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Amendolia B, Kilic N, Afridi F, Qari O, Bhat V, Nakhla D, Sadre S, Eckardt R, Nakhla T, Bhandari V, Aghai ZH. Delayed Cord Clamping for 45 Seconds in Very Low Birth Weight Infants: Impact on Hemoglobin at Birth and Close to Discharge. Am J Perinatol 2024; 41:e126-e132. [PMID: 35523407 DOI: 10.1055/a-1845-1816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES To assess the impact of delayed cord clamping (DCC) for 45 seconds on hemoglobin at birth and close to discharge in very low birth weight (VLBW) infants and to compare modes of delivery in infants who received DCC. STUDY DESIGN In a retrospective study, 888 VLBW infants (≤1,500 g) who survived to discharge and received immediate cord clamping (ICC) were compared with infants who received DCC. Infants who received DCC and born via Cesarean section (C-section) were compared with those born via vaginal birth. RESULTS A total of 555 infants received ICC and 333 DCC. Only 188 out of 333 VLBW infants (56.5%) born during the DCC period received DCC. DCC was associated with higher hemoglobin at birth (15.9 vs. 14.9 g/dL, p = 0.001) and close to discharge (10.7 vs. 10.1 g/dL, p < 0.001) and reduced need for blood transfusion (39.4 vs. 54.9%, p < 0.001). In the DCC group, hemoglobin at birth and close to discharge was similar in infants born via C-section and vaginal birth. CONCLUSION DCC for 45 seconds increased hemoglobin at birth and close to discharge and reduced need for blood transfusion in VLBW infants. DCC for 45 seconds was equally effective for infants born by C-section and vaginal delivery. Approximately 44% of VLBW infants did not receive DCC even after implementing DCC guidelines. KEY POINTS · Studies to date have shown that DCC improves mortality and short- and long-term outcomes in VLBW infants.. · No consistent guidelines for the duration of DCC in preterm and term neonates.. · DCC for 45 seconds increased hemoglobin at birth and close to discharge in VLBW infants..
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Affiliation(s)
- Barbara Amendolia
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Nicole Kilic
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Faraz Afridi
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Omar Qari
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Vishwanath Bhat
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Daniel Nakhla
- Rutgers University, The State University of NJ, New Brunswick, New Jersey
| | - Sara Sadre
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Rebecca Eckardt
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Tarek Nakhla
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Zubair H Aghai
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, Pennsylvania
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Quinn MK, Katheria A, Bennett M, Lu T, Lee H. Delayed Cord Clamping Uptake and Outcomes for Infants Born Very Preterm in California. Am J Perinatol 2024; 41:e981-e987. [PMID: 36351446 DOI: 10.1055/a-1975-4607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study is to investigate whether the purported benefits of delayed cord clamping (DCC) translate into a reduction in mortality and intraventricular hemorrhage (IVH) among preterm neonates in practice. STUDY DESIGN This was a prospective cohort study of very preterm infants constructed from data from the California Perinatal Quality Care Collaborative for infants admitted into 130 California neonatal intensive care units (NICUs) within the first 28 days of life from 2016 through 2020. Individual-level analyses were conducted using log-binomial regression models controlling for confounders and allowing for correlation within hospitals to examine the relationship of DCC to the outcomes of mortality and IVH. Hospital-level analyses were conducted using Poisson regression models with robust variance controlling for confounders. RESULTS Among 13,094 very preterm infants included (5,856 with DCC and 7,220 without), DCC was associated with a 43% lower risk of mortality (adjusted risk ratio [aRR]: 0.57; 95% confidence interval [CI]: 0.47-0.66). Furthermore, every 10% increase in the hospital rate of DCC among preterm infants was associated with a 4% lower hospital mortality rate among preterm infants (aRR: 0.96; 95% CI: 0.96-0.99). DCC was associated with severe IVH at the individual level, but not at the hospital level. CONCLUSION At the individual level and hospital level, the use of DCC was associated with lower mortality among preterm infants admitted to NICUs in California. These findings are consistent with clinical trial results, suggesting that the effects of DCC seen in clinical trials are translating to improved survival in practice. KEY POINTS · DCC was associated with lower mortality among very preterm newborns in California.. · Hospitals using DCC more often had lower very preterm mortality.. · DCC was not associated with IVH at the hospital level..
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Affiliation(s)
- Mary K Quinn
- Department of Pediatrics, Stanford University, Stanford, California
| | - Anup Katheria
- Department of Pediatrics, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
| | - Mihoko Bennett
- Department of Pediatrics, Stanford University, Stanford, California
| | - Tianyao Lu
- Department of Pediatrics, Stanford University, Stanford, California
| | - Henry Lee
- Department of Pediatrics, Stanford University, Stanford, California
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McDonald SD. 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 2023:151790. [PMID: 37349189 DOI: 10.1016/j.semperi.2023.151790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Deferred1 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.
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Affiliation(s)
- Sarah D McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, ON, Canada; Department of Radiology, McMaster University, ON, Canada.
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Liebowitz M, Kramer KP, Rogers EE. All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit. Clin Perinatol 2023; 50:399-420. [PMID: 37201988 DOI: 10.1016/j.clp.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Neonates requiring intensive care are in a critical period of brain development that coincides with the neonatal intensive care unit (NICU) hospitalization, placing these infants at high risk of brain injury and long-term neurodevelopmental impairment. Care in the NICU has the potential to be both harmful and protective to the developing brain. Neuro-focused quality improvement efforts address 3 main pillars of neuroprotective care: prevention of acquired injury, protection of normal maturation, and promotion of a positive environment. Despite challenges in measurement, many centers have shown success with consistent implementation of best and potentially better practices that may improve markers of brain health and neurodevelopment.
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Affiliation(s)
- Melissa Liebowitz
- Envision Physician Services, St. Francis Hospital, 6001 East Woodmen Road, Colorado Springs, CO 80923, USA
| | - Katelin P Kramer
- Department of Pediatrics, University of California, 550 16th Avenue, 5th Floor, San Francisco, CA 94143, USA; University of California, Benioff Children's Hospital, 550 16th Avenue, 5th Floor, San Francisco, CA 94143, USA.
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California, 550 16th Avenue, 5th Floor, San Francisco, CA 94143, USA; University of California, Benioff Children's Hospital, 550 16th Avenue, 5th Floor, San Francisco, CA 94143, USA. https://twitter.com/eerogersmd
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Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States; Division of Newborn Medicine, Harvard Medical School, Boston MA, United States.
| | - Justin Goldstein
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States
| | - Henry C. Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford CA, United States
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States,Division of Newborn Medicine, Harvard Medical School, Boston MA, United States
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Differential effects of delayed cord clamping on bilirubin levels in normal and diabetic pregnancies. Eur J Pediatr 2022; 181:3111-3117. [PMID: 35751710 DOI: 10.1007/s00431-022-04536-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/09/2022] [Accepted: 06/07/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED The purpose of the study is to investigate the effects of delayed cord clamping on bilirubin levels and phototherapy rates in neonates of diabetic mothers. This was a prospective study that enrolled pregnant women without pregnancy complications and those with diabetes. Their neonates were randomized in a 1:1 ratio to delayed cord clamping. The main outcomes were the neonatal transcutaneous bilirubin values on 2-4 days postpartum and the rate of requiring phototherapy in infants. A total of 261 pregnant women were included in the final analysis (132 women with diabetic pregnancies and 129 women with normal pregnancies). In diabetic pregnancies, neonatal bilirubin levels on the 2-4 days postpartum and phototherapy rates were significantly higher in the delayed cord clamping group than in the immediate cord clamping group (7.65 ± 1.83 vs 8.25 ± 1.96, P = 0.039; 10.35 ± 2.23 vs 11.54 ± 2.56, P = 0.002; 11.54 ± 2.94 vs 12.83 ± 3.07 P = 0.024, 18.2% vs 6.3%, P = 0.042), while in normal pregnancies, there was no statistical difference in bilirubin values and phototherapy rates between the delayed cord clamping group and the immediate cord clamping group (P > 0.05). After receiving delayed cord clamping, bilirubin levels on the third postnatal day and the rate of requiring phototherapy in infants were higher in the diabetic pregnancy group than in the normal pregnancy group (10.35 ± 2.23 vs 11.54 ± 2.56, P = 0.013). CONCLUSION Delayed cord clamping increased the risk of jaundice in newborns born to diabetic mothers, but had no effect in newborns from mothers with normal pregnancies. DCC may be a risk factor for increased bilirubin in infants of diabetic mothers. TRIAL REGISTRATION ClinicalTrials.gov: NCT04369313; date of registration: April 27, 2020 (retrospectively registered). WHAT IS KNOWN • Delayed cord clamping had significant benefits for newborns by increasing neonatal hemoglobin levels and reducing the risk of neonatal anemia, etc. • Delayed cord clamping may lead to neonatal hyperemia, erythrocytosis, and hyperbilirubinemia, which increases the risk of neonatal jaundice. WHAT IS NEW • Our trial focused on the differential effects of delayed cord clamping on jaundice in full-term newborns between diabetic pregnancies and normal pregnancies. And newborns of diabetic mothers who received delayed cord clamping had a significantly increased risk of jaundice compared to newborns with normal pregnancy. • Delayed cord clamping may be a risk factor for increased bilirubin levels in neonates of diabetic mothers.
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Whitesel E, Goldstein J, Lee HC, GuptaMMSc M. Quality Improvement for Neonatal Resuscitation and Delivery Room Care. SEMINARS IN SPINE SURGERY 2022:100961. [PMID: 35574250 PMCID: PMC9080026 DOI: 10.1016/j.semss.2022.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Henry C Lee
- Stanford University School of Medicine, Stanford, CA
| | - Munish GuptaMMSc
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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8
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Singh N, Brammer D. Delayed cord clamping in infants born less than 35 weeks: A retrospective study. J Neonatal Perinatal Med 2020; 14:391-395. [PMID: 33325400 DOI: 10.3233/npm-200497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Evidence supports delayed cord clamping (DCC) in preterm infants. However, practice variation exists, and many preterm infants do not receive DCC despite multiple benefits and lack of harm. We aim to 1) study the rate of DCC in preterm infants, 2) compare the difference between infants who received DCC and those who did not receive DCC and 3) investigate the reasons for not performing DCC. METHODS We conducted this retrospective study to evaluate DCC practice at our institution since its implementation in September 2015. We collected and analyzed the data on DCC of 30-45 sec duration in inborn infants < 35 weeks gestation admitted to the neonatal intensive care unit from June 2016- June 2019. The primary outcome was the rate of delayed cord clamping. RESULTS Of the 447 infants, 275 (62%) received DCC. The rate of DCC was 36%, 54%, and 66% in infants < 27 weeks, 27-29 weeks and > 30 weeks gestation, respectively (p = 0.001). Infants not receiving DCC were smaller, of lower gestational age, and more likely to be delivered via cesarean section than those who received DCC (p < 0.0001). Infants not receiving DCC had a higher rate of receiving PPV or intubation and a 1minute Apgar score of < 5 compared to those receiving DCC. We could not establish the reason for not performing DCC because of inadequate documentation in the medical records. CONCLUSIONS The rate of DCC is low in clinical practice, particularly among extremely preterm infants.
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Affiliation(s)
- N Singh
- Neonatology Division, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - D Brammer
- Neonatology Division, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Abstract
Objective: To examine the practice of delayed cord clamping and associated neonatal outcomes in preterm dichorionic twin gestations.Study design: This is a retrospective cohort study of women delivering dichorionic-diamniotic twin gestations between 23 and 32 weeks of gestation at a single large academic center between 2013 and 2015. Neonatal outcomes of twins receiving delayed cord clamping were compared to those who did not.Results: Of 58 eligible women delivering dichorionic twins, eight (13.8%) had both neonates receive delayed cord clamping, resulting in 16 neonates who received delayed cord clamping and 100 who did not. Neonates who received delayed cord clamping had no difference in umbilical artery pH, 5 min Apgar score, NICU length of stay, need for pressors, neonatal death, or other adverse outcomes.Conclusions: Delayed cord clamping in dichorionic twin gestations born at 32 weeks or less is feasible and in this small cohort does not appear to be associated with worse neonatal outcomes.
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Affiliation(s)
- Lilly Y Liu
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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10
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Timing of umbilical cord clamping and neonatal jaundice in singleton term pregnancy. Early Hum Dev 2020; 142:104948. [PMID: 31927308 DOI: 10.1016/j.earlhumdev.2019.104948] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/17/2019] [Accepted: 12/30/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Delayed cord clamping was not adopted widely in China because of the potential effect of neonatal hyperbilirubinemia, jaundice and polycythemia, and the optimal cord clamping time remained controversial. AIM To assess the effect of delayed cord clamping versus early cord clamping on neonatal jaundice for term infants. STUDY DESIGN This retrospective study included 1981 mother-infant pairs, who were assigned to early cord clamping groups (n = 1005) and delayed cord clamping group (n = 949). The delayed cord clamping included three subgroups (30-60 s, 61-90 s, 91-120 s). The main outcomes were transcutaneous bilirubin levels at 0 to 4 days of age, the rate of jaundice requiring phototherapy, the neonatal hematological status at 1 to 3 days after birth. RESULTS Compared with the early cord clamping group, the neonatal transcutaneous bilirubin level did not differ and the neonatal hematological status (hemoglobin and hematocrit levels) were improved in combined and three subgroups of delayed cord clamping group. Increasing the duration of cord clamping from 90 s to 120 s did not result in further increases in hemoglobin and hematocrit levels but led to a trend towards a higher risk of neonatal jaundice requiring phototherapy and neonatal polycythemia. CONCLUSIONS Delayed cord clamping for <90 s in healthy term infants may not only improve the early hematological status of newborns but also avoid excessive neonatal jaundice requiring phototherapy.
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Association of a Delayed Cord-Clamping Protocol With Hyperbilirubinemia in Term Neonates. Obstet Gynecol 2020; 133:754-761. [PMID: 30870273 DOI: 10.1097/aog.0000000000003172] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the implementation of a delayed cord-clamping protocol at an academic medical center, and its short-term associations on term neonates. METHODS This was a retrospective cohort study of women aged 18 years or older delivering a term neonate at an academic medical center before and 5-7 months after implementation of a universal delayed cord-clamping protocol (October-December 2015 and October-December 2016, respectively). The primary outcome measure was the mean peak neonatal transcutaneous bilirubin level, with secondary outcome measures including mean initial transcutaneous bilirubin levels, mean serum bilirubin levels, number of serum bilirubin levels drawn, incidence of clinical jaundice, and phototherapy. RESULTS Protocol adherence was 87.8%. Data are presented on 424 neonates. The mean peak neonatal transcutaneous bilirubin levels were significantly higher among neonates in the postprotocol group (10.0±3.4 mg/dL vs 8.4±2.7 mg/dL, P<.01). More neonates in the postprotocol group were diagnosed with jaundice (27.2% vs 16.6%; odds ratio [OR] 1.88; 95% CI 1.17-3.01) and required serum blood draws (43.7% vs 29.4%; OR 1.86; 95% CI 1.25-2.78). However, there were no differences in mean peak serum bilirubin levels between groups (9.7±3.0 mg/dL vs 9.1±3.1 mg/dL, P=.17) or need for phototherapy (5.2% vs 6.6%, OR 1.28; 95% CI 0.57-2.89). CONCLUSION Implementation of a delayed cord-clamping protocol for term neonates was associated with significantly higher mean transcutaneous bilirubin levels, an increased number of serum blood draws, and more clinical diagnoses of jaundice, although there was no increase in the incidence of phototherapy.
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Anton O, Jordan H, Rabe H. Strategies for implementing placental transfusion at birth: A systematic review. Birth 2019; 46:411-427. [PMID: 30264508 DOI: 10.1111/birt.12398] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Enhanced placental transfusion reduces adverse neonatal outcomes, including death. Despite being endorsed by the World Health Organization in 2012, the method has not been adopted widely in practice. METHODS We performed a systematic literature search and included quality improvement projects on placental transfusion at birth and studies on barriers to implementation. We extracted information on population, methods of implementation, obstacles to implementation, and strategies to overcome them. RESULTS We screened 99 studies out of which 18 were included in the review. The preferred methods of implementation were protocol development (86% of studies) reinforced by targeted education (64% of studies) and multidisciplinary team involvement (43% of studies). Barriers to implementation were mentioned in 12 studies and divided into four categories: general factors such as lack of staff awareness (5 studies) and professional resistance to change (5 studies); obstetrician-specific concerns, including the impact during cesarean (3 studies) and the risk of postpartum hemorrhage (3 studies); pediatrician-specific concerns, including the need for resuscitation (5 studies), risk of jaundice (3 studies), and polycythemia (2 studies); and logistical difficulties. The main strategies to facilitate placental transfusion at birth included effective multidisciplinary team collaboration, protocol development, targeted education, and constructive feedback sessions. CONCLUSIONS Placental transfusion implementation requires a multidisciplinary approach, with obstetricians, midwives, nurses, and pediatricians central to adoption of the practice. Understanding the obstacles to implementation informs strategies to increase placental transfusion adoption of practice worldwide. We suggest a stepwise approach to implementation and enhancement of placental transfusion into practice.
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Affiliation(s)
- Oana Anton
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK
| | - Harriet Jordan
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK
| | - Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK.,Academic Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK
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13
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Early versus delayed umbilical cord clamping on maternal and neonatal outcomes. Arch Gynecol Obstet 2019; 300:531-543. [PMID: 31203386 PMCID: PMC6694086 DOI: 10.1007/s00404-019-05215-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
Purpose Policies for timing of cord clamping varied from early cord clamping (ECC) in the first 30 s after birth, to delayed cord clamping (DCC) in more than 30 s after birth or when cord pulsation has ceased. DCC, an inexpensive method allowed physiological placental transfusion. The aim of this article is to review the benefits and the potential harms of early versus delayed cord clamping. Methods Narrative overview, synthesizing the findings of the literature retrieved from searches of computerized databases. Results Delayed cord clamping in term and preterm infants had shown higher hemoglobin levels and iron storage, the improved infants’ and children’s neurodevelopment, the lesser anemia, the higher blood pressure and the fewer transfusions, as well as the lower rates of intraventricular hemorrhage (IVH), chronic lung disease, necrotizing enterocolitis, and late-onset sepsis. DCC was seldom associated with lower Apgar scores, neonatal hypothermia of admission, respiratory distress, and severe jaundice. In addition, DCC was not associated with increased risk of postpartum hemorrhage and maternal blood transfusion whether in cesarean section or vaginal delivery. DCC appeared to have no effect on cord blood gas analysis. However, DCC for more than 60 s reduced drastically the chances of obtaining clinically useful cord blood units (CBUs). Conclusion Delayed cord clamping in term and preterm infants was a simple, safe, and effective delivery procedure, which should be recommended, but the optimal cord clamping time remained controversial.
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Meyer MP, Nevill E. Optimizing Cord Clamping in Preterm Infants: One Strategy Does Not Fit All. Front Pediatr 2019; 7:46. [PMID: 30873393 PMCID: PMC6400845 DOI: 10.3389/fped.2019.00046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/04/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael P. Meyer
- Middlemore Hospital, Auckland, New Zealand
- Department of Paediatrics, The University of Auckland, Auckland, New Zealand
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Mian Q, Cheung PY, O'Reilly M, Barton SK, Polglase GR, Schmölzer GM. Impact of delivered tidal volume on the occurrence of intraventricular haemorrhage in preterm infants during positive pressure ventilation in the delivery room. Arch Dis Child Fetal Neonatal Ed 2019; 104:F57-F62. [PMID: 29353261 DOI: 10.1136/archdischild-2017-313864] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Delivery of inadvertent high tidal volume (VT) during positive pressure ventilation (PPV) in the delivery room is common. High VT delivery during PPV has been associated with haemodynamic brain injury in animal models. We examined if VT delivery during PPV at birth is associated with brain injury in preterm infants <29 weeks' gestation. METHODS A flow-sensor was placed between the mask and the ventilation device. VT values were compared with recently described reference ranges for VT in spontaneously breathing preterm infants at birth. Infants were divided into two groups: VT<6 mL/kg or VT>6 mL/kg (normal and high VT, respectively). Brain injury (eg, intraventricular haemorrhage (IVH)) was assessed using routine ultrasound imaging within the first days after birth. RESULTS A total of 165 preterm infants were included, 124 (75%) had high VT and 41 (25%) normal VT. The mean (SD) gestational age and birth weight in high and normal VT group was similar, 26 (2) and 26 (1) weeks, 858 (251) g and 915 (250) g, respectively. IVH in the high VT group was diagnosed in 63 (51%) infants compared with 5 (13%) infants in the normal VT group (P=0.008).Severe IVH (grade III or IV) developed in 33/124 (27%) infants in the high VT group and 2/41 (6%) in the normal VT group (P=0.01). CONCLUSIONS High VT delivery during mask PPV at birth was associated with brain injury. Strategies to limit VT delivery during mask PPV should be used to prevent high VT delivery.
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Affiliation(s)
- Qaasim Mian
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Samantha K Barton
- The Ritchie Centre, Hudson Institute of Medical Research, and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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16
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Abstract
Advances made in the last several decades in the care of the fetus and newborn have had a significant impact on morbidity and mortality. Delayed umbilical cord clamping in the preterm newborn results in fewer transfusions for anemia, decreased intraventricular hemorrhage, and decreased necrotizing enterocolitis. Because of advances made in fetal ultrasound diagnosis and technological advances, fetal surgeries to treat congenital diaphragmatic hernia, myelomeningocele, twin-to-twin transfusion syndrome, fetal lower urinary tract obstructions, amniotic band syndrome, and congenital cystic adenoid malformation or congenital pulmonary airway malformations have improved the quality of life and survival for these patients.
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Affiliation(s)
- Karen M Frank
- Department of Nursing, Towson University, LI 322, 8000 York Road, Towson, MD 21252, USA.
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Clinical Outcomes in Preterm Infants Following Institution of a Delayed Umbilical Cord Clamping Practice Change. Adv Neonatal Care 2018; 18:223-231. [PMID: 29794839 DOI: 10.1097/anc.0000000000000492] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence supports a significant reduction in the incidence of intraventricular hemorrhage (IVH) in preterm infants receiving delayed umbilical cord clamping (DCC). PURPOSE This study evaluated clinical feasibility, efficacy, and safety outcomes in preterm infants (<36 weeks' gestational age) who received DCC following a practice change implementation intended to reduce the incidence of IVH. METHODS Infants receiving DCC (45-60 seconds) were compared with a sample of infants receiving immediate umbilical cord clamping (<15 seconds) in a retrospective chart review (N = 354). The primary outcome measure was the prevalence of IVH. Secondary safety outcome measures of 1- and 5-minute Apgar scores, axillary temperature on neonatal intensive care unit admission, and initial 24-hour bilirubin level were also evaluated. Gestational age was examined for its effect on outcomes. RESULTS Although the small number of infants with IVH precluded the ability to detect statistical significance, our raw data suggest DCC is efficacious in reducing the risk for IVH. For infants 29 or less weeks' gestational age, admission axillary temperature was significantly higher in those who received DCC. No differences were found in 1- and 5-minute Apgar scores, 24-hour bilirubin level, or hematocrit level between the two groups. Infants more than 29 weeks' gestational age who received DCC had significantly higher 1-minute Apgar scores, temperature, and 24-hour bilirubin level. IMPLICATIONS FOR PRACTICE Clinicians should advocate for the implementation of DCC as part of the resuscitative process for preterm neonates. IMPLICATIONS FOR RESEARCH Future studies are needed to evaluate the effect of DCC on other clinical outcomes and to investigate umbilical cord milking as an alternative approach to DCC.
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18
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Rhoades JS, Bierut T, Conner SN, Tuuli MG, Vesoulis ZA, Macones GA, Cahill AG. Delayed Umbilical Cord Clamping at <32 Weeks' Gestation: Implementation and Outcomes. Am J Perinatol 2017; 34:1048-1053. [PMID: 28561189 PMCID: PMC5578907 DOI: 10.1055/s-0037-1603591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study aims to evaluate the implementation of a delayed umbilical cord clamping (DCC) protocol for neonates <32 weeks. Secondarily, to evaluate the impact of DCC on maternal outcomes and on the ability to obtain umbilical cord blood gases. STUDY DESIGN Retrospective cohort study from November 2014 to March 2016 of patients delivered by 316/7 weeks. In 2014, an institutional protocol for DCC at <32 weeks was implemented. We assessed adherence to the protocol and compared adverse maternal outcomes (utilizing a hemorrhage composite). We evaluated the impact of DCC on the ability to obtain adequate umbilical cord blood gas specimens. RESULTS Of the 185 patients included in the study, 90 underwent DCC, and 72% of potentially eligible patients appropriately received DCC. There was no significant difference in the maternal hemorrhage composite outcome between DCC and immediate cord clamping (23.3 vs. 36.8%, adjusted odds ratio = 0.64, 95% confidence interval = 0.33, 1.26). There was also no significant difference in the ability to obtain a single or paired umbilical cord blood gas result. CONCLUSION Implementation of a DCC protocol for preterm neonates is feasible and was successful. We did not find an increase in maternal risk or a decrease in the ability to obtain umbilical cord blood gases following DCC.
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Affiliation(s)
- Janine S. Rhoades
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
| | - Tatiana Bierut
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
| | - Shayna N. Conner
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
| | - Methodius G. Tuuli
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
| | - Zachary A. Vesoulis
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - George A. Macones
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
| | - Alison G. Cahill
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
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Abstract
Necrotizing enterocolitis (NEC) is a multifactorial disease that occurs when multiple risk factors and/or stressors overlap, leading to profound inflammation and intestinal injury. Due to its multifactorial nature, there has been much uncertainty in identifying clear strategies for prevention of NEC. Despite these obstacles, the incidence of NEC has gradually been decreasing over the past 10 years, in part due to quality improvement (QI) initiatives to prevent NEC. Current QI strategies primarily target the various predisposing conditions. This article reviews the evidence on which QI interventions to prevent NEC have been based and provides examples of successful QI interventions.
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20
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Garg BD, Kabra NS, Bansal A. Role of delayed cord clamping in prevention of necrotizing enterocolitis in preterm neonates: a systematic review. J Matern Fetal Neonatal Med 2017; 32:164-172. [PMID: 28826265 DOI: 10.1080/14767058.2017.1370704] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is one of the leading causes of neonatal mortality and morbidity particularly in very-low-birth-weight (VLBW) neonates. The incidence of NEC varies across countries and neonatal centers in between 7% and 14%. AIMS The aim of this study is to evaluate the role of delayed cord clamping (DCC) for prevention of NEC in preterm neonates. METHOD The literature search was done for various randomized control trial (RCT) by searching the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, ongoing clinical trials, and abstract of conferences. RESULTS This review included six RCTs that fulfilled inclusion criteria. There was statistically significant reduction in the incidence of NEC in DCC group (12.2% versus 20.6%; risk ratio (RR) 0.59; 95% CI 0.37-0.94; p = .02; number needed to treat (NNT) 12). However, mortality due to any cause before hospital discharge was not statistically significant (RR 0.80; 95% CI 0.33-2.00; p = .64). CONCLUSION The role of DCC in the prevention of NEC is supported by the current evidences. However, given the small sample sizes and other limitations of these studies, current evidences are not sufficient. We need large high-quality trials, with sufficient power to reliably assess clinically relevant differences in important outcomes.
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21
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Liu LY, Feinglass JM, Khan JY, Gerber SE, Grobman WA, Yee LM. Evaluation of Introduction of a Delayed Cord Clamping Protocol for Premature Neonates in a High-Volume Maternity Center. Obstet Gynecol 2017; 129:835-843. [PMID: 28383377 PMCID: PMC5400681 DOI: 10.1097/aog.0000000000001987] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate adherence to a delayed cord clamping protocol for preterm births in the first 2 years after its introduction, perform a quality improvement assessment, and determine neonatal outcomes associated with protocol implementation and adherence. METHODS This is a retrospective cohort study of women delivering singleton neonates at 23-32 weeks of gestation in the 2 years before (preprotocol) and 2 years after (postprotocol) introduction of a 30-second delayed cord clamping protocol at a large-volume academic center. This policy was communicated to obstetric and pediatric health care providers and nurses and reinforced with intermittent educational reviews. Barriers to receiving delayed cord clamping were assessed using χ tests and multivariable logistic regression. Neonatal outcomes then were compared between all neonates in the preprotocol period and all neonates in the postprotocol period and between all neonates in the preprotocol period and neonates receiving delayed cord clamping in the postprotocol period using multivariable linear and logistic regression analyses. RESULTS Of the 427 eligible neonates, 187 were born postprotocol. Of these, 53.5% (n=100) neonates received delayed cord clamping according to the protocol. The rate of delayed cord clamping preprotocol was 0%. Protocol uptake and frequency of delayed cord clamping increased over the 2 years after its introduction. In the postprotocol period, cesarean delivery was the only factor independently associated with failing to receive delayed cord clamping (adjusted odds ratio [OR] 0.49, 95% confidence interval [CI] 0.25-0.96). In comparison with the preprotocol period, those who received delayed cord clamping in the postprotocol period had significantly higher birth hematocrit (β=2.46, P=.007) and fewer blood transfusions in the first week of life (adjusted OR 0.49, 95% CI 0.25-0.96). CONCLUSION After introduction of an institutional delayed cord clamping protocol followed by continued health care provider education and quality feedback, the frequency of delayed cord clamping progressively increased. Compared with historical controls, performing delayed cord clamping in eligible preterm neonates was associated with improved neonatal hematologic indices, demonstrating the effectiveness of delayed cord clamping in a large-volume maternity unit.
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Affiliation(s)
- Lilly Y. Liu
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joe M. Feinglass
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Janine Y. Khan
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Susan E. Gerber
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - William A. Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lynn M. Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
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22
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Oxygen Saturation and Heart Rate Ranges in Very Preterm Infants Requiring Respiratory Support at Birth. J Pediatr 2017; 182:41-46.e2. [PMID: 27939259 DOI: 10.1016/j.jpeds.2016.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 09/20/2016] [Accepted: 11/03/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the changes in preductal oxygen saturation (SpO2) and heart rate in preterm infants receiving continuous positive airway pressure (CPAP) and/or positive-pressure ventilation (PPV) at birth. STUDY DESIGN A prospective observational study at birth of infants aged <32 weeks separated into 2 gestational age (GA) groups: 230/7-276/7 weeks (group 1) and 280/7-316/7 weeks (group 2). Infants received delayed cord clamping (DCC) in accordance with institutional protocol. CPAP and/or PPV was applied at the clinical team's discretion. SpO2 and heart rate were recorded every minute for 10 minutes. Preductal SpO2 was targeted according to published nomograms. For heart rate, the goal was to maintain a stable heart rate >100 bpm. RESULTS The study cohort comprised 96 group 1 infants (mean GA, 26 ± 1 weeks; mean birth weight, 818 ± 208 g) and 173 group 2 infants (mean GA, 30 ± 1 weeks; mean birth weight, 1438 ± 374 g). In general, infants requiring respiratory support reached target values for heart rate and SpO2 more slowly than the published nomograms for spontaneously breathing preterm infants without respiratory support. Infants receiving CPAP reached SpO2 and heart rate targets faster than infants receiving PPV. In group 1, but not group 2 infants, DCC resulted in higher SpO2 and heart rate. CONCLUSION SpO2 and heart rate do not quickly and reliably reach the values achieved by spontaneously breathing preterm infants not requiring respiratory support.
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23
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Huang H, Cheung PY, O'Reilly M, van Os S, Solevåg AL, Aziz K, Schmölzer GM. Impact of Changing Clinical Practices on Early Blood Gas Analyses in Very Preterm Infants and Their Associated Inpatient Outcomes. Front Pediatr 2017; 5:11. [PMID: 28243581 PMCID: PMC5303872 DOI: 10.3389/fped.2017.00011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 01/16/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Early studies suggest an association of abnormal carbon dioxide (PCO2) or oxygen (PO2) levels with adverse inpatient outcomes in very preterm babies. Recent resuscitation practice changes, such as targeted oxygen therapy, end-expiratory pressure, and rescue surfactant may influence these associations. OBJECTIVE The aim of this study is to assess the range of the initial partial pressures of PCO2 and PO2 in preterm neonates <33 weeks gestational age after birth and their correlation to inpatient neonatal outcomes. STUDY DESIGN This is a prospective observational cohort study of infants <33 weeks gestational age with arterial or venous blood gas analysis performed within the first hour after birth. RESULTS One hundred seventy infants (arterial n = 75, venous n = 95) with mean (SD) gestational age of 28 (3) weeks and birth weight of 1,111 (403) g were included. None of the infants with arterial blood gases had hypocarbia (<30 mmHg), 32 (43%) had normocarbia (30-55 mmHg), and 43 (57%) had hypercarbia (>55 mmHg). Seventeen of the infants with arterial blood gases (22%) had hypoxia (<50 mmHg), 50 (67%) normoxia, and 8 (11%) hyperoxia (>80 mmHg). In infants with venous blood samples, none had venous PCO2 < 40 mmHg, 41 (43%) had venous PCO2 40-60 mmHg, and 54 (57%) had venous PCO2 > 60 mmHg. Multivariable logistic regression analysis showed no association of low or high PCO2 or PO2 with death or major inpatient morbidities. CONCLUSION With current resuscitation and stabilization practices, hyperoxia and hypocarbia was uncommon, and hypercarbia occurred frequently. None of these findings correlate with adverse inpatient outcomes or death. Our findings are in direct contrast to published observations using historical practices.
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Affiliation(s)
- Hongmei Huang
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, Hong Kong University-Shenzhen Hospital, Shenzhen, China
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, Hong Kong University-Shenzhen Hospital, Shenzhen, China; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Sylvia van Os
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton, AB , Canada
| | - Anne Lee Solevåg
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton, AB , Canada
| | - Khalid Aziz
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Bolstridge J, Bell T, Dean B, Mackley A, Moore G, Swift C, Viscount D, Paul DA, Pearlman SA. A quality improvement initiative for delayed umbilical cord clamping in very low-birthweight infants. BMC Pediatr 2016; 16:155. [PMID: 27623808 PMCID: PMC5022231 DOI: 10.1186/s12887-016-0692-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/26/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Due to clinical benefits, delayed cord clamping (DCC) is recommended in infants born before 37 weeks gestational age. The objective was to institute a delayed cord clamping program and to evaluate clinical outcomes one year after initiation. METHODS This study occured at Christiana Care Health System, a tertiary care facility with a 52 bed level 3 Neonatal Intensive Care Unit (NICU). A multidisciplinary team created a departmental policy, a DCC protocol and educational programs to support the development of a DCC program. A year after initiation of DCC, we evaluated two cohorts of very low birth weight (VLBW) infants (<1500 g) prior to (Cohort 1) and after initiation (Cohort 2) of DCC (n = 136 and n = 142 respectively). Chart review was conducted to evaluate demographic data and clinical outcomes. Analysis was completed with a retrospective, cohort analysis on an intention-to-treat basis. RESULTS There were no differences in demographic factors between the two cohorts. We demonstrated a 73 % compliance rate with the delayed cord clamping protocol and a decrease in the percentage of VLBW infants requiring red blood cell transfusion from 53.7 to 35.9 % (p = 0.003). We also found a decreased need for respiratory support in the second cohort with no increases in the balancing measures of admission hypothermia and jaundice requiring phototherapy. During the Control Phase ongoing monitoring and education has led to a 93.7 % compliance rate. CONCLUSIONS A multidisciplinary team including key leadership from the obstetric and pediatric departments allowed for the rapid and safe implementation of DCC.
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Affiliation(s)
- Jeff Bolstridge
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA.
| | - Tracy Bell
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA
| | - Barbara Dean
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA
| | - Amy Mackley
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA
| | - Gina Moore
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA
| | - Cheryl Swift
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA
| | - Dina Viscount
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA
| | - David A Paul
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA
| | - Stephen A Pearlman
- Department of Neonatology, Christiana Care Health System, 4755 Ogletown Stanton Rd, Suite 217, MAP I, Newark, DE, 19718, USA
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Fulton C, Stoll K, Thordarson D. Bedside resuscitation of newborns with an intact umbilical cord: Experiences of midwives from British Columbia. Midwifery 2016; 34:42-46. [DOI: 10.1016/j.midw.2016.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 01/12/2016] [Accepted: 01/17/2016] [Indexed: 11/26/2022]
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Effectiveness of Delayed Cord Clamping in Reducing Postdelivery Complications in Preterm Infants: A Systematic Review. J Perinat Neonatal Nurs 2016; 30:372-378. [PMID: 27776037 DOI: 10.1097/jpn.0000000000000215] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This systematic review evaluates the effectiveness of delayed cord clamping in preterm infants on reducing postdelivery complications of anemia, hemodynamic instability, and the development of intraventricular hemorrhages. Interventions included varying durations of delayed cord clamping with and without cord milking as compared with immediate cord clamping, shorter delays in cord clamping, and delayed cord clamping without cord milking. A comprehensive search of randomized controlled trials, observational, cohort, and before-after studies was conducted between 1946 and 2015 in the electronic databases of Ovid MEDLINE, Embase, and Google Scholar. Studies were critically appraised using the Critical Appraisal Skills Program guidelines. Twenty-seven studies were included in the review from 1997 to 2015 from varying countries. Outcome measures included hematocrit/hemoglobin levels, measured or calculated blood volumes levels, number and volume of blood transfusions, presence of hypotension and need for treatment, and development of intraventricular hemorrhage. Delayed cord clamping can lead to improved outcomes measures in preterm infants. This review supports the current recommendation to perform delayed cord clamping during preterm deliveries.
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27
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Lawton C, Acosta S, Watson N, Gonzales-Portillo C, Diamandis T, Tajiri N, Kaneko Y, Sanberg PR, Borlongan CV. Enhancing endogenous stem cells in the newborn via delayed umbilical cord clamping. Neural Regen Res 2015; 10:1359-62. [PMID: 26604879 PMCID: PMC4625484 DOI: 10.4103/1673-5374.165218] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
There is currently no consensus among clinicians and scientists over the appropriate or optimal timing for umbilical cord clamping. However, many clinical studies have suggested that delayed cord clamping is associated with various neonatal benefits including increased blood volume, reduced need for blood transfusion, increased cerebral oxygenation in pre-term infants, and decreased frequency of iron deficiency anemia in term infants. Human umbilical cord blood contains significant amounts of stem and progenitor cells and is currently used in the treatment of several life-threatening diseases. We propose that delayed cord clamping be encouraged as it enhances blood flow from the placenta to the neonate, which is accompanied by an increase supply of valuable stem and progenitor cells, as well as may improve blood oxygenation and increase blood volume, altogether reducing the infant's susceptibility to both neonatal and age-related diseases.
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Affiliation(s)
- Christopher Lawton
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Sandra Acosta
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Nate Watson
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Chiara Gonzales-Portillo
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Theo Diamandis
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Naoki Tajiri
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Yuji Kaneko
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Paul R Sanberg
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Cesar V Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
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Nicoll J, Cheung PY, Aziz K, Rajani V, O'Reilly M, Pichler G, Schmölzer GM. Exhaled Carbon Dioxide and Neonatal Breathing Patterns in Preterm Infants after Birth. J Pediatr 2015; 167:829-833.e1. [PMID: 26227435 DOI: 10.1016/j.jpeds.2015.06.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/10/2015] [Accepted: 06/26/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the amount of exhaled carbon dioxide (ECO2) with different breathing patterns in spontaneously breathing preterm infants after birth. STUDY DESIGN Preterm infants had a facemask attached to a combined carbon dioxide/flow sensor placed over their mouth and nose to record ECO2 and gas flow. A breath-by-breath analysis of the first 5 minutes of the recording was performed. RESULTS Thirty spontaneously breathing preterm infants, gestational age (mean ± SD) 30 ± 2 weeks and birth weight 1635 ± 499 g were studied. ECO2 from normal breaths and slow expirations was significantly larger than with other breathing patterns (P < .001). ECO2 per breath also increased with gestational age P < .001. The expiratory hold pattern was the most prevalent breathing pattern both during the first minute of recording and overall. Breathing pattern proportions also varied by gestational age. Finally, ECO2 from the fifth minute of recording was significantly greater than that produced during the first 4 minutes of recording (P ≤ .029). CONCLUSIONS ECO2 varies with different breathing patterns and increases with gestational age and over time. ECO2 may be an indicator of lung aeration and that postnatal ECO2 monitoring may be useful in preterm infants in the delivery room.
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Affiliation(s)
- Jessica Nicoll
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Khalid Aziz
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Vishaal Rajani
- Neuroscience and Mental Health Institute, Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gerhard Pichler
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
| | - Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Niermeyer S. A physiologic approach to cord clamping: Clinical issues. Matern Health Neonatol Perinatol 2015; 1:21. [PMID: 27057338 PMCID: PMC4823683 DOI: 10.1186/s40748-015-0022-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 08/20/2015] [Indexed: 11/15/2022] Open
Abstract
Background Recent experimental physiology data and a large, population-based observational study have changed umbilical cord clamping from a strictly time-based construct to a more complex equilibrium involving circulatory changes and the onset of respirations in the newly born infant. However, available evidence is not yet sufficient to optimize the management of umbilical cord clamping. Findings Current guidelines vary in their recommendations and lack advice for clinicians who face practical dilemmas in the delivery room. This review examines the evidence around physiological outcomes of delayed cord clamping and cord milking vs. immediate cord clamping. Gaps in the existing evidence are highlighted, including the optimal time to clamp the cord and the interventions that should be performed before clamping in infants who fail to establish spontaneous respirations or are severely asphyxiated, as well as those who breathe spontaneously. Conclusion Behavioral and technological changes informed by further research are needed to promote adoption and safe practice of physiologic cord clamping.
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Affiliation(s)
- Susan Niermeyer
- Section of Neonatology, University of Colorado School of Medicine, 13121 E. 17th Avenue, Mail Stop 8402, Aurora, CO 80045 USA
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Pichler G, Baik N, Urlesberger B, Cheung PY, Aziz K, Avian A, Schmölzer GM. Cord clamping time in spontaneously breathing preterm neonates in the first minutes after birth: impact on cerebral oxygenation - a prospective observational study. J Matern Fetal Neonatal Med 2015; 29:1570-2. [PMID: 26103783 DOI: 10.3109/14767058.2015.1054275] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To analyse impact of delayed cord clamping (DCC60sec) on cerebral regional tissue oxygenation (crSO2) and fractional tissue oxygen extraction (cFTOE) in spontaneously breathing preterm neonates during the first 15 min after birth. METHODS Two-centre observational study, crSO2 and cFTOE was monitored in neonates with DCC60sec or early cord clamping (ECC < 30 s). RESULTS Seventy-six infants (birth weight and gestational age 1736 ± 508 g and 31.8 ± 2.5 weeks) were included. DCC was associated with lower initial crSO2 and higher cFTOE and lower initial Apgar-score and heart rate. CONCLUSION Attending practitioners should be aware that DCC might impact initial immediate transition in spontaneously breathing preterm neonates.
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Affiliation(s)
- Gerhard Pichler
- a Department of Paediatrics, Division of Neonatology , Medical University of Graz , Graz , Austria .,b Department of Paediatrics, Research Unit for Neonatal Micro- and Macrocirculation , Medical University of Graz , Graz , Austria .,c Department of Pediatrics , University of Alberta , Edmonton , Canada .,d Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton , Canada , and
| | - Nariae Baik
- a Department of Paediatrics, Division of Neonatology , Medical University of Graz , Graz , Austria .,b Department of Paediatrics, Research Unit for Neonatal Micro- and Macrocirculation , Medical University of Graz , Graz , Austria
| | - Berndt Urlesberger
- a Department of Paediatrics, Division of Neonatology , Medical University of Graz , Graz , Austria .,b Department of Paediatrics, Research Unit for Neonatal Micro- and Macrocirculation , Medical University of Graz , Graz , Austria
| | - Po-Yin Cheung
- c Department of Pediatrics , University of Alberta , Edmonton , Canada .,d Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton , Canada , and
| | - Khalid Aziz
- c Department of Pediatrics , University of Alberta , Edmonton , Canada .,d Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton , Canada , and
| | - Alexander Avian
- e Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz , Graz , Austria
| | - Georg M Schmölzer
- a Department of Paediatrics, Division of Neonatology , Medical University of Graz , Graz , Austria .,c Department of Pediatrics , University of Alberta , Edmonton , Canada .,d Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton , Canada , and
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McAdams RM, Backes CH, Hutchon DJR. Steps for implementing delayed cord clamping in a hospital setting. Matern Health Neonatol Perinatol 2015; 1:10. [PMID: 27057327 PMCID: PMC4823694 DOI: 10.1186/s40748-015-0011-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/18/2015] [Indexed: 11/10/2022] Open
Abstract
Background Delayed umbilical cord clamping (DCC) permits placental-to-newborn transfusion and results in an increased neonatal blood volume at birth. Despite endorsement by numerous medical governing bodies, DCC in preterm newborns has been slow to be adopted into practice. The purpose of this article is to provide a framework to guide medical providers interested in implementing DCC in a hospital setting. A descriptive implementation guideline is presented based on the author’s personal experiences and the steps taken at the University of Washington (UW) to implement DCC in premature newborns <37 weeks’ gestational age. Quality improvement data was obtained to assess compliance with DCC performance over the initial six months following initiation of the treatment protocol in July 2014. An anonymous electronic survey was administered to obstetrical providers in January 2015 to assess DCC policy awareness and adherence. Results Important steps to consider regarding implementation of DCC in a hospital settings include applying a multidisciplinary educational approach aimed at motivating potential stakeholders potentially impacted by DCC, addressing safety concerns regarding DCC, and developing a standardized DCC treatment protocol. In the first month following DCC protocol implementation at UW, 79.2% (19/24) of premature newborns admitted to the neonatal intensive care unit received DCC, but compliance decreased over time, with DCC documented in only 40.1% (61/150) of newborns during the 6-month period following implementation. The majority of obstetrician survey respondents (90.9%, 20/22) were aware of the UW DCC policy for preterm deliveries, had performed DCC in the past 6 months (95.5%, 21/22), felt that they had sufficient understanding of the risks and benefits of DCC (90.9%, 20/22) and cited concerns for maternal hemorrhage and the need to resuscitate the baby as the main reasons to perform immediate cord clamping instead of DCC. Conclusion Healthcare providers interested in implementing DCC may benefit from a procedural practice plan that includes an assessment of organizational readiness to adopt a DCC protocol, methods to measure and encourage staff compliance, and ways to track outcome data of infants who underwent DCC. Strategies to improve protocol awareness after DCC has been implemented are recommended since compliance may decrease over time.
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Affiliation(s)
- Ryan M McAdams
- Department of Pediatrics, Division of Neonatology, University of Washington, Box 356320, Seattle, WA 98195-6320 USA
| | - Carl H Backes
- Department of Pediatrics and Department of Obstetrics and Gynecology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH USA
| | - David J R Hutchon
- Department of Obstetrics and Gynecology, Darlington Memorial Hospital, Darlington, UK
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Ruangkit C, Moroney V, Viswanathan S, Bhola M. Safety and efficacy of delayed umbilical cord clamping in multiple and singleton premature infants - A quality improvement study. J Neonatal Perinatal Med 2015; 8:393-402. [PMID: 26757008 DOI: 10.3233/npm-15915043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To evaluate the safety and efficacy of a quality improvement (QI) program of delayed umbilical cord clamping (DCC) in multiple and singleton preterm infants born at our center. METHODS After DCC protocol implementation, compliance and success rate were assessed. Clinical outcomes of selected 150 preterm infants <34 weeks gestation born in 2014 after protocol implementation (Epoch II) were compared to those of preterm infants born in 2013 before protocol implementation (Epoch I). RESULTS Overall protocol compliance rate was 92% (246/267). DCC was successfully performed in 77% (205/267) after protocol implementation. There were higher multiple births in Epoch II compared to Epoch I (27.3 vs. 15.3% , p < 0.01). At birth, infants in Epoch II had significantly decreased need for intubation in delivery room (23.3 vs. 39.3% , p < 0.01), had higher hematocrit (46.4±7.3 vs. 44.0±7.1% , p < 0.01) and less metabolic acidosis (base excess -4.1±2.7 vs. -5.3±4.2 mmol/L, p < 0.01) compared to those born in Epoch I. During hospital stay, fewer infants in Epoch II received rescue surfactant therapy (45.3 vs. 56.7% , p = 0.05), medical treatment for PDA (6.7 vs. 16.6% , p = 0.04%) and red blood cell transfusions (20.7 VS. 32.0% , p < 0.01) compared to Epoch I. CONCLUSIONS Protocol-guided practice of DCC for 30 seconds can be safely performed in multiple and singleton preterm infants. In addition to higher initial hematocrit, infants in our QI project had lower need for delivery room resuscitation and less metabolic acidosis at birth. We also observed decreased need for rescue surfactant therapy, medical treatment for PDA and red blood cell transfusions after DCC protocol implementation.
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Placental transfusion strategies in very preterm neonates: a systematic review and meta-analysis. Obstet Gynecol 2014; 124:47-56. [PMID: 24901269 DOI: 10.1097/aog.0000000000000324] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the effects of interventions promoting placental transfusion at delivery (delayed cord clamping or umbilical cord milking) compared with early cord clamping on outcomes among premature neonates of less than 32 weeks of gestation. DATA SOURCES A systematic search was conducted of PubMed, Embase, and ClinicalTrials.gov databases (January 1965 to December 2013) for articles relating to placental transfusion strategies in very preterm neonates. METHODS OF STUDY SELECTION Literature searches returned 369 articles with 82 considered in full. We only included data from studies with an average gestational age of less than 32 weeks of gestation enrolled in randomized trials of enhanced placental-fetal transfusion interventions (delayed cord clamping or umbilical cord milking) compared with early cord clamping. TABULATION, INTEGRATION, AND RESULTS We identified 12 eligible studies describing a total of 531 neonates with an average gestation of 28 weeks. Benefits of greater placental transfusion were decreased mortality (eight studies, risk ratio 0.42, 95% confidence interval [CI] 0.19-0.95, 3.4% compared with 9.3%, P=.04), lower incidence of blood transfusions (six studies, risk ratio 0.75, 95% CI 0.63-0.92, 49.3% compared with 66%, P<.01), and lower incidence of intraventricular hemorrhage (nine studies, risk ratio 0.62, 95% CI 0.43-0.91, 16.7% compared with 27.3%, P=.01). There was a weighted mean difference of -1.14 blood transfusions (six studies, 95% CI -2.01-0.27, P<.01) and a 3.24-mmHg increase in blood pressure at 4 hours of life (four studies, 95% CI 1.76-4.72, P<.01). No differences were observed between the groups across all available safety measures (5-minute Apgar scores, admission temperature, incidence of delivery room intubation, peak serum bilirubin levels). CONCLUSIONS Results of this meta-analysis suggest that enhanced placental transfusion (delayed umbilical cord clamping or umbilical cord milking) at birth provides better neonatal outcomes than does early cord clamping, most notably reductions in overall mortality, lower risk of intraventricular hemorrhage, and decreased blood transfusion incidence. The optimal umbilical cord clamping practice among neonates requiring immediate resuscitation remains uncertain.
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Chalkias A, Xanthos T, Syggelou A, Bassareo PP, Iacovidou N. Controversies in neonatal resuscitation. J Matern Fetal Neonatal Med 2014; 26 Suppl 2:50-4. [PMID: 24059553 DOI: 10.3109/14767058.2013.829685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Despite recent advances in perinatal medicine and in the art of neonatal resuscitation, resuscitation strategy and treatment methods in the delivery room should be individualized depending on the unique characteristics of the neonate. The constantly increasing evidence has resulted in significant treatment controversies, which need to be resolved with further clinical and experimental research.
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Affiliation(s)
- Athanasios Chalkias
- Medical School, National and Kapodistrian University of Athens , Athens , Greece
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Niermeyer S, Velaphi S. Promoting physiologic transition at birth: re-examining resuscitation and the timing of cord clamping. Semin Fetal Neonatal Med 2013; 18:385-92. [PMID: 24055300 DOI: 10.1016/j.siny.2013.08.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Delayed clamping of the umbilical cord is recommended for term and preterm infants who do not require resuscitation. However, the approach to the newly born infant with signs of fetal compromise, prematurity and extremely low birthweight, or prolonged apnea is less clear. Human and experimental animal data show that delaying the clamping of the umbilical cord until after the onset of respirations promotes cardiovascular stability in the minutes immediately after birth. Rather than regarding delayed cord clamping as a fixed time period before resuscitation begins, a more physiologic concept of transition at birth should encompass the relative timing of onset of respirations and cord occlusion. Further research to explore the potential benefits of resuscitation with the cord intact is needed.
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Affiliation(s)
- Susan Niermeyer
- Section of Neonatology, University of Colorado School of Medicine, 13121 E. 17th Avenue, B8402, Aurora, CO 80045, USA.
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Abstract
Delayed cord clamping is a collaboration between the obstetric team and the neonatal team. Although the optimal timing for clamping the umbilical cord after birth continues to be subject to study, delaying clamping for at least 30-60 seconds, with the newborn held at or below the level of the uterus/placenta supports normal physiology and has proven benefits. Practical issues such as thermoregulation and equipment can be overcome with team collaboration and prebriefing planning. Neonatal nurses who attend deliveries are perfectly poised to influence this practice and improve short- and long-term outcomes for their patients.
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