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Zemouri C, Mestdagh E, Stiers M, Torfs K, Kuipers Y. Deferred cord clamping to improve neonatal blood values: A systematic review and meta-analysis. Int J Nurs Stud 2024; 153:104718. [PMID: 38417349 DOI: 10.1016/j.ijnurstu.2024.104718] [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: 11/16/2023] [Revised: 01/01/2024] [Accepted: 02/05/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Practices related to umbilical cord clamping at birth should be evidence-based. Deferred cord clamping, compared to immediate cord clamping, shows benefits for preterm neonates but this may also apply to healthy term neonates. Different blood sampling techniques are used to measure effect of deferred and immediate cord clamping. OBJECTIVE To assess the statistical and effect size differences between blood biomarkers from umbilical cord and capillary blood samples of healthy term neonates following either immediate or deferred cord clamping. DESIGN Systematic review and meta-analysis. METHODS The databases PubMed, Medline, CENTRAL, CINAHL and EMBASE were systematically searched. We included studies with a randomised clinical trial design comparing deferred and immediate cord clamping among healthy term neonates born by a spontaneous vaginal birth, reporting on blood biomarkers. Studies including caesarean births and premature births/neonates were excluded. Study attributes, sampling technique, blood biomarkers, mean differences, and standard deviations were extracted. The standardised mean differences (SMD) and sampling errors were calculated for effect size estimation. Meta-analyses were performed if ≥2 studies reported the same outcome using RevMan 5. Subgroup analyses distinguished effects from umbilical cord and capillary blood samples. Moderator tests and publication bias analyses were performed using JASP. RESULTS Fifteen studies were included for analysis. The biomarkers haematocrit, haemoglobin, and bilirubin were reported in ≥2 studies and thus eligible for pooling. No differences were found in haemoglobin (SMD -0.04, 95%CI -0.57 to 0.49) or bilirubin values (SMD 0.13, 95%CI -0.03 to 0.28) between umbilical cord blood samples collected after deferred or immediate cord clamping. Deferred cord clamping led to lower haematocrit values (SMD -0.3, 95%CI -0.53 to -0.07). Higher haematocrit (SMD 0.67, 95%CI 0.37 to 0.97) and haemoglobin values (SMD 0.76, 95%CI 0.56 to 0.97) from capillary blood samples, collected 2 to 72 h postpartum, showed when cord clamping was deferred. No effect was found on bilirubin values (SMD 0.13, 95%CI -0.03 to 0.28) irrespective of the sampling technique. CONCLUSIONS Blood collected after deferred umbilical cord clamping showed increased haemoglobin and haematocrit values up to 72 h after birth, opposed to bilirubin values. Clinical evaluation of blood biomarkers from the umbilical cord shows different values compared to capillary blood. Sampling time and technique therefore seem essential in estimating the effects of deferred cord clamping. TWEETABLE ABSTRACT This meta-analysis shows that sampling time and technique are essential in estimating the effects of deferred cord clamping on neonatal blood values.
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Affiliation(s)
- Charifa Zemouri
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Zemouri et al, Amsterdam, the Netherlands
| | - Eveline Mestdagh
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Centre for Research and Innovation in Care, University Antwerp, Antwerp, Belgium
| | - Mieke Stiers
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium
| | - Kimberly Torfs
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium
| | - Yvonne Kuipers
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Centre for Research and Innovation in Care, University Antwerp, Antwerp, Belgium; School of Health and Social Care, Edinburgh Napier University, Edinburgh, Scotland, UK.
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Alikhani VS, Thies-Lagergren L, Svedenkrans J, Elfvin A, Bolk J, Andersson O. Stabilisation and resuscitation with intact cord circulation is feasible using a wide variety of approaches; a scoping review. Acta Paediatr 2023; 112:2468-2477. [PMID: 37767916 DOI: 10.1111/apa.16985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
AIM This scoping review identified studies on approaches to intact cord resuscitation and/or stabilisation (ICR/S) for neonates delivered by Caesarean section (C-section). METHODS A systematic literature search was carried out using the PubMed, Web of Science, Scopus, Cochrane and CINAHL databases to identify papers published in English from inception to 14 November 2022. RESULTS We assessed 2613 studies and included 18 from 10 countries, covering 1-125 C-sections: the United States, the United Kingdom, Australia, India, Italy, China, France, The Netherlands, New Zealand and Taiwan. The papers were published from 2014 to 2023, and the majority were randomised controlled trials and observational studies. Different platforms, equipment and staff positions in relation to the operating table were described. Options for resuscitation and stabilisation included different bedding and trolley approaches, and maintaining aseptic conditions was mainly addressed by the neonatal team scrubbing in. Hypothermia was prevented by using warm surfaces, polythene bags and radiant heaters. Equipment was kept easily accessible by mounting it on a trolley or a separate mobile pole. CONCLUSION We could not reach definitive conclusions on the optimal method for performing ICR/S during a C-section, due to study variations. However, a number of equipment and management options appeared to be feasible approaches.
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Affiliation(s)
- Vesta Seyed Alikhani
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Jenny Svedenkrans
- Department of Clinical Sciences Lund, Pediatrics/Neonatology, Lund University, Lund, Sweden
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jenny Bolk
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Ola Andersson
- Department of Clinical Sciences Lund, Pediatrics/Neonatology, Lund University, Lund, Sweden
- Department of Neonatology, Skåne University Hospital, Malmö, Sweden
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McDonald SD. Deferred cord clamping and cord milking: Certainty and quality of the evidence in meta-analyses, and systematic reviews of randomized control trials, guidelines, and implementation studies. Semin Perinatol 2023:151790. [PMID: 37349189 DOI: 10.1016/j.semperi.2023.151790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Deferred1 cord clamping (DCC) saves lives, so why is it not implemented more routinely? Despite neonatal benefits, DCC is under-utilized, particularly in preterm births. Umbilical cord milking (UCM) also improves some outcomes for preterm infants such as decreasing the need for transfusions. At term, DCC and UCM improve hematological indices. OBJECTIVE The objective of this chapter is to examine the quality of evidence for both preterm and term DCC (and UCM), clinical practice guidelines and implementation issues. METHODS Key evidence, primarily from network meta-analyses, meta-analyses and systematic reviews on both preterm and term DCC (and UCM) from randomized clinical trials, clinical practice guidelines and implementation studies, are summarized through a lens of the certainty and quality of the evidence. Regarding the certainty of evidence, for network meta-analysis the Confidence in Network Meta-analysis tool was used, and for meta-analyses the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used. Guideline quality was appraised with two tools: Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) and AGREE-Recommendation EXcellence (AGREE-REX). Implementation study quality was evaluated using The Mixed Method Appraisal tool. RESULTS In a network meta-analysis of 56 RCTs of cord management strategies, DCC reduced the odds of mortality in preterm infants by 30% compared to immediate cord clamping (ICC), including in the subgroup of infants born before 33 weeks', both with a moderate confidence assessment using the Confidence in Network Meta-analysis tool. DCC reduced the odds of any intraventricular hemorrhage (IVH) by 30%, and the odds of red blood cell transfusion by more than 50%, both with high ratings on the Confidence in Network Meta-analysis. Umbilical Cord Milking (UCM) did not reduce mortality compared to ICC. In contrast to the benefits shown in preterm birth with DCC, a systematic review showed that at term, there were no mortality benefits and few benefits at all except for improved hematological indices. A systematic review of clinical practice guidelines demonstrated that all of them endorsed DCC for uncompromised preterm infants, and 11 more cautiously noted that cord milking might be considered when DCC was not feasible. However, only half (49%) of the recommendations in the guidelines on the optimal duration of DCC were supported by high-quality evidence per AGREE-II and AGREE-REX. Fewer than one in 10 statements (8%) cited a mortality benefit with DCC for preterm infants. Regarding the uptake of DCC, a systematic review of 18 studies on facilitators and barriers to implementation found that almost all (12 of the 14 studies) focused on strategies such as protocols, policy, or toolkits; additionally, 8 of 14 studies used didactic teaching sessions. Only 8 of 18 studies scored high on all four domains of the Mixed Method Appraisal tool. CONCLUSIONS Compared to ICC, DCC in preterm infants conferred significant benefits for mortality, IVH and red blood cell transfusion, with confidence ratings of moderate (mortality) or high. Although guidelines worldwide encouraged preterm (and term) DCC, the quality of the clinical practice guidelines had room for improvement; only half of the recommendations on the optimal duration of preterm DCC were supported by high-quality evidence. Most guidelines did not mention a mortality benefit with preterm DCC and lacked details on practical aspects of implementation. Among implementation studies, which have focused mainly on protocols, policies, toolkits or didactic teaching, quality also demonstrated an opportunity for improvement.
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Affiliation(s)
- Sarah D McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, ON, Canada; Department of Radiology, McMaster University, ON, Canada.
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Song D, Jelks A, Narasimhan SR, Jegatheesan P. Cord management strategies in multifetal gestational births. Semin Perinatol 2023:151743. [PMID: 37005172 DOI: 10.1016/j.semperi.2023.151743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
Multifetal gestations are associated with high risks of neonatal mortality and morbidities primarily due to prematurity. Delayed cord clamping and cord milking facilitate the postnatal transition and improve outcomes. Limited evidence shows that delayed cord clamping for 30-60 s and cord milking are feasible without causing harm and potentially beneficial in uncomplicated multifetal deliveries. However, data on maternal bleeding from the limited studies are inconsistent. Based on current knowledge of the risk vs. benefits, it is reasonable to perform delayed cord clamping or cord milking (>28 weeks of gestation) in uncomplicated monochorionic and dichorionic multiples. Clearly defined criteria for suitable candidates, indications for clamping or milking the cord during delivery, and improved obstetric techniques in Cesarean deliveries are critical to minimize risks and optimize neonatal transition. Research is needed to identify safe and optimal cord-management strategies for improving survival and long-term outcomes in this high-risk population.
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Affiliation(s)
- Dongli Song
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea Jelks
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sudha Rani Narasimhan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Priya Jegatheesan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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Nagendla P, Manju A, Somasekhara Aradhya A, Shebannavar RN, Venkatagiri P. Sustaining immediate newborn care processes (delayed cord clamping and early breastfeeding initiation) in the delivery room: a quality improvement study. BMJ Open Qual 2022; 11:bmjoq-2021-001705. [PMID: 35584842 PMCID: PMC9119176 DOI: 10.1136/bmjoq-2021-001705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 05/08/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Immediate newborn care processes like delayed cord clamping (DCC) and early breastfeeding initiation (EBFI) in the delivery room have several benefits including survival. Despite the evidence, the practices have not been widely adopted. We used a point-of-care quality improvement (QI) to implement and sustain these two immediate newborn care processes in our delivery room over a period of 2 years through a series of plan-do-study-act (PDSA) cycles. METHODS All neonates above 30 weeks of gestation irrespective of the need for resuscitation except Rh-isoimmunisation were eligible for DCC. Neonates >35 weeks not requiring respiratory support or resuscitation were eligible for EBFI. The root causes of gaps in the quality were analysed by fishbone analysis. The key quantitative outcome measure was the percentage of eligible deliveries in which DCC and EBFI were done. Duration of DCC was also recorded in the sustenance phase. This implementation was done through three PDSA cycles and the practices were sustained for 2 years. RESULTS A total of 770 deliveries were part of this QI study from October 2018 to December 2020. There was a significant improvement in DCC (median) from a baseline of 25% to 96% over a 2-year period. Sensitisation, making DCC part of pre-birth checklist and recording outcomes on a dashboard daily helped to implement and sustain the processes over 2 years. As a co-process, EBFI improved (median) from a baseline of 50% to 97% without any major intervention in the system. CONCLUSIONS Immediate newborn care processes could be sustained by making them part of pre-birth preparation and dashboard recording by a QI initiative without any additional resources.
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Affiliation(s)
- Pranavi Nagendla
- Obstetrics & Gynaecology, Ovum Hospitals, Bangalore, Karnataka, India
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Schwaberger B, Urlesberger B, Schmölzer GM. Delivery Room Care for Premature Infants Born after Less than 25 Weeks' Gestation-A Narrative Review. CHILDREN-BASEL 2021; 8:children8100882. [PMID: 34682147 PMCID: PMC8534639 DOI: 10.3390/children8100882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
Premature infants born after less than 25 weeks' gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks' gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. Successful stabilization at birth has the potential to reduce morbidities and mortalities, while suboptimal DR care could increase long-term sequelae. This article reviews current neonatal resuscitation guidelines and addresses challenges during DR stabilization in extremely premature infants born after <25 weeks' gestation at the threshold of viability.
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Affiliation(s)
- Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T5H 3V9, Canada
- Correspondence: ; Tel.: +1-780-735-4660
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Knol R, Brouwer E, van den Akker T, DeKoninck P, van Geloven N, Polglase GR, Lopriore E, Herkert E, Reiss IKM, Hooper SB, Te Pas AB. Physiological-based cord clamping in very preterm infants - Randomised controlled trial on effectiveness of stabilisation. Resuscitation 2019; 147:26-33. [PMID: 31874212 DOI: 10.1016/j.resuscitation.2019.12.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/22/2019] [Accepted: 12/15/2019] [Indexed: 10/25/2022]
Abstract
AIM To test whether stabilising very preterm infants while performing physiological-based cord clamping (PBCC) is at least as effective as the standard approach of time-based delayed cord clamping (DCC). METHODS A randomised controlled non-inferiority study was performed in two centres from May until November 2018, including preterm infants born below 32 weeks of gestational age. Infants were allocated to PBCC or standard DCC. Infants receiving PBCC were stabilised on a purpose-built resuscitation table with an intact umbilical cord. The cord was clamped when the infant had regular spontaneous breathing, heart rate ≥100 bpm and SpO2 >90% while using FiO2 <0.40. In infants receiving DCC, the cord was clamped at 30-60 seconds after birth before they were transferred to the standard resuscitation table for further treatment and stabilisation. Primary outcome was time to reach respiratory stability. RESULTS Thirty-seven infants (mean gestational age 29 + 0 weeks) were included. Mean cord clamping time was 5:49 ± 2:37 min in the PBCC (n = 20) and 1:02 ± 0:30 min in the DCC group (n = 17). Infants receiving PBCC needed less time to reach respiratory stability (PBCC 5:54 ± 2:27 min; DCC 7:07 ± 2:54 min; mean difference corrected for gestational age -1:19 min, 95% CI [-3:04-0:27]), showing non-inferiority with the pre-defined limit of 1:15 min. No significant differences between the groups were found for maternal blood loss, postpartum haemorrhage, infant temperature at admission or short-term neonatal outcomes. CONCLUSION Stabilisation of very preterm infants with physiological-based cord clamping is at least as effective as with standard DCC. CLINICAL TRIAL REGISTRATION Netherlands Trial Register (NTR7194/NL7004).
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Affiliation(s)
- Ronny Knol
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Centre, Rotterdam, The Netherlands; Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Emma Brouwer
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Philip DeKoninck
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, The Netherlands; The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Nan van Geloven
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Enrico Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ellen Herkert
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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