptation and fewer days of oxygen and ventilation and fewer transfusions needed. For both term and preterm infants, few, if any, risks were associated with delayed cord clamping. Longitudinal studies of infants with immediate and delayed cord clamping are needed.

Placing the newborn on the maternal abdomen after delivery increases the volume and CD34 cell content in the umbilical cord blood collected: an old maneuver with new applications

OBJECTIVE

Our purpose was to increase the number of the progenitor cells in umbilical cord blood collected for transplantation.

STUDY DESIGN

We randomly assessed the effect of "upper" and "lower" positions of the newborn on the volume and progenitor cell (CD34(+)) content of the umbilical cord blood collected from 49 healthy, vaginally delivered, term neonates.

RESULTS

Twenty-two collections were performed in the "upper" and 27 in the "lower" position. The volume of umbilical cord blood obtained in the "upper" position was 108.1 +/- 19.1 mL compared with 42.6 +/- 19.5 mL in the "lower" position (P <.0001). Mononuclear cell separation revealed significantly higher numbers of cells in umbilical cord blood obtained in the "upper" group (P <.01). Although the percentage of CD34(+) cells was comparable, the absolute number of CD34(+) cells was significantly higher in the "upper" group because of the larger volume collected (P <.02). At 24 hours after delivery the hemoglobin levels were not significantly different between newborns of the 2 groups.

CONCLUSIONS

Placing the newborn on the maternal abdomen after delivery and before cord clamping may significantly increase the volume of umbilical cord blood collected and therefore the CD34(+) counts that improve transplantation success without placing the mother or the newborn at risk.

Effects of Leboyer childbirth on left- and right systolic time intervals in healthy term neonates

The Leboyer birth method requires that the newborn infant is placed on the mothers abdomen and the cord is clamped when it stops pulsating. Since late cord-clamping may result in marked hypervolemia and polycythemia of the neonate, we studied right and left ventricular systolic time intervals by means of pulsed-Doppler echocardiography. Left and right ventricular preejection periods (LPEP, RPEP), right time peak velocity (RTPV), left and right ventricular ejection times (LVET, RVET), and ratio of RTPV/RVET(c) corrected for heart rate were studied in 15 fullterm neonates with early (< 10s) cord clamping and in 15 fullterm neonates delivered according to Leboyer (cord clamping after 3 min) on day 1 (2-4 h after birth) and day 5. After Leboyer birth hematocrit was significantly increased on day 1 (0.61 +/- 0.06 vs. 0.53 +/- 0.07) and on day 5 (0.57 +/- 0.02 vs. 0.50 +/- 0.07). Blood pressure was similar in both groups and increased by about 10% from day 1 to day 5. LVET and RVET were not affected by the mode of placental transfusion, thereby suggesting normal left and right ventricular function after Leboyer birth. The LPEP/LVET (0.36 +/- 0.09 vs. 0.30 +/- 0.08) and RPEP/RVET ratio (0.41 +/- 0.11 vs. 0.33 +/- 0.08) were significantly higher in the Leboyer group (p < 0.05) compared to the early cord clamped group suggesting higher systemic and pulmonary resistance. RPEP decreased significantly by 17% in the control group from day 1 to day 5 (p < 0.05), but did not change in the Leboyer group. In the Leboyer group RPEP/RVET ratio decreased significantly from day 1 to day 5, whereas the control values did not change during the first five days. RTPV:RVET(c) is inversely related to pulmonary artery pressure. A normal ratio is > 0.35, or greater. Mean ratio of RTPV : RVET(c) was significantly lower in the Leboyer group (0.31 +/- 0.08) on day 1 compared to the control group (0.41 +/- 0.09; p < 0.05), but did not differ on day 5. The results suggest that Leboyer delivery was associated with transiently increased pulmonary and systemic resistance, whereas right and left ventricular functions were not affected. This may be explained by increased blood viscosity due to increased hematocrit.

Axillary temperature in transitional newborn infants before and after tub bath

Twenty healthy newborn infants (mean 38.4 weeks gestation and 3,294 g) were studied to compare axillary temperatures before and after a deep-water tub bath. The bath was given in the mother's room in a plastic bassinet filled with 5 to 5 1/2 inches of warm water. Mean time was 4.4 hours postbirth. Mean infant temperature was 98.2 degrees F (36.8 degrees C) prebath and 98.0 degrees F (36.7 degrees C) postbath. Mean change was -0.2 degree F (-0.1 degree C) and was not significantly different. This significant absence of heat loss during tub baths suggests that infants need not be separated from their mothers and kept in nurseries under infrared warmers to prevent heat loss during their first bath.

Evaluation of the meta-analyses on the effects, on both mother and baby, of the various components of 'active' management of the third stage of labour

In their comprehensive review of controlled trials, Prendiville and Elbourne (1989) used the technique of meta-analysis to study the effects, on both mother and baby, of various aspects of third stage management, acknowledging some of the shortcomings of the trials used. This paper questions some of the conclusions which these authors drew and, drawing on other evidence (some of which has been published since the review), puts forward alternative interpretations of some of the meta-analyses. Reference is also made to the updated meta-analyses in the Cochrane Pregnancy and Childbirth Database (Elbourne, 1994a-h). In addition, this paper examines the extent to which the findings of the Bristol and Dublin third stage trials (Prendiville et al, 1988; Begley, 1990) add to our understanding of what is effective care during the third stage of labour.

The effect of Leboyer delivery on blood viscosity and other hemorheologic parameters in term neonates

OBJECTIVE

This study was done to compare postnatal alterations in blood viscosity, hematocrit value, plasma viscosity, red blood cell aggregation, and red blood cell deformability in term neonates undergoing both early umbilical cord clamping and delivery according to the Leboyer method.

STUDY DESIGN

The umbilical cords of 15 healthy, term infants were clamped within 10 seconds of birth (early cord clamping), and 15 infants delivered according to the Leboyer method were placed on the mother's abdomen, and the umbilical cords were clamped 3 minutes after birth. Hemorheologic parameters were studied in umbilical cord blood at 2 hours, 24 hours, and 5 days from the time of delivery.

RESULTS

The residual fetal placental blood volume decreased from 45 +/- 8 ml/kg (x +/- SD) after early cord clamping to 25 +/- 5 ml/kg after delivery by the Leboyer method. After Leboyer-method delivery, the hematocrit value rose from 48% +/- 5% at birth to 58% +/- 6% 2 hours after delivery, 56% +/- 7% at 24 hours, and 54% +/- 8% after 5 days. Blood viscosity in the Leboyer-method group increased by 32% within the first 2 hours but did not change significantly during the following 5 days. Plasma viscosity, red blood cell aggregation, and red blood cell deformability were not affected by the mode of cord clamping.

CONCLUSIONS

Delivery by the Leboyer method leads to a significant increase in blood viscosity as a result of increasing hematocrit value, whereas other hemorheologic parameters are similar to those of infants with early cord clamping.

Analgesia and satisfaction in childbirth (the Queen Charlotte's 1000 Mother Survey)

Maternal satisfaction with the experience of childbirth was investigated in 1000 women having a vaginal delivery of a live child. Effective pain relief did not ensure a satisfactory birth experience. Epidural block produced the most effective analgesia but there were more dissatisfied women among the epidural patients than among those who did not receive this analgesia (p less than 0.05). Bad experience scores were evaluated one year later and were clearly related to a forceps delivery and long labour, both of which were more common in the epidural group. The desirability of an "epidural on demand" service should be tested against an "epidural when necessary" service.

Observations on the behavioral state of newborn infants during the first hour of life. A comparison of infants delivered by the Leboyer and conventional methods

Minute-by-minute observations are reported on the behavioral state during the first hour of life of 18 term infants delivered by the Leboyer (L) method and 18 by the conventional (C) method. The mothers were unmedicated and only two women in each group received epidural anesthetics. All deliveries were spontaneous and the infants were healthy. The behavioural states of both groups of infants were very similar, with the infants spending approximately 60% of the first hour in the quiet-alert state (median time: L = 41.5 C = 35.0 minutes) and only 10% of the time in the irritable-crying state. ALthough there were some individual differences, both groups of infants spent the second 30 minutes of the first hour predominantly in the quiet-alert state. The clinical relevance of these observations is that the first hour of life can be used to advantage in promoting parent-infant interaction.