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Orton M, Theilen L, Clark E, Baserga M, Lauer S, Ou Z, Presson AP, Dupont T, Katheria A, Singh Y, Chan B. Thermoregulation-Focused Implementation of Delayed Cord Clamping among <34 Weeks' Gestational Age Neonates. Am J Perinatol 2024; 41:e3099-e3106. [PMID: 37989208 DOI: 10.1055/s-0043-1776916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE Delayed cord clamping (DCC) is recommended for all neonates; however, adapting such practice can be slow or unsustainable, especially among preterm neonates. During DCC neonates are exposed to a cool environment, raising concerns for neonatal hypothermia. Moderate hypothermia may induce morbidities that counteract the potential benefits of DCC. A quality improvement project on a thermoregulation-focused DCC protocol was implemented for neonates less than 34 weeks' gestational age (GA). The aim was to increase the compliance rate of DCC while maintaining normothermia. STUDY DESIGN The DCC protocol was implemented on October 1, 2020 in a large Level III neonatal intensive care unit. The thermoregulation measures included increasing delivery room temperature and using heat conservation supplies (sterile polyethylene suit, warm towels, and thermal pads). Baseline characteristics, the compliance rate of DCC, and admission temperatures were compared 4 months' preimplementation and 26 months' postimplementation RESULTS: The rate of DCC increased from 20% (11/54) in preimplementation to 57% (240/425) in postimplementation (p < 0.001). The balancing measure of admission normothermia remained unchanged. In a postimplementation subgroup analysis, the DCC cohort had less tendency to experience admission moderate hypothermia (<36°C; 9.2 vs. 14.1%, p = 0.11). The DCC cohort had more favorable secondary outcomes including higher admission hematocrit, less blood transfusions, less intraventricular hemorrhage, and lower mortality. Improving the process measure of accurate documentation could help to identify implementation barriers. CONCLUSION Performing DCC in preterm neonates was feasible and beneficial without increasing admission hypothermia. KEY POINTS · Thermoregulation-focused DCC protocol was implemented to increase DCC while maintaining normothermia.. · DCC rate increased from 20 to 57% while admission normothermia rate remained the same.. · DCC practice on preterm neonates is safe and feasible while maintaining normothermia..
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Affiliation(s)
- Melissa Orton
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Lauren Theilen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Erin Clark
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Sarah Lauer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Tara Dupont
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Anup Katheria
- San Diego Neonatology, Department of Pediatrics, Sharp Mary Birch Hospital for Women and Newborn, San Diego, California
- Division of Neonatology, Department of Pediatrics, University of California at San Diego, San Diego, California
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California
| | - Belinda Chan
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Yan J, Ren JD, Zhang J, Li J, Zhang X, Ma Y, Gao L. The Short and Long Term Consequences of Delayed Cord Clamping on Late Pre-Term Infants. Int J Womens Health 2023; 15:361-368. [PMID: 36942048 PMCID: PMC10024498 DOI: 10.2147/ijwh.s385800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 02/20/2023] [Indexed: 03/14/2023] Open
Abstract
Objective To explore the effect of delayed cord clamping on preterm infants. Methods A retrospective analysis was conducted using the clinical data of 163 preterm infants with a gestational age of 34-36 weeks + 6 who were admitted to the neonatology department within 2 hours after birth. The blood routine examination indices within 2 hours and at 3-5 days after birth, the biochemical indices and arterial blood gas (ABG) indices within 2 hours after birth, and the hemoglobin level 5-6 months after birth were compared between the early cord clamping (ECC) group and the delayed cord clamping (DCC) group. Results Compared with the ECC group, the DCC group had significantly higher venous blood levels of red blood cells, hemoglobin, and hematocrit within 2 hours and at 3-5 days after birth. The ABG bicarbonate (HCO3) level within 2 hours after birth was obviously higher in the DCC group than in the ECC group, and the ABG absolute base excess(BE) and lactate levels were lower in the DCC group than in the ECC group (P < 0.05). There was no significant difference between the two groups in the incidence of hypothermia, hypoglycemia, respiratory distress, septicemia, feeding intolerance, polycythemia, and hyperbilirubinemia requiring phototherapy during hospitalization (P > 0.05). Compared with the ECC group, the DCC group had a significantly higher venous blood hemoglobin level 5-6 months after birth. The incidence of anemia in the DCC group was significantly lower than in the ECC group (P < 0.05). Conclusion Delayed cord clamping can significantly increase the hemoglobin levels of preterm infants at birth and at 5-6 months after birth and can improve the oxygen circulation supply to the organs of such infants. Therefore, delayed cord clamping can improve the prognosis of preterm infants.
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Affiliation(s)
- Jie Yan
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Jian-Dong Ren
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
- Correspondence: Jian-Dong Ren, Department of Neonatology, Suzhou Ninth People’s Hospital, No. 2666 Ludang Road, Wujiang District, Suzhou, Jiangsu, 215000, People’s Republic of China, Tel +8615050371917, Email
| | - Jie Zhang
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Jun Li
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Xu Zhang
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Yan Ma
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Li Gao
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
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Umbilical cord clamping time and maternal satisfaction. Midwifery 2022; 115:103487. [PMID: 36126369 DOI: 10.1016/j.midw.2022.103487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 08/21/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Clamping of the umbilical cord is part of the third stage of delivery. Delayed cord clamping (DCC) is recommended due to its contribution to prevention of anaemia. There is no evidence on the effect of DCC on maternal satisfaction. The aim of this study is to evaluate the effect of different sociodemographic and obstetric factors, including the timing of cord clamping, on maternal satisfaction with the birth experience in our healthcare system. DESIGN Pragmatic non-drug intervention study with simple random assignment of participating mothers (Clinical Trials N°: NCT03624335). SETTING A public, university-level hospital in Villarreal city, eastern Spain. PARTICIPANTS Childbearing woman, gestation week between 35 and 42 weeks, with regular medical pregnancy checks, single pregnancy and vaginal delivery (N = 198, 80% of the women recruited). INTERVENTIONS umbilical cord clamping within 60 seconds of the birth (Early cord clamping, ECC) versus umbilical cord clamping after pulsation had been ceased (Delayed cord clamping, DCC). MEASUREMENTS Birth satisfaction was measured using the Mackey Childbirth Satisfaction Rating Scale (MCSRS). Additionally, sociodemographic data, degree of knowledge about the moment of clamping and type of breastfeeding data were recorded. The Mann-Whitney and Kruskal-Wallis tests for comparison of the mean of two, three, or more groups, respectively, and Chi-square and Spearman for comparison of two qualitative and quantitative variables, respectively, were used. To determine the weight of each factor of MCSRS, an exploratory factor analysis was carried out using the maximum likelihood method for factor extraction and the varimax method for factor rotation. The adequacy of the factor analysis was checked by mean of Kaiser-Meyer-Olkin test and Bartlett sphericity test. The level of significance was set at a p-value of < 0.05. FINDINGS The average degree of satisfaction was 4.55/5 (SD: 0.37). No statistically significant difference was observed between mothers' satisfaction according to mother level of study or mother's place of birth, while it changed significantly with age (p = 0.0398). Within the obstetric variables, satisfaction was significantly associated with spontaneous amniorrhexis, the duration of the second stage of delivery, and the Apgar value of the newborn at the first minute of life, and was independent of the number of previous pregnancies and deliveries, use of intrapartum oxytocin, epidural analgesia, episiotomy, the weight of the child at birth and type of breastfeeding. Furthermore, there was no relationship between the time of clamping and satisfaction (p = 0.5178). KEY CONCLUSIONS Maternal satisfaction with the birth experience varies with the age of the childbearing woman, and some intrapartum factors and the result is not influenced by the time of clamping of the umbilical cord. Therefore, this component of the physiological management of childbirth provides additional benefits for the health of the neonate, without negative consequences on the final perception of the maternal health care received. IMPLICATIONS FOR PRACTICE If there are no reasons that justify an early umbilical cord clamping, delaying it brings benefits to the neonate, without negatively affecting the maternal assessment of the experience of childbirth.
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Bruinsma MAW, de Boer MA, Prins S, Abheiden CNH. Does placental abruption cause neonatal anemia? Acta Obstet Gynecol Scand 2022; 101:917-922. [PMID: 35582929 DOI: 10.1111/aogs.14376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/27/2022] [Accepted: 04/14/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Placental abruption can result in serious perinatal morbidity and mortality. However, it is not clear whether placental abruption could lead to neonatal anemia, as a direct relationship has not been described yet. The objective of this study is to investigate whether there is a relationship between occurrence of placental abruption and neonatal anemia. MATERIAL AND METHODS All women with a clinical diagnoses of placental abruption between January 2016 and April 2021 in Amsterdam UMC, from both the VU University Medical Center and Amsterdam Medical Center, were included. Demographic data and delivery outcomes were collected retrospectively using the medical files. The primary outcome was neonatal anemia, defined as hemoglobin levels less than the fifth percentile for gestational age. RESULTS A total of 65 mothers and 65 neonates were included in our study. Average gestational age was 30 + 5 weeks. Mean hemoglobin level of the neonates at birth was 16.5 g/dl (10.2 mmol/L) with hemoglobin levels comparable to the reference curve. Two neonates (3.6%) were diagnosed with anemia based on their hemoglobin level at birth, and six (9.2%) neonates received a blood transfusion within 24 h after birth. CONCLUSIONS With this study, we found that the hemoglobin levels of the neonates born after placental abruption are comparable to the reference curve and do not show more neonates than expected below the fifth percentile for gestational age. It remains unclear whether there is fetal blood loss during a placental abruption but our results suggest that at least a big amount of fetal blood is not lost, since we did not found a large number of anemic neonates. Severe neonatal anemia in the case of placental abruption does not need to be expected.
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Affiliation(s)
- Marieke A W Bruinsma
- Obstetrics and Gynecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Pregnancy and Birth, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Marjon A de Boer
- Obstetrics and Gynecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Pregnancy and Birth, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Sandra Prins
- Neonatology Amsterdam, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Child Development, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Carolien N H Abheiden
- Obstetrics and Gynecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Pregnancy and Birth, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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Nutritional Assessment in Preterm Infants: A Practical Approach in the NICU. Nutrients 2019; 11:nu11091999. [PMID: 31450875 PMCID: PMC6770216 DOI: 10.3390/nu11091999] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/21/2019] [Indexed: 12/17/2022] Open
Abstract
A practical approach for nutritional assessment in preterm infants under intensive care, based on anthropometric measurements and commonly used biochemical markers, is suggested. The choice of anthropometric charts depends on the purpose: Fenton 2013 charts to assess intrauterine growth, an online growth calculator to monitor intra-hospital weight gain, and Intergrowth-21st standards to monitor growth after discharge. Body weight, though largely used, does not inform on body compartment sizes. Mid-upper arm circumference estimates body adiposity and is easy to measure. Body length reflects skeletal growth and fat-free mass, provided it is accurately measured. Head circumference indicates brain growth. Skinfolds estimate reasonably body fat. Weight-to-length ratio, body mass index, and ponderal index can assess body proportionality at birth. These and other derived indices, such as the mid-upper arm circumference to head circumference ratio, could be proxies of body composition but need validation. Low blood urea nitrogen may indicate insufficient protein intake. Prealbumin and retinol binding protein are good markers of current protein status, but they may be affected by non-nutritional factors. The combination of a high serum alkaline phosphatase level and a low serum phosphate level is the best biochemical marker for the early detection of metabolic bone disease.
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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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BATMAN D, ÇOBAN A. Gecikmiş Umbilikal Kord Klempleme ve Kord Sıvazlama Uygulamalarinin Prematüre Yenidoğanlarda Etkileri. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2019. [DOI: 10.30934/kusbed.475344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chiruvolu A, Daoud Y, Inzer RW. Effect of delayed cord clamping on very preterm twins. Early Hum Dev 2018; 124:22-25. [PMID: 30099274 DOI: 10.1016/j.earlhumdev.2018.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 07/27/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The very preterm infants of twin births may particularly benefit from delayed cord clamping (DCC) as the likelihood of unfavorable outcome is greater compared to singletons. Unfortunately, there is paucity of available information regarding safety and efficacy of DCC in this group. OBJECTIVE To report the clinical consequences of delayed cord clamping (DCC) in very preterm twins, born between 230/7 and 316/7 weeks gestation. STUDY DESIGN In this pre and post intervention retrospective cohort study, we compared 30 very preterm infants born from 15 twin deliveries during historic study period to 32 very preterm infants born from 16 twin deliveries during DCC study period. During historic study period (August 19, 2013 to January 31, 2015), infants included were eligible to receive DCC, but their cords were immediately clamped. DCC study period (February 1, 2015 to January 31, 2017) included infants who had DCC performed for 60 s after birth. RESULTS The Apgar scores and other resuscitation variables were similar between both groups. After adjusting for gestational age and mode of delivery, significantly fewer infants in the DCC cohort needed red blood cell (RBC) transfusions in first week of life compared to the historic cohort (15.6% vs. 43.3%; P = 0.03). Death and other major neonatal outcomes were similar between both groups. CONCLUSION DCC in very preterm twins was safe, feasible and not associated with any adverse neonatal outcomes compared to early cord clamping. DCC was associated with a significant reduction in early RBC transfusions.
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Affiliation(s)
- Arpitha Chiruvolu
- Division of Neonatology, Department of Pediatrics, Baylor University Medical Center, Pediatrix Medical Group, Dallas, TX, USA.
| | - Yahya Daoud
- Department of Quantitative Sciences, Center for Clinical Effectiveness, Office of Chief Quality Officer, Baylor Scott & White Health Care System, Dallas, TX, USA
| | - Robert W Inzer
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
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Cervantes LL, Zuñiga JA. Strategies to Avoid Neonatal Blood Transfusions for Families of the Jehovah's Witness Faith. Nurs Womens Health 2018; 22:332-337. [PMID: 30077239 DOI: 10.1016/j.nwh.2018.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/14/2018] [Accepted: 03/01/2018] [Indexed: 06/08/2023]
Abstract
Beliefs and restrictions regarding acceptance of blood products by members of the Jehovah's Witness faith often provoke discussion among health care professionals regarding alternative interventions. Establishing and maintaining an open dialog with women and families of the Jehovah's Witness faith regarding their beliefs on the use of blood and blood products are vital in creating a therapeutic relationship between families and the health care team. Such rapport facilitates the discussion of strategies to avoid blood transfusions for newborns and provides women and families multiple opportunities to develop of a holistic birth plan congruent with their beliefs.
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Chiruvolu A, Elliott E, Rich D, Stone GL, Qin H, Inzer RW. Effect of delay in cord clamping 45 versus 60 s on very preterm singleton infants. Early Hum Dev 2018. [PMID: 29518646 DOI: 10.1016/j.earlhumdev.2018.02.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the range of timing suggested by American College of Obstetricians and Gynecologists 30 to 60 s, preterm infants may potentially derive more short and long-term benefits with delayed cord clamping (DCC) for at least 60 s. However, there are concerns with longer resuscitation delay in this vulnerable population. OBJECTIVE To compare the clinical consequences of 45 versus 60 s delay in umbilical cord clamping in singleton infants born between 230/7 to 316/7 weeks gestation. STUDY DESIGN We implemented DCC process in very preterm singleton infants, initially for 45 s and later, modified the policy to increase the delay to 60 s. We compared the infants born and received DCC (n = 60) during the 45 s study period (DCC-45 cohort), from Aug.19, 2013, to Aug.18, 2014 to the infants born and received DCC (n = 63) during the 60 s study period (DCC-60 cohort), from Feb.1, 2015, to Jan.31, 2016. RESULTS The incidence of necrotizing enterocolitis in DCC-60 cohort was 0% compared to 8% in the DCC-45 cohort (P = 0.02). Similarly, incidence of culture-positive sepsis was significantly lower in the DCC-60 cohort compared to DCC-45 cohort (8% versus 18%; P = 0.04). Incidence of mortality and other major morbidities were similar between both groups. Length of stay was significantly lower in DCC-60 cohort compared to DCC-45 cohort. CONCLUSION DCC for 60 s in very preterm singleton infants was safe, feasible and not associated with any adverse maternal or neonatal short-term outcomes compared to DCC for 45 s.
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Affiliation(s)
- Arpitha Chiruvolu
- Division of Neonatology, Department of Pediatrics, Baylor University Medical Center, Pediatrix Medical Group, Dallas, TX, USA.
| | - Elise Elliott
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
| | - Diana Rich
- Department of Nursing, Baylor University Medical Center, Dallas, TX, USA
| | - Genna Leal Stone
- Department of Nursing, Baylor University Medical Center, Dallas, TX, USA
| | - Huanying Qin
- Department of Quantitative Health Sciences, Baylor Scott & White Health Care System, Dallas, TX, USA
| | - Robert W Inzer
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
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Ghirardello S, Di Tommaso M, Fiocchi S, Locatelli A, Perrone B, Pratesi S, Saracco P. Italian Recommendations for Placental Transfusion Strategies. Front Pediatr 2018; 6:372. [PMID: 30560107 PMCID: PMC6287578 DOI: 10.3389/fped.2018.00372] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/13/2018] [Indexed: 12/13/2022] Open
Abstract
At delivery, if the cord is not clamped, blood continues to pass from the placenta to the newborn during the first minutes of life, allowing the transfer of 25-35 ml/kg of placental blood to the newborn, depending on gestational age, the timing of cord clamping, the position of the infant at birth, the onset of respiration, and administration of uterotonics to the mother. However, deriving benefits from delayed cord clamping (DCC) are not merely related to placental-to-fetal blood transfusion; establishing spontaneous ventilation before cutting the cord improves venous return to the right heart and pulmonary blood flow, protecting the newborn from the transient low cardiac output, and systemic arterial pressure fluctuations. Recent meta-analyses showed that delayed cord clamping reduces mortality and red blood cell transfusions in preterm newborns and increases iron stores in term newborns. Various authors suggested umbilical cord milking (UCM) as a safe alternative when delayed cord clamping is not feasible. Many scientific societies recommend waiting 30-60 s before clamping the cord for both term and preterm newborns not requiring resuscitation. To improve the uptake of placental transfusion strategies, in 2016 an Italian Task Force for the Management of Umbilical Cord Clamping drafted national recommendations for the management of cord clamping in term and preterm deliveries. The task force performed a detailed review of the literature using the GRADE methodological approach. The document analyzed all clinical scenarios that operators could deal with in the delivery room, including cord blood gas analysis during delayed cord clamping and time to cord clamping in the case of umbilical cord blood banking. The panel intended to promote a more physiological and individualized approach to cord clamping, specifically for the most preterm newborn. A feasible option to implement delayed cord clamping in very preterm deliveries is to move the neonatologist to the mother's bedside to assess the newborn's clinical condition at birth. This option could safely guarantee the first steps of stabilization before clamping the cord and allow DCC in the first 30 s of life, without delaying resuscitation. Contra-indications to placental transfusion strategies are clinical situations that may endanger mother 's health and those that may delay immediate newborn's resuscitation when required.
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Affiliation(s)
- Stefano Ghirardello
- Neonatal Intensive Care Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mariarosaria Di Tommaso
- Health Sciences Department, University of Firenze, Careggi University Hospital, Florence, Italy
| | - Stefano Fiocchi
- Neonatology and Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Anna Locatelli
- Obstetrics and Gynecology Unit, School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Barbara Perrone
- Division of Neonatology and NICU, Salesi Children's Hospital, Ancona, Italy
| | - Simone Pratesi
- Neonatology Unit, Careggi University Hospital, Florence, Italy
| | - Paola Saracco
- Department of Pediatric Sciences, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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Bagna R, Spada E, Mazzone R, Saracco P, Boetti T, Cester EA, Bertino E, Coscia A. Efficacy of Supplementation with Iron Sulfate Compared to Iron Bisglycinate Chelate in Preterm Infants. Curr Pediatr Rev 2018; 14:123-129. [PMID: 29366419 PMCID: PMC6416193 DOI: 10.2174/1573396314666180124101059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 07/24/2017] [Accepted: 01/20/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Strategies to prevent anaemia in preterm infants include drawing fewer blood samples, the use of recombinant human erythropoietin and iron supplementation. Although iron sulfate is the most commonly used pharmaceutical formulation for iron supplementation, there are few studies comparing different iron salts in infants. OBJECTIVE This is a study of retrospective data comparison of two groups of preterm infants receiving erythropoietin to evaluate the efficacy of iron bisglycinate chelate to iron sulfate. SUBJECTS AND METHODS Three-hundred infants of gestational age ≤32 weeks were enrolled: 225 were supplemented with iron sulfate (3 mg/kg/day) and 75 were supplemented with iron bisglycinate chelate (0.75 mg/kg/day). The effect on erythropoiesis was assessed with a general linear model that estimates the response variables (values for Haemoglobin, Haematocrit, absolute values and percentage Reticulocytes, Reticulocyte Haemoglobin content) based on treatment, time, birth weight, and gestational age. RESULTS Supplementation with iron bisglycinate chelate at a dose of 0.75 mg/kg/day demonstrated an efficacy comparable to iron sulfate at a dose of 3 mg/kg/day in both populations of preterm infants. The two cohorts had similar erythropoietic response, without significant differences. CONCLUSIONS The higher bioavailability of iron bisglycinate chelate resulted in a lower load of elemental iron, a quarter of the dose, and achieved equivalent efficacy compared to iron sulfate. Iron bisglycinate chelate may appear to be an alternative to iron sulfate in the prevention and treatment of preterm newborn anaemia.
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Affiliation(s)
- Rossana Bagna
- Neonatology and Neonatal Intensive Care Unit, University Hospital, Citta della Salute e della Scienza, Turin, Italy
| | - Elena Spada
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Raffaela Mazzone
- SS Haematology and Coagulation, Department of Laboratory Medicine, Citta della Salute e della Scienza, Turin, Italy
| | - Paola Saracco
- SS Paediatric Haematology, University Department of Paediatric Science, Citta della Salute e della Scienza, Turin, Italy
| | - Tatiana Boetti
- Paediatrics and Neonatology Unit, Cardinal Massaia Hospital, Asti, Italy
| | - Elena Andrea Cester
- Neonatology and Neonatal Intensive Care Unit, University Hospital, Citta della Salute e della Scienza, Turin, Italy
| | - Enrico Bertino
- Neonatology and Neonatal Intensive Care Unit, University Hospital, Citta della Salute e della Scienza, Turin, Italy
| | - Alessandra Coscia
- Neonatology and Neonatal Intensive Care Unit, University Hospital, Citta della Salute e della Scienza, Turin, Italy
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Gams RL, Popp KK, Cramer J, George TN, Rauk PN, Sommerness SA, Sublette JA. How to Engage Your Team to Implement Delayed Cord Clamping. Nurs Womens Health 2017; 21:489-498. [PMID: 29223212 DOI: 10.1016/j.nwh.2017.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 06/23/2017] [Indexed: 06/07/2023]
Abstract
This article describes how a health care team changed practice by implementing delayed cord clamping as standard practice. After administration of a survey to assess clinicians' knowledge and to discover barriers to this proposed practice change, members of a multidisciplinary committee used the results to create a guideline for delayed cord clamping and a plan for successful implementation. Integral to embedding and sustaining changes in practice was development of the Delivery Room Brief and Debrief Tool and inclusion of the process into nursing guidelines and the electronic health record. Through the use of these tools and teamwork, delayed cord clamping was implemented as standardized practice across six hospitals within this health care system.
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Effects of Delayed Cord Clamping on Intraventricular Hemorrhage in Preterm Infants. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.6570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.
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Affiliation(s)
- Deepak Sharma
- National Institute of Medical Science, Jaipur, Rajasthan India
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Kuo K, Gokhale P, Hackney DN, Ruangkit C, Bhola M, March M. Maternal outcomes following the initiation of an institutional delayed cord clamping protocol: an observational case–control study. J Matern Fetal Neonatal Med 2017; 31:197-201. [DOI: 10.1080/14767058.2017.1280018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kelly Kuo
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine Division, Oregon Health & Science University, Portland, OR, USA
| | - Priyanka Gokhale
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
| | - David N. Hackney
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine Division, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Chayatat Ruangkit
- Department of Pediatrics, Division of Neonatology, Ramathibodi Hospital, Mahidol University, Salaya, Thailand
| | - Monika Bhola
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
| | - Melissa March
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine Division, University Hospitals Case Medical Center, Cleveland, OH, USA
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Clampage tardif du cordon ombilical chez les enfants prématurés nés avant 37 semaines d’aménorrhée : étude observationnelle prospective. Arch Pediatr 2017; 24:118-125. [DOI: 10.1016/j.arcped.2016.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/29/2016] [Accepted: 11/22/2016] [Indexed: 11/22/2022]
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Abstract
"Golden 60 minutes "or "Golden Hour" is defined as the first hour of the newborn after birth. This hour includes resuscitation care, transport to nursery from place of birth and course in nursery. The concept of "Golden hour" includes evidence based interventions that are done in the first 60 min of postnatal life for the better long term outcome of the preterm newborn especially extreme premature, extreme low birth weight and very low birth weight. The evidence shows that the concept of "Golden 60 minutes" leads to reduction in neonatal complications like hypothermia, hypoglycemia, intraventricular hemorrhage, chronic lung disease and retinopathy of prematurity. In this review, we have covered various interventions included in "Golden hour" for preterm newborn namely delayed cord clamping, prevention of hypothermia, respiratory and cardiovascular system support, prevention of sepsis, nutritional support and communication with family.
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Sharma D, Sharma P, Shastri S. Golden 60 minutes of newborn's life: Part 2: Term neonate. J Matern Fetal Neonatal Med 2016; 30:2728-2733. [PMID: 27844484 DOI: 10.1080/14767058.2016.1261399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The concept of "Golden 60 minutes" or "Golden Hour" has been derived from adult trauma. It has been defined as the first 60 min of postnatal life. It has been seen that care received by any newborn in the initial first hour has implications in the future life, showing the importance of golden hour. The major cause of neonatal mortality term newborn is asphyxia, which can be reduced with effective resuscitation. In golden hour approach for term newborn, the importance is given to effective and evidence based resuscitation, post-resuscitation care, delayed cord clamping, prevention of hypothermia, immediate breast feeding, prevention of hypoglycemia, and starting of therapeutic hypothermia in case of moderate to severe asphyxia. In this part of review, we will cover all the golden hour interventions in term neonate with current evidence.
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Affiliation(s)
| | - Pradeep Sharma
- b Department of Medicine , Mahatma Gandhi Medical College , Jaipur , India
| | - Sweta Shastri
- c Department of Pathology , N.K.P. Salve Medical College , Nagpur , India
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Patel PN, Banerjee J, Godambe SV. Resuscitation of extremely preterm infants - controversies and current evidence. World J Clin Pediatr 2016; 5:151-8. [PMID: 27170925 PMCID: PMC4857228 DOI: 10.5409/wjcp.v5.i2.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/24/2015] [Accepted: 01/16/2016] [Indexed: 02/06/2023] Open
Abstract
Despite significant advances in perinatal medicine, the management of extremely preterm infants in the delivery room remains a challenge. There is an increasing evidence for improved outcomes regarding the resuscitation and stabilisation of extremely preterm infants but there is a lack of evidence in the periviable (gestational age 23-25 wk) preterm subgroup. Presence of an experienced team during the delivery of extremely preterm infant to improve outcome is reviewed. Adaptation from foetal to neonatal cardiorespiratory haemodynamics is dependent on establishing an optimal functional residual capacity in the extremely preterm infants, thus enabling adequate gas exchange. There is sufficient evidence for a gentle approach to stabilisation of these fragile infants in the delivery room. Evidence for antenatal steroids especially in the periviable infants, delayed cord clamping, strategies to establish optimal functional residual capacity, importance of temperature control and oxygenation in delivery room in extremely premature infants is reviewed in this article.
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Garabedian C, Rakza T, Drumez E, Poleszczuk M, Ghesquiere L, Wibaut B, Depoortere MH, Vaast P, Storme L, Houfflin-Debarge V. Benefits of Delayed Cord Clamping in Red Blood Cell Alloimmunization. Pediatrics 2016; 137:e20153236. [PMID: 26908660 DOI: 10.1542/peds.2015-3236] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Several studies have shown the benefits of delayed cord clamping (DCC) in preterm and in healthy newborns at short and long term. Our objective was to evaluate the potentials benefits and risks of DCC in red cell alloimmunization. METHODS This was a comparative before/after study of all living born neonates followed after fetal anemia requiring in utero transfusion. DCC was defined as cord clamping 30 seconds after birth. RESULTS We included a continuous series of 72 neonates: 36 without DDC (group 1) and 36 with DDC (group 2). Hemoglobin at birth was lower in group 1 (10.2 vs 13.4 g/dL, P = .0003); 7 (25%) neonates in group 1 vs 24 (70.6%) in group 2 had no anemia at birth (P = .004). The rate of transfusion was similar between the 2 groups. Postnatal exchange transfusions were more likely performed in the group without DCC than in the group with DCC (47.2% vs 19.4%, P = .0124). Delay between birth and first transfusion was higher in group 2 (0 [0-13] vs 1 [0-21], P = .0274). The maximum level of bilirubin, the rate of intensive phototherapy, and the total duration of phototherapy were similar in the 2 groups. CONCLUSIONS This study highlights a significant benefit of DCC in anemia secondary to red blood cell alloimmunization with a resulting decreased postnatal exchange transfusion needs, an improvement in the hemoglobin level at birth and longer delay between birth and first transfusion with no severe hyperbilirubinemia.
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Affiliation(s)
| | | | - Elodie Drumez
- Department of Biostatistics, University of Lille North of France, CHRU Lille, France; and
| | | | | | - Bénédicte Wibaut
- Institute of Hematology and Transfusion, Jeanne de Flandre Hospital, CHRU of Lille, France
| | | | | | - Laurent Storme
- Neonatology Unit, and Faculty of Medicine, University of Lille North of France, CHRU Lille, France
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Ersdal HL, Linde J, Auestad B, Mduma E, Lyanga S, Svensen E, Perlman J. Timing of cord clamping in relation to start of breathing or ventilation among depressed neonates-an observational study. BJOG 2015; 123:1370-7. [DOI: 10.1111/1471-0528.13778] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2015] [Indexed: 11/29/2022]
Affiliation(s)
- HL Ersdal
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
| | - J Linde
- Department of Paediatrics; Stavanger University Hospital; Stavanger Norway
| | - B Auestad
- Department of Mathematics and Natural Sciences; University of Stavanger; Stavanger Norway
- Department of Research; Stavanger University Hospital; Stavanger Norway
| | - E Mduma
- Department of Research; Stavanger University Hospital; Stavanger Norway
- Department of Research; Haydom Lutheran Hospital; Haydom Tanzania
| | - S Lyanga
- Department of Research; Haydom Lutheran Hospital; Haydom Tanzania
| | - E Svensen
- Centre for International Health; University of Bergen; Bergen Norway
| | - J Perlman
- Department of Pediatrics; Weill Cornell Medical College; New York NY USA
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Schorn MN, Moore E, Spetalnick BM, Morad A. Implementing Family-Centered Cesarean Birth. J Midwifery Womens Health 2015; 60:682-90. [PMID: 26618328 DOI: 10.1111/jmwh.12400] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cesarean birth is recognized as a physical and psychological stressor for many women. Maternity practices during cesarean birth should meet women's needs, while maintaining safety, to optimize the experience. Family-centered cesarean birth is a package of interventions that encourages a woman to participate in choosing interventions that would be helpful when undergoing a planned or unplanned cesarean birth. Included in family-centered cesarean birth is implementation of skin-to-skin care in the operating room for neonates who appear term and healthy. The process of attempting to implement family-centered cesarean birth at one academic center is presented, including steps for implementation, benefits, challenges, and areas for continued improvement and research. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.
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Chiruvolu A, Tolia VN, Qin H, Stone GL, Rich D, Conant RJ, Inzer RW. Effect of delayed cord clamping on very preterm infants. Am J Obstet Gynecol 2015. [PMID: 26196456 DOI: 10.1016/j.ajog.2015.07.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Despite significant proposed benefits, delayed umbilical cord clamping (DCC) is not practiced widely in preterm infants largely because of the question of feasibility of the procedure and uncertainty regarding the magnitude of the reported benefits, especially intraventricular hemorrhage (IVH) vs the adverse consequences of delaying the neonatal resuscitation. The objective of this study was to determine whether implementation of the protocol-driven DCC process in our institution would reduce the incidence of IVH in very preterm infants without adverse consequences. STUDY DESIGN We implemented a quality improvement process for DCC the started in August 2013 in infants born at ≤32 weeks' gestational age. Eligible infants were left attached to the placenta for 45 seconds after birth. Neonatal process and outcome data were collected until discharge. We compared infants who received DCC who were born between August 2013 and August 2014 with a historic cohort of infants who were born between August 2012 and August 2013, who were eligible to receive DCC, but whose cord was clamped immediately after birth, because they were born before the protocol implementation. RESULTS DCC was performed on all the 60 eligible infants; 88 infants were identified as historic control subjects. Gestational age, birthweight, and other demographic variables were similar between both groups. There were no differences in Apgar scores or admission temperature, but significantly fewer infants in the DCC cohort were intubated in delivery room, had respiratory distress syndrome, or received red blood cell transfusions in the first week of life compared with the historic cohort. A significant reduction was noted in the incidence of IVH in the DCC cohort compared with the historic control group (18.3% vs 35.2%). After adjustment for gestational age, an association was found between the incidence of IVH and DCC with IVH was significantly lower in the DCC cohort compared with the historic cohort; an odds ratio of 0.36 (95% confidence interval, 0.15-0.84; P < .05). There were no significant differences in deaths and other major morbidities. CONCLUSION DCC, as performed in our institution, was associated with significant reduction in IVH and early red blood cell transfusions. DCC in very preterm infants appears to be safe, feasible, and effective with no adverse consequences.
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Early versus delayed umbilical cord clamping in infants with congenital heart disease: a pilot, randomized, controlled trial. J Perinatol 2015; 35:826-31. [PMID: 26226244 PMCID: PMC5095614 DOI: 10.1038/jp.2015.89] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 04/30/2015] [Accepted: 06/11/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Delayed umbilical cord clamping (DCC) at birth may provide a better neonatal health status than early umbilical cord clamping (ECC). However, the safety and feasibility of DCC in infants with congenital heart disease (CHD) have not been tested. This was a pilot, randomized, controlled trial to establish the safety and feasibility of DCC in neonates with CHD. STUDY DESIGN Pregnant women admitted >37 weeks gestational age with prenatal diagnosis of critical CHD were enrolled and randomized to ECC or DCC. For ECC, the umbilical cord was clamped <10 s after birth; for DCC, the cord was clamped ~120 s after delivery. RESULTS Thirty infants were randomized at birth. No differences between the DCC and ECC groups were observed in gestational age at birth or time of surgery. No differences were observed across all safety measures, although a trend for higher peak serum bilirubin levels (9.2±2.2 vs 7.3±3.2 mg dl(-1), P=0.08) in the DCC group than in the ECC group was noted. Although similar at later time points, hematocrits were higher in the DCC than in the ECC infants during the first 72 h of life. The proportion of infants not receiving blood transfusions throughout hospitalization was higher in the DCC than in the ECC infants (43 vs 7%, log-rank test P=0.02). CONCLUSION DCC in infants with critical CHD appears both safe and feasible, with fewer infants exposed to red blood cell transfusions than with ECC. A more comprehensive appraisal of this practice is warranted.
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Song D, Jegatheesan P, DeSandre G, Govindaswami B. Duration of Cord Clamping and Neonatal Outcomes in Very Preterm Infants. PLoS One 2015; 10:e0138829. [PMID: 26390401 PMCID: PMC4577121 DOI: 10.1371/journal.pone.0138829] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 09/03/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Delayed cord clamping (DCC, ≥30 s) increases blood volume in newborns and is associated with fewer blood transfusions and short-term neonatal complications. The optimal timing of cord clamping for very preterm infants should maximize placental transfusion without interfering with stabilization and resuscitation. AIM We compared the effect of different durations of DCC, 30-45 s vs. 60-75 s, on delivery room (DR) and neonatal outcomes in preterm infants <32 weeks gestational age (GA). METHODS This is a single-center prospective observational study. Data were collected prospectively from eligible infants from two groups: 30-45 s DCC group (January 2008 to February 2011, n = 187) and 60-75 s DCC group (March 2011 to April 2014, n = 166). RESULTS The 60-75 s DCC group compared to the 30-45 s DCC group had higher hematocrits at <2 hours (49.2% vs. 47.4%, p = 0.02). In infants <28 weeks GA, the 12-36 hours hematocrit was higher in the 60-75 s DCC group compared to the 30-45 s DCC group (47.9% vs. 42.1%, p = 0.002). The 60-75 s DCC group had reductions in DR intubation (11% vs. 22%, p = 0.004), hypothermia on admission (1% vs. 5%, p = 0.01), surfactant therapy (13% vs. 28%, p = 0.001), intubation in the first 24 hours (20% vs. 34%, p = 0.004), any intubation (27% vs. 40%, p = 0.007), and any red blood cell transfusion (20% vs. 33%, p = 0.008) during the hospitalization compared to the 30-45 s DCC group. These reductions remained significant after adjusting for GA, gender and >48 hours of antenatal steroid exposure. There was no difference between the two groups in neonatal death, intraventricular hemorrhage, chronic lung disease, late onset sepsis, necrotizing enterocolitis and severe retinopathy of prematurity. CONCLUSION In this study cohort increasing DCC duration from 30-45 s to 60-75 s is associated with decreased hypothermia on admission, neonatal respiratory interventions and red blood cell transfusions without increase in neonatal mortality and morbidities.
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Affiliation(s)
- Dongli Song
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, California, United States of America
- * E-mail:
| | - Priya Jegatheesan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, California, United States of America
| | - Glenn DeSandre
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, California, United States of America
| | - Balaji Govindaswami
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, California, United States of America
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Affiliation(s)
- Roger F Soll
- The University of Vermont College of Medicine, Burlington, Vermont; Vermont Oxford Network, Burlington, Vermont; and
| | - William O Tarnow-Mordi
- WINNER Centre for Newborn Research, NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
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Boere I, Roest AAW, Wallace E, Ten Harkel ADJ, Haak MC, Morley CJ, Hooper SB, te Pas AB. Umbilical blood flow patterns directly after birth before delayed cord clamping. Arch Dis Child Fetal Neonatal Ed 2015; 100:F121-5. [PMID: 25389141 DOI: 10.1136/archdischild-2014-307144] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delayed umbilical cord clamping (DCC) affects the cardiopulmonary transition and blood volume in neonates immediately after birth. However, little is known of blood flow in the umbilical vessels immediately after birth during DCC. The objective is to describe the duration and patterns of blood flow through the umbilical vessels during DCC. METHODS Arterial and venous umbilical blood flow was measured during DCC using Doppler ultrasound in uncomplicated term vaginal deliveries. Immediately after birth, the probe was placed in the middle of the umbilical cord, pattern and duration of flow in vein and arteries were evaluated until cord clamping. RESULTS Thirty infants were studied. Venous flow: In 10% no flow was present, in 57% flow stopped at 4:34 (3:03-7:31) (median (IQR) min:sec) after birth, before the cord was clamped. In 33%, flow continued until cord clamping at 5:13 (2:56-9:15) min:sec. Initially, venous flow was intermittent, increasing markedly during large breaths or stopping and reversing during crying, but then became continuous. Arterial flow: In 17% no flow was present, in 40% flow stopped at 4:22 (2:29-7:17) min:sec, while cord pulsations were still palpable. In 43% flow continued until the cord was clamped at 5:16 (3:32-10:10) min:sec. Arterial flow was pulsatile, unidirectional towards placenta or bidirectional to/from placenta. In 40% flow became continuous towards placenta later on. CONCLUSIONS During delayed umbilical cord clamping, venous and arterial umbilical flow occurs for longer than previously described. Net placental transfusion is probably the result of several factors of which breathing could play a major role. Umbilical flow is unrelated to cessation of pulsations.
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Affiliation(s)
- I Boere
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - A A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - E Wallace
- The Ritchie Centre, Monash Institute for Medical Research, Monash University, Clayton, Victoria, Australia
| | - A D J Ten Harkel
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - M C Haak
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - C J Morley
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - S B Hooper
- The Ritchie Centre, Monash Institute for Medical Research, Monash University, Clayton, Victoria, Australia
| | - A B te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
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Abstract
Birth asphyxia accounts for about 23% of the approximately 4 million neonatal deaths each year worldwide (Black et al., Lancet, 2010, 375(9730):1969-87). The majority of newborn infants require little assistance to undergo physiologic transition at birth and adapt to extrauterine life. Approximately 10% of infants require some assistance to establish regular respirations at birth. Less than 1% need extensive resuscitative measures such as chest compressions and approximately 0.06% require epinephrine (Wyllie et al. Resuscitation, 2010, 81 Suppl 1:e260–e287). Transition at birth is mediated by significant changes in circulatory and respiratory physiology. Ongoing research in the field of neonatal resuscitation has expanded our understanding of neonatal physiology enabling the implementation of improved recommendations and guidelines on how to best approach newborns in need for intervention at birth. Many of these recommendations are extrapolated from animal models and clinical trials in adults. There are many outstanding controversial issues in neonatal resuscitation that need to be addressed. This article provides a comprehensive and critical literature review on the most relevant and current research pertaining to evolving new strategies in neonatal resuscitation. The key elements to a successful neonatal resuscitation include ventilation of the lungs while minimizing injury, the judicious use of oxygen to improve pulmonary blood flow, circulatory support with chest compressions, and vasopressors and volume that would hasten return of spontaneous circulation. Several exciting new avenues in neonatal resuscitation such as delayed cord clamping, sustained inflation breaths, and alternate vasopressor agents are briefly discussed. Finally, efforts to improve resuscitative efforts in developing countries through education of basic steps of neonatal resuscitation are likely to decrease birth asphyxia and neonatal mortality.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Division of Neonatology, Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
| | - Bobby Mathew
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Division of Neonatology, Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
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Pichler G, Cheung PY, Binder C, O’Reilly M, Schwaberger B, Aziz K, Urlesberger B, Schmölzer GM. Time course study of blood pressure in term and preterm infants immediately after birth. PLoS One 2014; 9:e114504. [PMID: 25514747 PMCID: PMC4267788 DOI: 10.1371/journal.pone.0114504] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 11/10/2014] [Indexed: 11/26/2022] Open
Abstract
Objective To describe temporal changes in systolic, diastolic, and mean blood pressure (SBP, DBP, and MBP, respectively) in term and preterm infants immediately after birth. Methods Prospective observational two-center study. In term infants SBP, DBP, and MBP were assessed non-invasively every minute for the first 15 minutes, and in preterm infants every minute for the first 15 minutes, as well as at 20, 25, 30, 45, and 60 minutes after birth. Regression analyses were performed by gender and respiratory support in all neonates; and by mode of delivery, cord clamping time, and development of ultrasound-detected brain injury in preterm neonates. Results Term infants (n = 54) had a mean (SD) birth weight of 3298 (442) g and gestational age of 38 (1) weeks, and preterm infants (n = 94) weighed 1340 (672) g and were 30 (3) weeks gestation. Term infants’ SBP, DBP and MBP within the first 15 minutes after birth were independent of gender or respiratory support. Linear mixed regression analysis showed that preterm infants, who were female, born vaginally, had delayed cord clamping and did not require positive pressure ventilation nor develop periventricular injury or ventriculomegaly, had significantly higher SBP, DBP, and MBP at some measurement points within the first hour after birth. Conclusions We present novel reference ranges of BP immediately after birth in a cohort of term and preterm neonates. They may aid in optimization of cardiovascular support during early transition at all gestations.
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Affiliation(s)
- Gerhard Pichler
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
- Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Corinna Binder
- Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
| | - Megan O’Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
| | - Khalid Aziz
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
- Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
- * E-mail:
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Effect of umbilical cord milking on morbidity and survival in extremely low gestational age neonates. Am J Obstet Gynecol 2014; 211:519.e1-7. [PMID: 24881823 DOI: 10.1016/j.ajog.2014.05.037] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/08/2014] [Accepted: 05/24/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Delayed umbilical cord clamping benefits extremely low gestational age neonates (ELGANs) but has not gained wide acceptance. We hypothesized that milking the umbilical cord (MUC) would avoid resuscitation delay but improve hemodynamic stability and reduce rates for composite outcome of severe intraventricular hemorrhage, necrotizing enterocolitis, and/or death before discharge. STUDY DESIGN We implemented a joint neonatal/maternal-fetal quality improvement process for MUC starting September 2011. The MUC protocol specified that infants who were born at <30 weeks of gestation undergo MUC 3 times over a duration of <30 seconds at delivery. Obstetric and neonatal data were collected until discharge. We compared the MUC group to retrospective ELGAN cohort delivered at our center between January 2010 and August 2011. Analysis was intention-to-treat. RESULTS We identified 318 ELGANs: 158 eligible for MUC and 160 retrospective control neonates. No adverse events were reported with cord milking. There was no difference in neonatal resuscitation, Apgar scores, or admission temperature. Hemodynamic stability was improved in the MUC group with higher mean blood pressures through 24 hours of age, despite less vasopressor use (18% vs 32%; P < .01). The initial hematocrit value was higher (50% vs 45%; P < .01), and red cell transfusions were fewer (57% vs 79%; P < .01) in MUC vs control infants. Presence of the composite outcome was significantly less in MUC vs the historic control infants (22% v 39%; odds ratio, 1.81; 95% confidence interval, 1.06-3.10). There were also reductions in intraventricular hemorrhage, necrotizing enterocolitis, and death before hospital discharge. CONCLUSION MUC improves early hemodynamic stability and is associated with lower rates of serious morbidity and death among ELGANs.
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Ersdal HL, Linde J, Mduma E, Auestad B, Perlman J. Neonatal outcome following cord clamping after onset of spontaneous respiration. Pediatrics 2014; 134:265-72. [PMID: 25022738 DOI: 10.1542/peds.2014-0467] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Evolving data indicate that cord clamping (CC) beyond 30 to 60 seconds after birth is of benefit for all infants. Recent experimental data demonstrated that ventilation before CC improved cardiovascular stability by increasing pulmonary blood flow. The objective was to describe the relationship between time to CC, onset of spontaneous respirations (SR), and 24-hour neonatal outcome. METHODS In a rural Tanzanian hospital, trained research assistants, working in shifts, have observed every delivery (November 2009-February 2013) and recorded data including time interval from birth to SR and CC, fetal heart rate, perinatal characteristics and outcome (normal, death, admission). RESULTS Of 15,563 infants born, 12,780 (84.3%) initiated SR at 10.8 ± 16.7 seconds, and CC occurred at 63 ± 45 seconds after birth. Outcomes included 12,730 (99.7%) normal, 31 deaths, and 19 admitted; 11,967 were of birth weight (BW) ≥2500 g and 813 <2500 g. By logistic modeling, the risk of death/admission was consistently higher if CC occurred before SR. Infants of BW <2500 g were more likely to die or be admitted. The risk of death/admission decreased by 20% for every 10-second delay in CC after SR; this risk declined at the same rate in both BW groups. CONCLUSIONS Healthy self-breathing neonates are more likely to die or be admitted if CC occurs before or immediately after onset of SR. These clinical observations support the experimental findings of a smoother cardiovascular transition when CC is performed after initiation of ventilation.
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Affiliation(s)
- Hege Langli Ersdal
- Department of Anesthesiology and Intensive Care, andSAFER (Stavanger Acute medicine Foundation for Education and Research), Stavanger University Hospital, Norway; Departments ofHealth Studies, and
| | - Jørgen Linde
- SAFER (Stavanger Acute medicine Foundation for Education and Research), Stavanger University Hospital, Norway; Departments ofHealth Studies, and
| | - Estomih Mduma
- SAFER (Stavanger Acute medicine Foundation for Education and Research), Stavanger University Hospital, Norway; Departments ofHealth Studies, andDepartment of Research, Haydom Lutheran Hospital, Haydom, Tanzania; and
| | - Bjørn Auestad
- Mathematics and Natural Sciences, University of Stavanger, Norway
| | - Jeffrey Perlman
- Department of Pediatrics, Weill Cornell Medical College, New York, New York
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Tarnow-Mordi WO, Duley L, Field D, Marlow N, Morris J, Newnham J, Paneth N, Soll RF, Sweet D. Timing of cord clamping in very preterm infants: more evidence is needed. Am J Obstet Gynecol 2014; 211:118-23. [PMID: 24686151 DOI: 10.1016/j.ajog.2014.03.055] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 10/25/2022]
Abstract
In December 2012, the American College of Obstetricians and Gynecologists published a Committee Opinion entitled "Timing of umbilical cord clamping after birth." It stated that "evidence exists to support delayed cord clamping in preterm infants, when feasible. The single most important benefit for preterm infants is the possibility for a nearly 50% reduction in IVH." However, the Committee Opinion added that the ideal timing of umbilical cord clamping has yet to be determined and recommended that large clinical trials be conducted in the most preterm infants. Published randomized controlled trials include <200 infants of <30 weeks' gestation, with assessments of neurodevelopmental outcome in less than one-half of the children. This is a major gap in the evidence. Without reliable data from randomized controlled trials that optimally include childhood follow-up evaluations, we will not know whether delayed cord clamping may do more overall harm than good. Ongoing trials of delayed cord clamping plan to report childhood outcomes in >2000 additional very preterm infants. Current recommendations may need to change when these results become available. Greater international collaboration could accelerate resolution of whether this promising intervention will improve disability-free survival in about 1 million infants who will be born very preterm globally each year.
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Vain NE, Satragno DS, Gorenstein AN, Gordillo JE, Berazategui JP, Alda MG, Prudent LM. Effect of gravity on volume of placental transfusion: a multicentre, randomised, non-inferiority trial. Lancet 2014; 384:235-40. [PMID: 24746755 DOI: 10.1016/s0140-6736(14)60197-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Delayed cord clamping allows for the passage of blood from the placenta to the baby and reduces the risk of iron deficiency in infancy. To hold the infant for more than 1 min at the level of the vagina (as is presently recommended), on the assumption that gravity affects the volume of placental transfusion, is cumbersome, might result in low compliance, and interferes with immediate contact of the infant with the mother. We aimed to assess whether gravity affects the volume of placental transfusion METHODS We did a multicentre non-inferiority trial at three university-affiliated hospitals in Argentina. We obtained informed consent from healthy mothers with normal term pregnancies admitted early in labour. Vigorous babies born vaginally were randomly assigned in a 1:1 ratio by computer-generated blocks and sequentially numbered sealed opaque envelopes to be held for 2 min before clamping the umbilical cord, at the level of the vagina (introitus group) or on the mother's abdomen or chest (abdomen group). Newborn babies were weighed immediately after birth and after cord clamping. The primary outcome was the difference in weight (as a proxy of placental transfusion volume). The prespecified non-inferiority margin was 18 g (20%). We used t test and χ(2) test for group comparison, and used a multivariable linear regression analysis to control for covariables. This trial is registered with ClinicalTrials.gov, number NCT01497353. FINDINGS Between Aug 1, 2011, and Aug 31, 2012, we allocated 274 newborn babies to the introitus group and 272 to the abdomen group. 77 newborn babies in the introitus group and 78 in the abdomen group were ineligible after randomisation (eg, caesarean section, forceps delivery, short umbilical cord or nuchal cord). Mean weight change was 56 g (SD 47, 95% CI 50-63) for 197 babies in the introitus group compared with 53 g (45, 46-59) for 194 babies in the abdomen group, supporting non-inferiority of the two approaches (difference 3 g, 95% CI -5.8 to 12.8; p=0.45). We did not note any serious adverse events during the study. INTERPRETATION Position of the newborn baby before cord clamping does not seem to affect volume of placental transfusion. Mothers could safely be allowed to hold their baby on their abdomen or chest. This change in practice might increase obstetric compliance with the procedure, enhance maternal-infant bonding, and decrease iron deficiency in infancy. FUNDING Foundation for Maternal and Child Health (FUNDASAMIN).
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Affiliation(s)
- Nestor E Vain
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina; Foundation for Maternal and Child Health (FUNDASAMIN), Buenos Aires, Argentina; Trinidad Palermo Private Hospital, Buenos Aires, Argentina.
| | - Daniela S Satragno
- Foundation for Maternal and Child Health (FUNDASAMIN), Buenos Aires, Argentina
| | - Adriana N Gorenstein
- Foundation for Maternal and Child Health (FUNDASAMIN), Buenos Aires, Argentina; Trinidad Palermo Private Hospital, Buenos Aires, Argentina
| | - Juan E Gordillo
- Institute of Maternity Our Lady of Mercy, San Miguel de Tucumán, Argentina
| | - Juan P Berazategui
- Foundation for Maternal and Child Health (FUNDASAMIN), Buenos Aires, Argentina
| | | | - Luis M Prudent
- Foundation for Maternal and Child Health (FUNDASAMIN), Buenos Aires, Argentina
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Lundberg C, Øian P, Klingenberg C. Umbilical cord clamping at birth--practice in Norwegian maternity wards. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 133:2369-73. [PMID: 24287837 DOI: 10.4045/tidsskr.12.0707] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The timing and practice used for umbilical cord clamping of neonates are controversial internationally as well as in Norway. We therefore wished to investigate routines and practices for umbilical cord clamping of neonates in Norway. MATERIAL AND METHOD A web-based questionnaire was sent to heads of departments of all maternity wards in Norway (n = 52). They were asked about their practice with regard to umbilical cord clamping of neonates and whether written routines had been prepared for this purpose. We defined early umbilical cord clamping as immediate or within 30 seconds and late clamping as ≥ 1 minute or not until pulsation in the umbilical cord had ceased. RESULTS Fifty (96%) of the maternity institutions returned a completed questionnaire. Twelve institutions (24%) reported to clamp the umbilical cord of full-term neonates early, and 38 (76%) reported to practise late clamping. Nineteen maternity wards (38%) followed written routines for umbilical cord clamping of full-term neonates, and among these, early umbilical cord clamping was practised in nine (47%). In the 31 maternity wards that had no written routines, early umbilical cord clamping was practised in three (10%). Twenty-seven of the maternity wards reported that the child is placed on the maternal abdomen before clamping of the umbilical cord, 14 reported that the child commonly is held below the introitus before umbilical cord clamping, and the rest did not report any consistent practice. INTERPRETATION There is wide variation in the practice for umbilical cord clamping in Norwegian maternity wards, many of which have no written guidelines. We argue that national guidelines for umbilical cord clamping of neonates should be established.
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Abstract
Intrapartum-related hypoxia leading to deaths and disabilities continues to be a global challenge, especially in resource-limited settings. Primary prevention during labour is likely to have a significant impact, but secondary prevention with focus on immediate basic stabilization at birth can effectively reduce a large proportion of these adverse outcomes as demonstrated in the resource-rich settings. Infants who fail to initiate and establish spontaneous respirations at birth often respond to early interventions such as drying, stimulation, clearing the airways, as well as bag mask ventilation applied within the first minute after birth. Simple resuscitation education such as 'Helping Babies Breathe', which focuses on the very basic steps and pays attention to comprehensive program development with local ownership and accountability, can help transfer competency into clinical practice and lead to sustainable programs impacting neonatal mortality and morbidity.
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Affiliation(s)
- H L Ersdal
- Department of Anaesthesiology & Intensive Care and SAFER (Stavanger Acute medicine Foundation for Education and Research), Stavanger University Hospital, Norway.
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Menget A, Mougey C, Thiriez G, Riethmuller D. Intérêt du clampage retardé du cordon ombilical chez le nouveau-né. Arch Pediatr 2013; 20:1022-7. [DOI: 10.1016/j.arcped.2013.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 06/17/2013] [Accepted: 06/19/2013] [Indexed: 11/16/2022]
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