Placental transfusion strategies in very preterm neonates: a systematic review and meta-analysis

Early or delayed cord clamping during transition of term newborns: does it make any difference in cerebral tissue oxygenation?

BACKGROUND

According to the World Health Organization's recommendation, delayed cord clamping in term newborns can have various benefits. Cochrane metaanalyses reported no differences for mortality and early neonatal morbidity although a limited number of studies investigated long-term neurodevelopmental outcomes. The aim of our study is to compare the postnatal cerebral tissue oxygenation values in babies with early versus delayed cord clamping born after elective cesarean section.

METHODS

In this study, a total of 80 term newborns delivered by elective cesarean section were included. Infants were randomly grouped as early (clamped within 15 s, n:40) and delayed cord clamping (at the 60th second, n:40) groups. Peripheral arterial oxygen saturation (SpO2) and heart rate were measured by pulse oximetry while regional oxygen saturation of the brain (rSO2) was measured with near-infrared spectrometer. Fractional tissue oxygen extraction (FTOE) was calculated for every minute between the 3rd and 15th minute after birth. (FTOE = pulse oximetry value-rSO2/pulse oximetry value). The measurements were compared for both groups.

RESULTS

The demographical characteristics, SpO2 levels (except postnatal 6th, 8th, and 14th minutes favoring DCC p < 0.05), heart rates and umbilical cord blood gas values were not significantly different between the groups (p > 0.05). rSO2 values were significantly higher while FTOE values were significantly lower for every minute between the 3rd and 15th minutes after birth in the delayed cord clamping group (p < 0.05).

CONCLUSION

Our study revealed a significant increase in cerebral rsO2 values and a decrease in FTOE values in the delayed cord clamping (DCC) group, indicating a positive impact on cerebral oxygenation and hemodynamics. Furthermore, the DCC group exhibited a higher proportion of infants with cerebral rSO2 levels above the 90th percentile. This higher proportion, along with a lower of those with such parameter below the 10th percentile, suggest that DCC may lead to the targeted/optimal cerebral oxygenetaion of these babies. As a result, we recommend measuring cerebral oxygenation, in addition to peripheral SpO2, for infants experiencing perinatal hypoxia and receiving supplemental oxygen.

Delayed Cord Clamping Uptake and Outcomes for Infants Born Very Preterm in California

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..

Impact of Delayed Cord Clamping on Red Blood Cell Transfusion and Related Outcomes in Very Low Birth Weight Infants

OBJECTIVE

Delayed cord clamping (DCC) for 30 to 60 seconds after birth facilitates placental transfusion, increases blood volume, and decreases red blood cell (RBC) transfusion in preterm infants. Study objective was to determine (1) RBC transfusion burden over a 5-year period, (2) impact of DCC practice on RBC transfusions, and (3) association of RBC transfusion on outcomes in very low birthweight (VLBW) preterm infants.

STUDY DESIGN

A retrospective medical chart review was performed in 787 VLBW infants between 2016 and 2020. Demographic factors, DCC status, number of RBC transfusions, and neonatal outcomes were determined in eligible infants. Adjusted association between DCC, RBC transfusion, and outcomes were determined using logistic and linear regression methods.

RESULTS

Of the 538 eligible VLBW infants, 62% (N = 332) received RBC transfusions. Proportion receiving RBC transfusion were significantly higher for infants <1,000 g (N = 217, 65.4%) and gestational age (GA) <29 weeks (N = 256, 77.1%) than larger (1,001-1,250 g, N = 77, 23.2% and 1,251-1,500 g, N = 38, 11.4%) and older GA ≥ 29 weeks' infants (N = 76, 22.9%, p < 0.05). Of the 81/538 (15.1%) who received DCC, 48 (59.2%) received no RBC transfusion (p < 0.001). In multivariable logistic regression analysis, preterm infants with DCC were 55% less likely to receive RBC transfusions as compared with infants with no DCC. At any given GA, the number of RBC transfusions in preterm infants with DCC was 25% lower as compared with infants without DCC (p < 0.05). Transfusion was associated with 8-fold increased odds for bronchopulmonary dysplasia and 4-fold increased odds for medical and surgically treated patent ductus arteriosus compared with no transfusion. There was no significant association of transfusion with neonatal sepsis, laser treated retinopathy of prematurity, necrotizing enterocolitis, and intraventricular hemorrhage.

CONCLUSION

DCC was significantly associated with reduced RBC transfusion, but fewer preterm infants received DCC. Further research is needed to explore the feasibility of providing neonatal resuscitation during DCC in preterm infants.

KEY POINTS

· Delayed cord clamping significantly reduced the need for RBC transfusions.. · Fewer very preterm infants received DCC.. · Future research is needed to explore feasibility of neonatal resuscitation during DCC..

Umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis

BACKGROUND

Placental management strategies such as umbilical cord milking and delayed cord clamping may provide a range of benefits for the newborn. The aim of this review was to assess the effectiveness of umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia.

METHODS

Three databases and five clinical trial registries were systematically reviewed to identify randomised controlled trials comparing umbilical cord milking or delayed cord clamping with control in term and preterm infants. The primary outcome was neonatal hypoglycaemia (study defined). Two independent reviewers conducted screening, data extraction and quality assessment. Quality of the included studies was assessed using the Cochrane Risk of Bias tool (RoB-2). Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis using a random effect model was done using Review Manager 5.4. The review was registered prospectively on PROSPERO (CRD42022356553).

RESULTS

Data from 71 studies and 14 268 infants were included in this review; 22 (2 537 infants) compared umbilical cord milking with control, and 50 studies (11 731 infants) compared delayed with early cord clamping. For umbilical cord milking there were no data on neonatal hypoglycaemia, and no differences between groups for any of the secondary outcomes. We found no evidence that delayed cord clamping reduced the incidence of hypoglycaemia (6 studies, 444 infants, RR = 0.87, CI: 0.58 to 1.30, p = 0.49, I2 = 0%). Delayed cord clamping was associated with a 27% reduction in neonatal mortality (15 studies, 3 041 infants, RR = 0.73, CI: 0.55 to 0.98, p = 0.03, I2 = 0%). We found no evidence for the effect of delayed cord clamping for any of the other outcomes. The certainty of evidence was low for all outcomes.

CONCLUSION

We found no data for the effectiveness of umbilical cord milking on neonatal hypoglycaemia, and no evidence that delayed cord clamping reduced the incidence of hypoglycaemia, but the certainty of the evidence was low.

Premature infants receiving delayed cord clamping with and without cord milking: a randomized control trial

BACKGROUND

Preterm infants often have long hospital stays and frequent blood tests; they often develop anemia requiring multiple blood transfusions. Placental transfusion via delayed cord clamping (DCC) or umbilical cord milking (UCM) helps increase blood volume. We hypothesized umbilical cord milking (UCM), together with DCC, would be superior in reducing blood transfusions.

OBJECTIVES

To compare the effects of DCC and DCC combined with UCM on hematologic outcomes among preterm infants.

METHODS

One hundred twenty singleton preterm infants born at 280/7- 336/7 weeks of gestation at Thammasat University Hospital were enrolled in an open-label, randomized, controlled trial. They were placed into three groups (1:1:1) by a block-of-three randomization: DCC for 45 s, DCC with UCM performed before clamping (DCM-B), and DCC with UCM performed after clamping (DCM-A). The primary outcomes were hematocrit levels and number of infants receiving blood transfusions during the first 28 days of life. Intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) were secondary outcomes. Analyses were performed with an intent-to-treat approach.

RESULTS

One hundred twenty preterm infants were randomized. There was no statistically significant difference in neonatal outcomes; hematocrit on admission 54.0 ± 5.5, 53.3 ± 6.0, and 54.3 ± 5.8 (p = 0.88), receiving blood transfusions 25%, 20%, and 12.5% (p = 0.24), incidence of NEC 7.5, 0 and 10% (p = 0.78) in the DCC, DCM-B and DCM-A groups, respectively. There were no preterm infants with severe IVH, polycythemia, maternal or neonatal death.

CONCLUSION

The placental transfusion techniques utilized, DCC and DCC combined with UCM, provided the same benefits for preterm infants born at GA 28 and 33 weeks in terms of reducing the need for RBC transfusions, severities of IVH and incidence of NEC without increasing comorbidity.

TRIAL REGISTRATION

TCTR20190131002 . Registered 31 January 2019-Retrospectively registered.

Midwifery and nursing: Considerations on cord management at birth

Mounting evidence overwhelmingly supports the practice of the return of an infant's placental blood volume at the time of birth. Waiting just a few minutes before clamping the umbilical cord can provide health benefits to infants of all gestational ages. Despite the robust evidence, uptake of delayed cord clamping (DCC) into mainstream obstetrical practice is moving slowly. The practice of DCC is influenced by various factors that include the setting in which the birth takes place, the use of evidence-informed guidelines and other influences that facilitate or hinder the practice of DCC. Through communication, collaboration, and unique disciplinary perspectives, midwives and nurses work with other members of their respective care team to develop strategies for best practice to improve an infant's well-being through optimal cord management. Midwifery has been practiced for centuries throughout the world and midwives have supported DCC since the beginning of recorded history. An important tenet of midwifery philosophy is watchful waiting and non-intervention in normal processes. Nurses are vital to care of birthing families in- and out-of-hospitals as well as in prenatal and postpartum ambulatory care. Nurses and midwives are positioned to be involved in the process of adapting to the mounting evidence for DCC. Strategies to increase better utilization of the practice of DCC have been proposed. For all, teamwork and collaboration among disciplines participating in maternity care are essential for adapting to the new evidence. Involving midwives and nurses as partners in an interdisciplinary approach to plan, implement and sustain DCC at birth increases success.

Cardiac Asystole at Birth Re-Visited: Effects of Acute Hypovolemic Shock

Births involving shoulder dystocia or tight nuchal cords can deteriorate rapidly. The fetus may have had a reassuring tracing just before birth yet may be born without any heartbeat (asystole). Since the publication of our first article on cardiac asystole with two cases, five similar cases have been published. We suggest that these infants shift blood to the placenta due to the tight squeeze of the birth canal during the second stage which compresses the cord. The squeeze transfers blood to the placenta via the firm-walled arteries but prevents blood returning to the infant via the soft-walled umbilical vein. These infants may then be born severely hypovolemic resulting in asystole secondary to the loss of blood. Immediate cord clamping (ICC) prevents the newborn's access to this blood after birth. Even if the infant is resuscitated, loss of this large amount of blood volume may initiate an inflammatory response that can enhance neuropathologic processes including seizures, hypoxic-ischemic encephalopathy (HIE), and death. We present the role of the autonomic nervous system in the development of asystole and suggest an alternative algorithm to address the need to provide these infants intact cord resuscitation. Leaving the cord intact (allowing for return of the umbilical cord circulation) for several minutes after birth may allow most of the sequestered blood to return to the infant. Umbilical cord milking may return enough of the blood volume to restart the heart but there are likely reparative functions that are carried out by the placenta during the continued neonatal-placental circulation allowed by an intact cord.

Umbilical cord milking-benefits and risks

The most common methods for providing additional placental blood to a newborn are delayed cord clamping (DCC) and umbilical cord milking (UCM). However, DCC carries the potential risk of hypothermia due to extended exposure to the cold environment in the operating room or delivery room, as well as a delay in performing resuscitation. As an alternative, umbilical cord milking (UCM) and delayed cord clamping with resuscitation (DCC-R) have been studied, as they allow for immediate resuscitation after birth. Given the relative ease of performing UCM compared to DCC-R, UCM is being strongly considered as a practical option in non-vigorous term and near-term neonates, as well as preterm neonates requiring immediate respiratory support. However, the safety profile of UCM, particularly in premature newborns, remains a concern. This review will highlight the currently known benefits and risks of umbilical cord milking and explore ongoing studies.

A newborn's "life line" - A review of umbilical cord management strategies

Literature supporting various umbilical management strategies have increased substantially over the past decade. Delayed cord clamping and umbilical cord milking are increasing embraced by obstetricians and neonatologists, and multiple international governing bodies now endorse these practices. This review summarizes the benefits and limitations of the different umbilical cord management strategies for term, near-term, and preterm neonates. Additional studies are underway to elucidate the safety profile of these practices, long term outcomes, and variations within these strategies that could potentially augment the benefits.

The hematological impact of umbilical cord milking versus delayed cord clamping in premature neonates: a randomized controlled trial

BACKGROUND

The hematological impact of umbilical cord milking (UCM) was compared to that of delayed cord clamping (DCC) as a faster placental transfusion technique for preterm neonates (between 24 and 34 + 6 weeks gestation). A comparison of important neonatal morbidities was also made.

METHODS

This was an open-label randomized trial conducted from June 8, 2017, to April 22, 2019. Two hundred patients with preterm deliveries (24 and 34 + 6 weeks gestation) were assigned to the DCC or UCM group at random at a ratio of 1:1. The study power was 80% for a difference in the hematocrit value of 3% and Hb value of one gram, and an alpha error of 0.05.

RESULTS

The following variables were analyzed in the comparison of UCM vs. DCC: first draw hemoglobin: 17.0 ± 1.9 vs. 16.8 ± 1.8 gm/dl (95% CI -0.75-0.29, P 0.383); first draw hematocrit: 55.6 ± 6.4 vs. 55.2 ± 6.4% (95% CI -2.18-1.38, P 0.659); peak hematocrit: 56.9 ± 6.4 vs. 56.3 ± 6.7% (95% CI -2.41-1.26, P 0.537); the need for respiratory assistance (47% vs. 30%, P 0.020), inotropes (16% vs. 6%, P 0.040), and blood transfusion (26% vs. 12%, P 0.018); and the occurrence of intraventricular hemorrhage (9% vs. 5%, P 0.407), necrotizing enterocolitis (6% vs. 2%, P 0.279), sepsis (25% vs. 15%, P 0.111), and neonatal death (13% vs. 4%, P 0.40).

CONCLUSION

UCM facilitated a rapid transfer of placental blood equivalent to that of DCC for premature neonates. However, it resulted in increased rates of interventions and morbidities, especially in extremely preterm neonates.

TRIAL REGISTRATION

The clinical trial was registered on May 10, 2017, with registration number (NCT03147846).

Pathogenesis and prevention of intraventricular hemorrhage

Despite improvements in the mortality rates of preterm infants, rates of germinal matrix intraventricular hemorrhage (IVH) have remained static with an overall incidence of 25% in infants less than 32 weeks. The importance of the lesion relates primarily to the underlying injury to the developing brain and the associated long-term neurodevelopmental consequences. This clinical-orientated review focuses on the pathogenesis of IVH and discusses the evidence behind proposed prevention strategies.

Epidemiological Investigation on the Current Practice of Umbilical Cord Clamping in China

OBJECTIVE

Despite known benefits, the timing of and method used for umbilical cord clamping (UCC) in neonates remain controversial in China, as well as internationally. The objective of this study was to assess knowledge, attitudes, and practice of UCC amongst health care providers in China, as recommended by medical professional organizations.

STUDY DESIGN

A web-based questionnaire on cord clamping practices was administered to midwives, obstetricians, and neonatologists in 126 hospitals from 16 provinces. The provinces were selected from seven different regions of China.

RESULTS

A total of 5,005 (60.5% of eligible respondents) health care providers returned completed questionnaires. The awareness rates for immediate cord clamping (ICC) and delayed cord clamping (DCC) were over 85%, but the implementation rate for DCC was relatively low (ICC 58.3% vs. DCC 41.6%). Most neonates were placed below the introitus (92.8%) during cord clamping and this correlated with the route of delivery. The choice of UCC was impelled by different factors. Benefits for neonates influenced the choice of ICC (50%) and promoting a larger blood volume to stabilize systemic circulation influenced the choice of DCC (92.3%). Majority (91.5%) of respondents acquiesced that it was necessary to develop national clinical guidelines for UCC.

CONCLUSION

The majority of obstetricians, neonatologists, and midwives who participated in this study had a positive perception of DCC. However, this did not translate to daily practice. The practice of UCC is variable and there are no standard guidelines.

KEY POINTS

· The first large-scale epidemiological investigation of umbilical cord ligation is in China.. · The survey included three commonly used umbilical cord clamping methods.. · The respondents included neonatologists..

Cardiopulmonary Resuscitation with an Intact Umbilical Cord

The body of literature supporting different umbilical management strategies has increased over the past decade as the role of cord management in neonatal transition is realized. Multiple international governing bodies endorse delayed cord clamping, and this practice is now widely accepted by obstetricians and neonatologists. Although term and preterm neonates benefit in some ways from delayed cord clamping, additional research on variations in this practice, including resuscitation with an intact cord, aim to find the optimal cord management practice that reduces mortality and major morbidities.

Making the Argument for Intact Cord Resuscitation: A Case Report and Discussion

We use a case of intact cord resuscitation to argue for the beneficial effects of an enhanced blood volume from placental transfusion for newborns needing resuscitation. We propose that intact cord resuscitation supports the process of physiologic neonatal transition, especially for many of those newborns appearing moribund. Transfer of the residual blood in the placenta provides the neonate with valuable access to otherwise lost blood volume while changing from placental respiration to breathing air. Our hypothesis is that the enhanced blood flow from placental transfusion initiates mechanical and chemical forces that directly, and indirectly through the vagus nerve, cause vasodilatation in the lung. Pulmonary vascular resistance is thereby reduced and facilitates the important increased entry of blood into the alveolar capillaries before breathing commences. In the presented case, enhanced perfusion to the brain by way of an intact cord likely led to regained consciousness, initiation of breathing, and return of tone and reflexes minutes after birth. Paramount to our hypothesis is the importance of keeping the umbilical cord circulation intact during the first several minutes of life to accommodate physiologic neonatal transition for all newborns and especially for those most compromised infants.

Perinatal care for the extremely preterm infant

Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (20^0/7-25^6/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.

Delayed cord clamping in small for gestational age preterm infants

BACKGROUND

Infants with restricted growth for age are frequently exposed to insufficient placental circulation and are more likely to develop postnatal complications. Delayed cord clamping at birth for these infants requires further exploration.

OBJECTIVE

This study aimed to compare the short-term neonatal outcomes of delayed cord clamping with that of early cord clamping in small for gestational age preterm infants and to explore whether the effects of delayed cord clamping in small for gestational age preterm infants are different from that in non-small for gestational age preterm infants.

STUDY DESIGN

We conducted a national retrospective cohort study, including infants born at <33 weeks' gestation and admitted to the Canadian Neonatal Network units between January 2015 and December 2017. Small for gestational age infants (birthweight of <10th percentile for gestational age and sex) who received delayed cord clamping ≥30 seconds were compared with those who received early cord clamping. In addition, non-small for gestational age infants who received delayed cord clamping were compared with those who received early cord clamping. The main study outcomes included composite outcome of mortality or major morbidity, neonatal morbidity rate, mortality rate, peak serum bilirubin, and number of blood transfusions. Multivariable logistic and linear regression models with a generalized estimation equation approach were used to account for the clustering of infants within centers.

RESULTS

Overall, 9722 infants met the inclusion criteria. Of those infants, 1027 (10.6%) were small for gestational age. The median (interquartile range) gestational age was 31 weeks (range, 28-32 weeks). After adjusting for potential confounders, delayed cord clamping in small for gestational age infants was associated with a reduction in the composite outcome of mortality or major morbidity (adjusted odds ratio, 0.60; 95% confidence interval, 0.42-0.86) compared with early cord clamping. There was no difference between the 2 groups in peak serum bilirubin. Many associated benefits of delayed cord clamping in small for gestational age infants were similar to those in non-small for gestational age infants.

CONCLUSION

Delayed cord clamping in small for gestational age preterm infants was associated with decreased odds of mortality or major morbidity. Many of the benefits of delayed cord clamping in the small for gestational age preterm infants were similar to those identified in the non-small for gestational age preterm infants.

The impact of initial hematocrit values after birth on peri-/intraventricular hemorrhage in extremely low birth weight neonates

AIM

Peri-/intaventricular hemorrhage (P/IVH) is a common condition in preterm neonates and is responsible for substantial adverse neurological outcome especially in extremely low birth weight infants. As hematocrit after birth is a surrogate marker for blood volume, this study aimed to evaluate the effect of initial hematocrit values after birth on P/IVH development in extreme low birth weight (ELBW) neonates.

PATIENTS AND METHODS

A prospective cohort analysis of 92 eligible ELBW neonates was performed. The relationship between initial hematocrit values in ELBW neonates after birth and subsequent development of P/IVH was examined.

RESULTS

Twenty-nine of 92 infants developed P/IVH. There were significant differences in initial Hct and maximum carbon dioxide (max PCO₂) in the first 3 days levels in the P/IVH group compared with no P/IVH group. Initial Hct level at birth in the P/IVH group were significantly lower than the no P/IVH group while max PCO₂ in the first 3 days were found to be significantly high in the P/IVH group. There were no significant differences in other baseline demographic, perinatal, and neonatal characteristics while in univariate analysis, higher gestational age and initial Hct were associated with decreased likelihood of P/IVH. In multiple regression analysis after adjustment, only initial Hct remained significantly associated with P/IVH. There was no difference between the population by subgroups of IVH (IVH I-II and IVH III-IV) according to hematocrit and the severity of IVH.

CONCLUSION

Higher initial Hct at birth is associated with decreased P/IVH in ELBW infants. We hypothesized the argument that ELBW infants who have lower initial Hct at birth have less suboptimal volume status that predisposing lower cerebral blood flow and the resultant decrease in cerebral blood flow precede the development of P/IVH.

Management of Placental Transfusion to Neonates After Delivery

This review summarizes high-quality evidence supporting delayed umbilical cord clamping to promote placental transfusion to preterm and term neonates. In preterm neonates, delayed cord clamping may decrease mortality and the need for blood transfusions. Although robust data are lacking to guide cord management strategies in many clinical scenarios, emerging literature is reviewed on numerous topics including delivery mode, twin gestations, maternal comorbidities (eg, gestational diabetes, red blood cell alloimmunization, human immunodeficiency virus [HIV] infection, and severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection) and neonatal complications (eg, fetal growth restriction, congenital heart disease, and the depressed neonate). Umbilical cord milking is an alternate method of rapid placental transfusion, but has been associated with severe intraventricular hemorrhage in extremely preterm neonates. Data on long-term outcomes are discussed, as well as potential contraindications to delayed cord clamping. Overall, delayed cord clamping offers potential benefits to the estimated 140 million neonates born globally every year, emphasizing the importance of this simple and no-cost strategy.

Immediate vs delayed cord clamping in preterm infants: A systematic review and meta-analysis

To compare and evaluate the efficacy and safety of immediate cord clamping (ICC) and delayed cord clamping (DCC) in preterm infants. We performed a comprehensive and systematic meta-analysis of randomised controlled trials (RCTs) assessing ICC and DCC in preterm infants by searching PUBMED, EMBASE, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Database (from inception to 30 September 2020). Summary odds ratios or mean differences with 95% confidence intervals were calculated using a fixed- or random-effect model. A total of 20 RCTs with 1807 preterm infants were included in the study. DCC provided more benefits in increasing the haematocrit and haemoglobin levels at 24 hours of life (%), thus reducing the incidence of anaemia, necrotising enterocolitis, length of hospital stay and mortality than when ICC was performed. No significant differences were found between ICC and DCC in terms of peak bilirubin level; need for blood transfusion, mechanical ventilation (MV) and phototherapy; duration of MV and phototherapy; and incidences of intraventricular haemorrhage, retinopathy of prematurity, patent ductus arteriosus, respiratory distress syndrome, sepsis, jaundice, polycythaemia, periventricular leukomalacia and bronchopulmonary dysplasia. DCC is a safe, beneficial and feasible intervention for preterm infants. However, rigorously designed and large-scale RCTs are necessary to identify the role and ideal timing of DCC.

Effects of delayed cord clamping in intrauterine growth-restricted neonates: a randomized controlled trial

The time of cord clamping in intrauterine growth-restricted (IUGR) neonates remains an area of uncertainty. This assessor-blinded randomized controlled trial compared the effects of delayed cord clamping (DCC) with early cord clamping (ECC) on the systemic blood flow (SBF) and cerebral hemodynamics in IUGR neonates of gestational age ≥28 weeks, not requiring resuscitation. Eligible newborns were randomized to DCC (cord clamping after 60 s; n=55) or ECC (cord clamping within 30 s; n=55) group immediately after delivery. The primary outcome variable was superior vena cava (SVC) blood flow at 24±2 h. The secondary outcome variables were right ventricular output (RVO), anterior cerebral artery (ACA) blood flow velocity (BFV), superior mesenteric artery (SMA)-BFV and venous hematocrit at 24±2 h, peak total serum bilirubin (TSB), incidences of polycythemia, intraventricular hemorrhage, respiratory distress, feeding intolerance, and necrotizing enterocolitis, outcome, duration of hospital stay, screening audiometry, and serum ferritin levels at the postnatal age of 3 months. Compared to ECC, DCC was associated with significantly higher SVC flow (101.22±21.02 and 81.27±19.12 mL/kg/min, in DCC and ECC groups, respectively; p<0.0001), and significantly increased RVO, SMA-BFV, venous hematocrit, and serum ferritin levels. Though peak TSB was significantly higher with DCC, duration of phototherapy was comparable. ACA-BFV, incidence of polycythemia, and other outcomes were comparable between the groups.Conclusions: DCC was a safe and beneficial intervention in IUGR infants with an improved SBF and SMA-BFV and an increased hematocrit and serum ferritin levels without higher incidences of polycythemia and requirement of phototherapy for significant hyperbilirubinemia.Trial registration: Clinical Trials Registry of India (CTRI/2019/05/018904) What is Known: • Delayed cord clamping (DCC) increases superior vena cava (SVC) blood flow in preterm neonates. • DCC increases hematocrit and serum ferritin in intrauterine growth-restricted (IUGR) neonates, but there may be an associated risk of polycythemia and neonatal hyperbilirubinemia. What is New: • DCC increases SVC blood flow, right ventricular output, superior mesenteric artery blood flow velocity, venous hematocrit, and serum ferritin in IUGR neonates. • Incidences of polycythemia and duration of phototherapy for significant neonatal hyperbilirubinemia do not increase with DCC.

Placental transfusion: may the "force" be with the baby

Placental transfusion results in a significant decrease in the risk of death for extremely preterm infants. With immediate cord clamping (ICC), these infants can leave up to one-half of their normal circulating in utero blood volume in the placenta. Extremely preterm infants are at highest risk of harm from ICC yet are currently the most likely to receive ICC. Receiving a placenta transfusion provides infants with life-saving components and enhanced perfusion. We present some lesser-known but important effects of placental transfusion. New research reveals that enhanced vascular perfusion causes an organ's endothelial cells to release angiocrine responses to guide essential functions. High progesterone levels and pulmonary artery pressure in the first few hours of life assist with neonatal adaptation. We propose that lack of essential blood volume may be a major factor contributing to inflammation, morbidities, and mortality that preterm infants frequently encounter.

Germinal Matrix-Intraventricular Hemorrhage: A Tale of Preterm Infants

Germinal matrix-intraventricular hemorrhage (GM-IVH) is a common intracranial complication in preterm infants, especially those born before 32 weeks of gestation and very-low-birth-weight infants. Hemorrhage originates in the fragile capillary network of the subependymal germinal matrix of the developing brain and may disrupt the ependymal lining and progress into the lateral cerebral ventricle. GM-IVH is associated with increased mortality and abnormal neurodevelopmental outcomes such as posthemorrhagic hydrocephalus, cerebral palsy, epilepsy, severe cognitive impairment, and visual and hearing impairment. Most affected neonates are asymptomatic, and thus, diagnosis is usually made using real-time transfontanellar ultrasound. The present review provides a synopsis of the pathogenesis, grading, incidence, risk factors, and diagnosis of GM-IVH in preterm neonates. We explore brief literature related to outcomes, management interventions, and pharmacological and nonpharmacological prevention strategies for GM-IVH and posthemorrhagic hydrocephalus.

A 3-armed multicenter randomized controlled trial: Placental Transfusion in Very Preterm Infants (PT-VPI)

Preterm infants constitute an important proportion of neonatal deaths and various complications, and very preterm infants (VPI) are more likely to develop severe complications, such as intraventricular hemorrhage (IVH), anemia, and sepsis. It has been confirmed that placental transfusion can supplement blood volume in infants and reduce preterm-associated complications, which is further conducive to the development of the nervous system and a better long-term prognosis. Based on these advantages, placental transfusion has been widely used in VPI. There are three main types of placental transfusion: delayed cord clamping (DCC), intact umbilical cord milking (I-UCM), and cut umbilical cord milking (C-UCM). However, the optimal method for PT-VPI remains controversial, and it is urgent to identify the best method of placental transfusion. We plan to fully evaluate the safety and effectiveness of these three placental transfusion methods in VPI in a 3-arm multicenter randomized controlled trial: Placental Transfusion in Very Preterm Infants (PT-VPI). Trial registration: chictr.org.cn, number ChiCTR2000030953.

Cesarean delivery: an evidence-based review of the technique

The cesarean section is utilized to deliver babies since the late 19^th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.

The effect of umbilical cord milking on cerebral blood flow in very preterm infants: a randomized controlled study

OBJECTIVE

To compare the effect of umbilical cord milking (UCM) vs. early cord clamping (ECC) on cerebral blood flow (CBF).

METHOD

Preterm infants <31 weeks' gestation were randomized to receive UCM or ECC at birth. Blood flow velocities and resistive & pulsatility indices of middle and anterior cerebral arteries were measured at 4-6 and 10-12 h after birth as an estimate of CBF.

RESULTS

Randomization allocated 37 infants to UCM and 36 to ECC. Maternal and antenatal variables were similar. There were no significant differences between groups in middle or anterior CBF velocities and resistive indices at either study time point. CBF variables were not correlated with mean blood pressure, systemic blood flow, or intraventricular hemorrhage.

CONCLUSIONS

In very preterm infants, UCM compared with ECC was not shown to change CBF indices during the first 12 h of age or correlate with other hemodynamic measures or with intraventricular hemorrhage.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01487187.

Iron Nutrition, Erythrocytes, and Erythropoietin in the NICU: Erythropoietic and Neuroprotective Effects

Prematurity, maternal diabetes, maternal smoking, being medically underserved, and small size for gestational age are common characteristics of neonates in the NICU and can predispose them to develop congenital iron deficiency. Iron is critical for organ development. In the fetus and newborn, iron is prioritized for red blood cell production, sometimes at the expense of other tissues, including the brain. It is critical to optimize iron levels in newborns to support erythropoiesis, growth, and brain development. Available studies support improved neurodevelopmental outcomes with either iron supplementation or delayed umbilical cord clamping at birth. Erythropoietic doses of erythropoietin/erythrocyte-stimulating agents may also improve neurocognitive outcomes. However, the literature on the effect of liberal red blood cell transfusions on long-term neurodevelopment is mixed. Understanding age-specific normal values and monitoring of iron indices can help individualize and optimize the iron status of patients in the NICU.

Effect of delayed cord clamping on stem cell transfusion and hematological parameters in preterm infants with placental insufficiency: a pilot randomized trial

The feasibility of delayed cord clamping (DCC) in preterm infants with placental insufficiency (PI) is questionable. We aimed to study the effect of DCC on stem cell transfusion, hematological parameters, and clinical outcomes in preterm infants born to mothers with PI. Preterm infants, < 34 weeks' gestation, born to mothers with PI were randomized based on the timing of umbilical cord clamping into delayed clamping for 60 s (DCC group) or immediate cord clamping (ICC group) groups at time of birth. CD34 percentage as a marker of stem cell transfusion, early and late-onset anemia, hypothermia, hypotension, polycythemia, hyperbilirubinemia, duration of oxygen therapy, bronchopulmonary dysplasia, intra-ventricular hemorrhage, necrotizing enterocolitis, sepsis, mortality, and length of hospital stay were compared between studied groups. We found that peripheral blood CD34 percentage was significantly higher in DCC compared with that in the ICC group (median (IQR) of 0.5 (0.40-0.7) versus 0.35 (0.20-0.5), p = 0.004). Infants in the DCC group had significantly lower episodes of anemia of prematurity at 2 months, red blood cell transfusion, and shorter duration of oxygen therapy compared with those in the ICC group.Conclusion: In conclusion, DCC compared with ICC increased stem cell transfusion and decreased early- and late-onset anemia in preterm infants with placental insufficiency.Trial registration: NCT03731546 www.clinicaltrials.gov What is Known: • Delayed cord clamping has been recommended by the American Academy of Pediatrics as a standard of care practice during delivery of preterm infants. • The feasibility of DCC in preterm infants with placental insufficiency (PI) is uncertain. What is New: • This randomized controlled trial demonstrated that DCC in the delivery room care of preterm infants born to mothers with placental insufficiency increased stem cell transfusion and decreased early- and late-onset anemia.

Guidelines on Deferred Cord Clamping and Cord Milking: A Systematic Review

CONTEXT

Deferred cord clamping (DCC) saves lives. It reduces extremely preterm infants' mortality by 30%, yet a minority of eligible infants receive it. This may in part be due to lack of awareness or confidence in evidence, or conflicting or vague guidelines.

OBJECTIVE

To systematically review clinical practice guidelines and other statements on DCC and cord milking.

DATA SOURCES

Ten academic and guideline databases were searched.

STUDY SELECTION

Clinical practice guidelines and other statements (position statements and consensus statements) providing at least 1 recommendation on DCC or umbilical cord milking among preterm or term infants were included.

DATA EXTRACTION

Data from included statements were extracted by 2 independent reviewers, and discrepancies were resolved through consensus. Guideline quality was appraised with modified Appraisal of Guidelines for Research and Evaluation II and Appraisal of Guidelines for Research and Evaluation Recommendation Excellence tools.

RESULTS

Forty-four statements from 35 organizations were included. All endorsed DCC for uncompromised preterm infants, and 11 cautiously stated that cord milking may be considered when DCC is infeasible. Only half (49%) of the recommendations on the optimal duration of DCC were supported by high-quality evidence. Only 8% of statements cited a mortality benefit of DCC for preterm infants.

LIMITATIONS

Because systematic reviews of guidelines are relatively novel, there are few tools to inform study execution; however, we used the Appraisal of Guidelines for Research and Evaluation II and the Appraisal of Guidelines for Research and Evaluation Recommendation Excellence to assess quality and were methodologically informed by previous systematic reviews of guidelines.

CONCLUSIONS

Statements worldwide clearly encouraged DCC. Their implementability would benefit from noting the preterm mortality benefit of DCC and more granularity.

A Comparison of Strategies for Managing the Umbilical Cord at Birth in Preterm Infants

OBJECTIVE

To evaluate the rates of practice, and the associations between different cord management strategies at birth (delayed cord clamping [DCC], umbilical cord milking [UCM], and early cord clamping [ECC]) and mortality or major morbidity, rates of blood transfusion, and peak serum bilirubin in a large national cohort of very preterm infants.

STUDY DESIGN

We retrospectively studied preterm infants <33 weeks of gestation admitted to the Canadian Neonatal Network between January 2015 and December 2017. Patients who received ECC (<30 seconds), UCM, or DCC (≥30 seconds) were compared. Multiple generalized linear/quantile logistic regression models were used.

RESULTS

Of 12 749 admitted infants, 9729 were included; 4916 (50.5%) received ECC, 394 (4.1%) UCM, and 4419 (45.4%) DCC. After adjustment for potential confounders identified between groups in univariate analyses, the odds of mortality or major morbidity were higher in the ECC group when compared with UCM group (aOR, 1.18; 95% CI, 1.03-1.35). Mortality and intraventricular hemorrhage were associated with ECC as compared with DCC (aOR, 1.6 [95% CI, 1.22-2.1] and aOR, 1.29 [95% CI, 1.19-1.41], respectively). The odds of severe intraventricular hemorrhage were higher with UCM compared with DCC (aOR, 1.38; 95% CI, 1.05-1.81). Rates of blood transfusion were higher with ECC compared with UCM and DCC (aOR, 1.67 [95% CI, 1.31-2.14] and aOR, 1.68 [95% CI, 1.35-2.09], respectively), although peak serum bilirubin levels were not significantly different.

CONCLUSIONS

Both DCC and UCM were associated with better short-term outcomes than ECC; however, the odds of severe intraventricular hemorrhage were higher with UCM compared with DCC.

Intraventricular hemorrhage in preterm babies

Germinal matrix-intraventricular hemorrhage (GM-IVH) is a major complication of prematurity and inversely associated with gestational age and birth weight. The hemorrhage originates from the germinal matrix with an immature capillary bed where vascularization is intense and active cell proliferation is high. It occurs in around 20% of very low-birth-weight preterm neonates. Germinal matrix-intraventricular hemorrhage is less common in females, the black race, and with antenatal steroid use, but is more common in the presence of mechanical ventilation, respiratory distress, pulmonary bleeding, pneumothorax, chorioamnionitis, asphyxia, and sepsis. Ultrasonography is the diagnostic tool of choice for intraventricular hemorrhage and its complications. Approximately 25-50% of the germinal matrix-intraventricular hemorrhage cases are asymptomatic and diagnosed during routine screening. These cases are usually patients with low-grade hemorrhage. Neurologic findings are prominent in severe intraventricular hemorrhage cases. The major complications of the germinal matrix-intraventricular hemorrhage in preterm babies are periventricular hemorrhagic infarction, posthemorrhagic ventricular dilatation, periventricular leukomalacia, and cerebellar hemorrhage. It is an important cause of mortality and morbidity. The management of hemodynamics and ventilation of patients, appropriate follow-up, and early diagnosis and treatment can minimize morbidity. Prognosis in intraventricular hemorrhage is related to the severity of bleeding, parenchymal damage, and the presence of seizures and shunt surgery. The main determinant of prognosis is periventricular hemorrhagic infarction and its severity. Moderate-severe intraventricular hemorrhage can cause posthemorrhagic hydrocephalus, cerebral palsy, and mental retardation. Even mild germinal matrix-intraventricular hemorrhage can result in developmental disorders. Long-term problems such as neurodevelopmental disorders and cerebral palsy are as important as short-term problems. Improving the quality of life of these babies should be aimed through appropriate treatment and follow-up. In this review, intraventricular hemorrhage and complications are discussed.

Randomized Study of Delayed Cord Clamping of 30 to 60 Seconds in the Larger Infant Born Preterm

In a randomized study of infants born preterm (gestational age 28-34 6/7 weeks), we evaluated delayed cord clamping for 30 (n = 50) vs 60 (n = 55) seconds. The primary outcome of initial hematocrit differed by 2.8% (P = .006), being greater with 60 seconds. There were no differences in secondary outcomes and no adverse consequences between groups. These findings should serve as a stimulus to many centers that are reluctant to implement delayed cord clamping in this targeted larger premature population.

A randomized controlled study of immediate versus delayed umbilical cord clamping in infants born by elective caesarean section

BACKGROUND

Delayed umbilical cord clamping is associated with greater haemoglobin concentration and iron storage between 3 and 6 months of life and with less need of blood transfusion and lower incidence of neonatal hypotension compared to early umbilical cord clamping.

METHODS

The aim was to test the hypothesis that delayed cord clamping is better than early cord clamping in term infants born by elective caesarean section. Group A was subjected to immediate cord clamping while in the Group B, the umbilical cord was clamped 1 min after birth. Primary aim was revealed the difference in pre-ductal saturation between two groups while secondary aim was investigating the difference in HR, Ht, bilirubin and glycaemia. Pre-ductal SpO₂ and HR were recorded at 5 and 10 min after birth, T was analysed 10 min after birth, glycaemia was revealed at 120 min while Ht and bilirubin were collected at 72 h.

RESULTS

132 newborns were enrolled in the study and allocated in ratio 1:1 to group A or B. Delayed cord clamping did not improve SpO_2, HR and T values compared to immediate cord clamping (p > 0,05). However, Group B showed greater haematocrit and bilirubin values at 72 h compared to Group A (56,71 ± 6663 vs 51,56 ± 6929; p < 0,05 and 8,54 ± 2,90 vs 7,06 ± 2,76; p < 0,05). Glycaemia value did not differ between two groups (p > 0,05).

CONCLUSIONS

Group B did not reveal any differences in SpO₂, HR, T and glycaemia compared to Group A. Group B showed greater values of haematocrit and bilirubin but without need of phototherapy.

TRIAL REGISTRATION

Umbilical Cord Clamping: What Are the Benefits; NCT03878602. Registered 18 March 2019 retrospectively registered.

Early anemia and neonatal morbidity in extremely low birth-weight preterm infants

Background: Extremely low birth-weight (ELBW) preterm infants remain at high risk for mortality and major morbidities, and nearly all need packed red blood cell transfusions within their first weeks of life. The overall objective of this study was to assess the association between anemia at admission to neonatal intensive care unit (NICU) with the neonatal morbidity and mortality in ELBW infants.Methods: This retrospective study was conducted on 106 patients with ELBW admitted at our level III NICU from January 2006 to December 2015. The subjects were divided into two groups: (1) patients with anemia at admission and (2) patients without anemia. Their characteristics and outcomes were compared. Statistical analysis was performed using the Statistical Package for the Social Sciences software, version 24.0 (IBM New York, USA), and a value of p < 0.05 was considered statistically significant.Results: Of the 106 ELBW, 34 (32%) presented with anemia at admission and 72 (68%) without anemia. Anemia-naive presented mean hemoglobin at the admission of 12.8 ± 1.5 g/dl and nonanemic 16.8 ± 2.1 g/dl, p < .001). The anemic group presented a lower gestational age (26 ± 2 vs. 27 ± 2 SD weeks, p = .025), greater need for inotropic support (52.9 vs. 31.9%, p = .041), longer period of invasive mechanical ventilation (9 vs. 2 days, p = .012), higher FiO₂ need (0.8 vs. 0.4, p < .001), more frequent hemodynamically significant patent ductus arteriosus (HS-PDA) (64.7 vs. 41.7%, p = .006) and severe intra-periventricular hemorrhage (IPVH) (41.2 vs. 16.7%, p = 0.005). The multivariate analysis confirmed an association between anemia at admission and HS-PDA (OR = 3.2; 95% CI: 1.1-9.5, p = 0.044) and severe IPVH (OR = 3.3; 95% CI: 1.0-9.9, p = .038). In anemic infants, ionotropic support and IPVH >2 were considered independent factors for mortality.Conclusion: In this ELBW series, the presence of anemia at admission to the NICU was associated with HS-PDA and severe IPVH. Preventive strategies for early anemia must be encouraged.

Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes

BACKGROUND

Infants born preterm (before 37 weeks' gestation) have poorer outcomes than infants at term, particularly if born before 32 weeks. Early cord clamping has been standard practice over many years, and enables quick transfer of the infant to neonatal care. Delayed clamping allows blood flow between the placenta, umbilical cord and baby to continue, and may aid transition. Keeping baby at the mother's side enables neonatal care with the cord intact and this, along with delayed clamping, may improve outcomes. Umbilical cord milking (UCM) is proposed for increasing placental transfusion when immediate care for the preterm baby is needed. This Cochrane Review is a further update of a review first published in 2004 and updated in 2012.

OBJECTIVES

To assess the effects on infants born at less than 37 weeks' gestation, and their mothers of: 1) delayed cord clamping (DCC) compared with early cord clamping (ECC) both with immediate neonatal care after cord clamping; 2) DCC with immediate neonatal care with cord intact compared with ECC with immediate neonatal care after cord clamping; 3) DCC with immediate neonatal care after cord clamping compared with UCM; 4) UCM compared with ECC with immediate neonatal care after cord clamping.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (10 November 2017), and reference lists of retrieved studies. We updated the search in November 2018 and added nine new trial reports to the awaiting classification section to be assessed at the next update.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing delayed with early clamping of the umbilical cord (with immediate neonatal care after cord clamping or with cord intact) and UCM for births before 37 weeks' gestation. Quasi-RCTs were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Random-effects are used in all meta-analyses. Review authors assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

This update includes forty-eight studies, involving 5721 babies and their mothers, with data available from 40 studies involving 4884 babies and their mothers. Babies were between 24 and 36+6 weeks' gestation at birth and multiple births were included. The data are mostly from high-income countries. Delayed clamping ranged between 30 to 180 seconds, with most studies delaying for 30 to 60 seconds. Early clamping was less than 30 seconds and often immediate. UCM was mostly before cord clamping but some were milked after cord clamping. We undertook subgroup analysis by gestation and type of intervention, and sensitivity analyses by low risk of selection and attrition bias.All studies were high risk for performance bias and many were unclear for other aspects of risk of bias. Certainty of the evidence using GRADE was mostly low, mainly due to imprecision and unclear risk of bias.Delayed cord clamping (DCC) versus early cord clamping (ECC) both with immediate neonatal care after cord clamping (25 studies, 3100 babies and their mothers)DCC probably reduces the number of babies who die before discharge compared with ECC (average risk ratio (aRR) 0.73, 95% confidence interval (CI) 0.54 to 0.98, 20 studies, 2680 babies (moderate certainty)).No studies reported on 'Death or neurodevelopmental impairment' in the early years'.DCC may make little or no difference to the number of babies with severe intraventricular haemorrhage (IVH grades 3 and 4) (aRR 0.94, 95% CI 0.63 to 1.39, 10 studies, 2058 babies, low certainty) but slightly reduces the number of babies with any grade IVH (aRR 0.83, 95% CI 0.70 to 0.99, 15 studies, 2333 babies, high certainty).DCC has little or no effect on chronic lung disease (CLD) (aRR 1.04, 95% CI 0.94 to 1.14, 6 studies, 1644 babies, high certainty).Due to insufficient data, we were unable to form conclusions regarding periventricular leukomalacia (PVL) (aRR 0.58, 95% CI 0.26 to 1.30, 4 studies, 1544 babies, low certainty) or maternal blood loss of 500 mL or greater (aRR 1.14, 95% CI 0.07 to 17.63, 2 studies, 180 women, very low certainty).We identified no important heterogeneity in subgroup or sensitivity analyses.Delayed cord clamping (DCC) with immediate neonatal care with cord intact versus early cord clamping (ECC) (one study, 276 babies and their mothers)There are insufficient data to be confident in our findings, but DCC with immediate neonatal care with cord intact may reduce the number of babies who die before discharge, although the data are also compatible with a slight increase in mortality, compared with ECC (aRR 0.47, 95% CI 0.20 to 1.11, 1 study, 270 babies, low certainty). DCC may also reduce the number of babies who die or have neurodevelopmental impairment in early years (aRR 0.61, 95% CI 0.39 to 0.96, 1 study, 218 babies, low certainty). There may be little or no difference in: severe IVH; all grades IVH; PVL; CLD; maternal blood loss ≥ 500 mL, assessed as low certainty mainly due to serious imprecision.Delayed cord clamping (DCC) with immediate neonatal care after cord clamping versus umbilical cord milking (UCM) (three studies, 322 babies and their mothers) and UCM versus early cord clamping (ECC) (11 studies, 1183 babies and their mothers)There are insufficient data for reliable conclusions about the comparative effects of UCM compared with delayed or early clamping (mostly low or very low certainty).

AUTHORS' CONCLUSIONS

Delayed, rather than early, cord clamping may reduce the risk of death before discharge for babies born preterm. There is insufficient evidence to show what duration of delay is best, one or several minutes, and therefore the optimum time to clamp the umbilical cord remains unclear. Whilst the current evidence supports not clamping the cord before 30 seconds at preterm births, future trials could compare different lengths of delay. Immediate neonatal care with the cord intact requires further study, and there are insufficient data on UCM.The nine new reports awaiting further classification may alter the conclusions of the review once assessed.

Strategies for implementing placental transfusion at birth: A systematic review

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.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes

Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

Delayed clamping vs milking of umbilical cord in preterm infants: a randomized controlled trial

BACKGROUND

It has been established that delayed umbilical cord clamping in preterm infants results in improvement in neonatal anemia, need for transfusion, incidence of necrotizing enterocolitis, and intraventricular hemorrhage by increasing neonatal circulating blood volume. However, the effects of umbilical cord milking as an alternative to delayed clamping in preterm infants are unclear.

OBJECTIVE

The primary objective of this study was to compare the effect of delayed clamping vs milking of the umbilical cord on the initial hematocrit concentration in preterm births (23-34 weeks gestation). In addition, we sought to compare the effects of delayed clamping vs milking on the incidences of intraventricular hemorrhage, necrotizing enterocolitis, and need for transfusion (secondary objectives).

STUDY DESIGN

The study was an unblinded randomized controlled trial of singleton preterm infants who were born 23 weeks 0 days to 34 weeks 6 days gestation and were assigned to 1 of 2 controlled study groups: delayed cord clamping for 60 seconds or milking of the cord towards the infant 4 times before clamping. Randomization occurred via block randomization with an allocation ratio of 1 to 1. The patients' third stage of delivery was standardized for route of delivery and randomization arm. All comparisons were preformed with an intent-to-treat analysis approach. The study was powered at 80% with a probability value of .05 for the primary outcome measure of a hematocrit difference of 3% between the 2 groups.

RESULTS

Of the 204 randomized patients, 104 were assigned to the delayed subgroup, and 100 were assigned to the milking subgroup. There were no significant differences in baseline maternal characteristics noted between groups. Though there was not any statistically significant difference in neonatal outcomes between the cord clamping and milking groups, the occurrences of transfusion (15.5% vs 9.1%; P=.24), necrotizing enterocolitis (5.8% vs 3.0%; P=.49), and intraventricular hemorrhage (15.5% vs 10.1%; P=.35) were all lower in the milking group. The milking group had higher initial hematocrit concentration compared with the delayed clamping group, although this was not significant (51.8 [6.2%] vs 49.9 [7.7%]; P=.07]. Peak bilirubin levels and need for phototherapy were similar between groups.

CONCLUSION

This study demonstrates that milking the umbilical cord may be an acceptable alternative to delayed cord clamping because there were similar effects on neonatal hematocrit concentrations and the need for neonatal transfusions and no increased risk for complications or neonatal morbidity. The present data support the concept that milking of the umbilical cord may offer an efficient and timely method of providing increased blood volume to the infant.

Safety and Ergonomic Challenges of Ventilating a Premature Infant During Delayed Cord Clamping

Delayed cord clamping (DCC) is endorsed by multiple professional organizations for both term and preterm infants. In preterm infants, DCC has been shown to reduce intraventricular hemorrhage, lower incidence of necrotizing enterocolitis, and reduce the need for transfusions. Furthermore, in preterm animal models, ventilation during DCC leads to improved hemodynamics. While providing ventilation and continuous positive airway pressure (CPAP) during DCC may benefit infants, the logistics of performing such a maneuver can be complicated. In this simulation-based study, we sought to explore attitudes of providers along with the safety and ergonomic challenges involved with safely resuscitating a newborn infant while attached to the placenta. Multidisciplinary workshops were held simulating vaginal and Caesarean deliveries, during which providers started positive pressure ventilation and transitioned to holding CPAP on a preterm manikin. Review of videos identified 5 themes of concerns: sterility, equipment, mobility, space and workflow, and communication. In this study, simulation was a key methodology for safe identification of various safety and ergonomic issues related to implementation of ventilation during DCC. Centers interested in implementing DCC with ventilation are encouraged to form multidisciplinary work groups and utilize simulations prior to performing care on infants.

Neuroprotective Care of Extremely Preterm Infants in the First 72 Hours After Birth

Birth at extremely low gestational ages presents a significant threat to infants' survival, health, development, and future well-being. After birth, a critical period of brain development must continue outside the womb. Neuro-supportive and neuroprotective family centered developmental care for and standardized care practices for extremely preterm infants have been shown to improve outcomes. Neuroprotective interventions must include a focus on the emotional connections of infants and their families. Being in skin-to-skin contact with the mother is the developmentally expected environment for all mammals and is especially important for supporting physiologic stability and neurodevelopment of preterm infants.

Association between hemoglobin concentrations at discharge from the neonatal intensive care unit with markers of neurodevelopmental outcomes in premature neonates

BACKGROUND

Premature neonates are often subjected to multiple transfusions with red blood cells during their hospitalization in the neonatal intensive care unit (NICU). The hemoglobin threshold for transfusion prior to discharge from the NICU varies significantly among different centers. The aim of the present study is to investigate the association between hemoglobin concentration at discharge with neurodevelopmental outcomes in premature neonates.

METHODS

Retrospective observation study with regression analysis was performed with follow up assessment in the neuro-developmental outpatient clinic at 30 months of adjusted age.

RESULTS

Data from 357 neonates born at less than 37 weeks' gestation were analyzed. Sensory and motor neurodevelopment at 30 months of adjusted age, were not associated with the hemoglobin concentration at discharge (p=0.5891 and p=0.4575, respectively). There was no association between the hemoglobin concentration at discharge with fine or gross motor development (p=0.1582 and p=0.3805, respectively). Hemoglobin concentration at discharge was not associated with poor neurodevelopmental outcomes up until 30 months of adjusted age.

CONCLUSIONS

The data of the present study indicate that the hemoglobin concentration of premature neonates at the time of discharge is not associated with poorer markers of neurodevelopmental outcomes at 30 months of adjusted age. Comorbidities such as BPD and IVH that are present to premature neonates were identified as potential risk factors for certain aspects of the neurodevelopment.

Association of Deferred vs Immediate Cord Clamping With Severe Neurological Injury and Survival in Extremely Low-Gestational-Age Neonates

IMPORTANCE

Deferred cord clamping (DCC) is recommended for term and preterm neonates to reduce neonatal complications. Information on the association of DCC with outcomes for extremely low-gestational-age neonates is limited.

OBJECTIVE

To compare neonatal outcomes after DCC and immediate cord clamping (ICC) in extremely low-gestational-age neonates.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, eligible neonates born between January 1, 2011, and December 31, 2015, were divided into 2 groups: DCC and ICC. Neonates were recruited from tertiary neonatal intensive care units participating in the Canadian Neonatal Network, and analysis began in January 2018. Neonates were eligible if they were born at 22 to 28 weeks' gestational age and admitted to a participating Canadian Neonatal Network neonatal intensive care unit during the study period. Neonates who were born outside a tertiary-level neonatal intensive care unit, were moribund at birth, needed palliative care before delivery, had major congenital anomalies, or lacked cord clamping information were excluded.

MAIN OUTCOMES AND MEASURES

Composite of severe neurological injury (intraventricular hemorrhage grade ≥3 with or without persistent periventricular echogenicity) or mortality before discharge.

RESULTS

Of 8221 admitted neonates, 4680 were included in the study, of whom 1852 (39.6%) received DCC and 2828 (60.4%) received ICC. There were 974 (52.7%) male neonates in the DCC group and 1540 (54.5%) male neonates in the ICC group. Median (interquartile range) gestational age was 27 (25-28) weeks for the DCC group and 26 (25-27) weeks for the ICC group. Median (interquartile range) birth weight was 930 (760-1120) g and 870 (700-1060) g for DCC and ICC groups, respectively. Neonates who received DCC had significantly reduced odds of the composite outcome of severe neurological injury or mortality (adjusted odds ratio [AOR], 0.80; 95% CI, 0.67-0.96), mortality (AOR, 0.74; 95% CI, 0.59-0.93), and severe neurological injury (AOR, 0.80; 95% CI, 0.64-0.99). The odds of bronchopulmonary dysplasia (AOR, 1.00; 95% CI, 0.84-1.19), retinopathy of prematurity stage 3 or higher (AOR, 0.94; 95% CI, 0.71-1.25), necrotizing enterocolitis stage 2 or higher (AOR, 0.86; 95% CI, 0.66-1.12), late-onset sepsis (AOR, 1.02; 95% CI, 0.85-1.22), and receipt of 2 or more blood transfusions (AOR, 0.93; 95% CI, 0.79-1.10) did not differ between the groups. Propensity score-matched analyses revealed lower odds of mortality (AOR, 0.79; 95% CI, 0.65-0.95), late-onset sepsis (AOR, 0.81; 95% CI, 0.69-0.95), and treatment for hypotension (AOR, 0.75; 95% CI, 0.60-0.95) in the DCC group.

CONCLUSIONS AND RELEVANCE

In this study of extremely low-gestational-age neonates who received DCC or ICC, DCC was associated with reduced risk for the composite outcome of severe neurological injury or mortality.

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.