No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Milking Compared With Delayed Cord Clamping to Increase Placental Transfusion in Preterm Neonates A Randomized Controlled Trial
Abstract
To compare two strategies to enhance placento-fetal blood transfusion in preterm neonates before 33 weeks of gestation.
We recruited women at risk for singleton preterm deliveries. All delivered before 33 completed weeks of gestation. In this single-center trial, women were randomized to either standard treatment (clamping the cord for 30 seconds after delivery) or repeated (four times) milking of the cord toward the neonate. Exclusion criteria included inadequate time to obtain consent before delivery, known congenital abnormalities of the fetus, Rhesus sensitization, or fetal hydrops.
Of 58 neonates included the trial, 31 were randomized to cord clamping and 27 were randomized to repeated milking of the cord. Mean birth weight was 1,263±428 g in the clamping group and 1,235±468 g in the milking group, with mean gestational age of 29.2±2.3 weeks and 29.5±2.7 weeks, respectively. Mean hemoglobin values for each group at 1 hour after birth were 17.3 g/L for clamping and 17.5 g/L for milking (P=.71). There was no significant difference in number of neonates undergoing transfusion (clamping group, 15; milking group, 17; P=.40) or the median number of transfusions within the first 42 days of life (median [range]: clamping group 0 [0-7]; milking group 0 [0-20]; P=.76).
Milking the cord four times achieved a similar amount of placento-fetal blood transfusion compared with delaying clamping the cord for 30 seconds.
National Research Register UK, www.nihr.ac.uk/Pages/default.aspx, N0051177741.
I.
... However, the difference was not statistically significant. Similar results were found in studies conducted by Samantha et al [11] , Rabe et al [12] and Jaiswal et al [13] . In study conducted by Katheria et al [14] , birth hemoglobin was compared in instead of hematocrit. ...
... There are very few studies comparing the effect of UCM and DCC in both term and near-term neonates. Previous studies published by Katheria et al [14] , Samantha et al [11] and Rabe et al [12] were all conducted only in preterm neonates. Also, our randomization was stratified into vaginal delivery and caesarean section which was not done by any other study. ...
... Large sample size provides more accurate mean values and hence the data is more reliable. Most of the previously published studies have modest sample size of less than 200 [2,[12][13][14][15] . ...
Aim: To compare the effect of delayed cord clamping versus milking of umbilical cord on initial hematocrit in term and near-term neonates. Methods : This randomized controlled trial included 374 pregnant women of more than 34 weeks period of gestation. They were randomized into umbilical cord milking group and delayed cord clamping group. In umbilical cord milking group, 119 underwent vaginal delivery and 68 underwent caesarean section. In delayed cord clamping group, 117 underwent vaginal delivery and 70 underwent caesarean section. Results : Mean hematocrit in cord sample was 47.02±7.13% in umbilical cord milking group and 48.04±8.36% in delayed cord clamping group and the difference was not statistically significant (p=0.21). Mean hematocrit at 30±6 hours was 54.48±5.84% in umbilical cord milking group and 50.9±7.1% in delayed cord clamping group and the difference was statistically significant(p=0.01). Requirement of phototherapy in umbilical cord milking group was 18.18% and in delayed cord clamping group was 19.25%(p=0.79). Rate of neonatal intensive care unit admissions was 2.67% in umbilical cord milking group and 7.49% in delayed cord clamping group(p=0.034). Conclusion : Umbilical cord milking lead to significant increase in hematocrit levels without increasing the requirement of phototherapy and neonatal intensive care unit admissions. Hence, umbilical cord milking can be used as an alternative to delayed cord clamping in both term and near-term neonates.
... One study [32] of 58 preterm neonates (24 0/7 -32 6/7 weeks) found blood glucose concentration on admission to neonatal unit was 3.1 ± 1.5 mmol/l (n = 27) in the UCM group compared to 2.7 ± 1.4 mmol/l in the DCC group (31 infants) (Mean Difference (MD) = 0.40 (-0.35 to 1.15), p = 0.30). ...
... In the 11 studies [32,[41][42][43][44][45][46][47][48][49][50] that reported neonatal mortality data, 76/1 378 infants died before discharge Fig. 6) The evidence suggests that UCM results in little to no difference in neonatal mortality (RR = 0.79, CI:0.44 to 1.41, p = 0.42, I 2 = 27%). ...
... Evidence from eight studies [32,39,41,43,47,49,51,52] suggest that UCM may result in little to no difference in length of hospital stay (886 infants, MD = 1.20, CI: -1.76 to 4.16, p = 0.43, I 2 = 26%, low certainty of evidence) (Fig. 7). ...
Background
Placental management strategies such as umbilical cord milking and delayed cord clamping may provide a range of benefits for the newborn. The aim of this review was to assess the effectiveness of umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia.
Methods
Three databases and five clinical trial registries were systematically reviewed to identify randomised controlled trials comparing umbilical cord milking or delayed cord clamping with control in term and preterm infants. The primary outcome was neonatal hypoglycaemia (study defined). Two independent reviewers conducted screening, data extraction and quality assessment. Quality of the included studies was assessed using the Cochrane Risk of Bias tool (RoB-2). Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis using a random effect model was done using Review Manager 5.4. The review was registered prospectively on PROSPERO (CRD42022356553).
Results
Data from 71 studies and 14 268 infants were included in this review; 22 (2 537 infants) compared umbilical cord milking with control, and 50 studies (11 731 infants) compared delayed with early cord clamping. For umbilical cord milking there were no data on neonatal hypoglycaemia, and no differences between groups for any of the secondary outcomes. We found no evidence that delayed cord clamping reduced the incidence of hypoglycaemia (6 studies, 444 infants, RR = 0.87, CI: 0.58 to 1.30, p = 0.49, I² = 0%). Delayed cord clamping was associated with a 27% reduction in neonatal mortality (15 studies, 3 041 infants, RR = 0.73, CI: 0.55 to 0.98, p = 0.03, I² = 0%). We found no evidence for the effect of delayed cord clamping for any of the other outcomes. The certainty of evidence was low for all outcomes.
Conclusion
We found no data for the effectiveness of umbilical cord milking on neonatal hypoglycaemia, and no evidence that delayed cord clamping reduced the incidence of hypoglycaemia, but the certainty of the evidence was low.
... Conclusions Compared with delayed cord clamping, umbilical cord milking may increase the risk of severe intraventricular hemorrhage in preterm infants with a gestational age of <34 weeks; however, more highquality large-sample randomized controlled trials are needed for further confirmation. [14] Katheria 2020 [16] Finn 2019 [17] Katheria 2015 [18] Pratesi 2018 [19] 林玲 2021 [20] 石爽 2021 [21] 喻玲 2020 [22] Rabe 2011 [23] Krueger 2015 [24] 樊雪梅 2018 [25] 样本量 Katheria 2020 [16] Finn 2019 [17] Katheria 2015 [18] Pratesi 2018 [19] 林玲 2021 [20] 石爽 2021 [21] 喻玲 2020 [22] Rabe 2011 [23] Krueger 2015 [24] 樊雪梅 2018 [25] 随机方法 Immediate umbilical cord clamping, as a traditional way of umbilical cord management, not only blocks placental transfusion after birth in newborns, but also increases the risk of adverse outcomes in newborns [1][2] . In recent years, umbilical cord management has gradually developed from immediate umbilical cord clamping to placental transfusion, and the placenta can continue gas exchange after delivery and provide additional blood volume and erythrocytes to the newborns, benefiting more to the newborns [3][4] . ...
... Conclusions Compared with delayed cord clamping, umbilical cord milking may increase the risk of severe intraventricular hemorrhage in preterm infants with a gestational age of <34 weeks; however, more highquality large-sample randomized controlled trials are needed for further confirmation. [14] Katheria 2020 [16] Finn 2019 [17] Katheria 2015 [18] Pratesi 2018 [19] 林玲 2021 [20] 石爽 2021 [21] 喻玲 2020 [22] Rabe 2011 [23] Krueger 2015 [24] 樊雪梅 2018 [25] 样本量 Katheria 2020 [16] Finn 2019 [17] Katheria 2015 [18] Pratesi 2018 [19] 林玲 2021 [20] 石爽 2021 [21] 喻玲 2020 [22] Rabe 2011 [23] Krueger 2015 [24] 樊雪梅 2018 [25] 随机方法 Immediate umbilical cord clamping, as a traditional way of umbilical cord management, not only blocks placental transfusion after birth in newborns, but also increases the risk of adverse outcomes in newborns [1][2] . In recent years, umbilical cord management has gradually developed from immediate umbilical cord clamping to placental transfusion, and the placenta can continue gas exchange after delivery and provide additional blood volume and erythrocytes to the newborns, benefiting more to the newborns [3][4] . ...
... Eight included literatures [14, 16-20, 23,25] used the randomization method and reported the method generated by the randomized sequence. Nine literatures [14,[16][17][18][19][20][23][24][25] achieved allocation concealment, so the selection bias was small. Four literatures [14,18,20,24] used blind method, so the implementation bias was large. ...
Objectives:
To study the influence of umbilical cord milking versus delayed cord clamping on the early prognosis of preterm infants with a gestational age of <34 weeks.
Methods:
PubMed, Web of Science, Embase, the Cochrane Library, CINAHL, China National Knowledge Infrastructure, Wanfang Data, Weipu Database, and SinoMed were searched for randomized controlled trials on umbilical cord milking versus delayed cord clamping in preterm infants with a gestational age of <34 weeks published up to November 2021. According to the inclusion and exclusion criteria, two researchers independently performed literature screening, quality evaluation, and data extraction. Review Manger 5.4 was used for Meta analysis.
Results:
A total of 11 articles were included in the analysis, with 1 621 preterm infants in total, among whom there were 809 infants in the umbilical cord milking group and 812 in the delayed cord clamping group. The Meta analysis showed that compared with delayed cord clamping, umbilical cord milking increased the mean blood pressure after birth (weighted mean difference=3.61, 95%CI: 0.73-6.50, P=0.01), but it also increased the incidence rate of severe intraventricular hemorrhage (RR=1.83, 95%CI: 1.08-3.09, P=0.02). There were no significant differences between the two groups in hemoglobin, hematocrit, blood transfusion rate, proportion of infants undergoing phototherapy, bilirubin peak, and incidence rates of complications such as periventricular leukomalacia and necrotizing enterocolitis (P>0.05).
Conclusions:
Compared with delayed cord clamping, umbilical cord milking may increase the risk of severe intraventricular hemorrhage in preterm infants with a gestational age of <34 weeks; however, more high-quality large-sample randomized controlled trials are needed for further confirmation.
... The SysRev identified 7 trials (1073 infants) for this comparison. 196,[224][225][226][227][228][229] For the critical outcome of survival to discharge, moderate-certainty evidence from 5 trials involving 1000 infants could not exclude benefit or harm from later cord clamping. [224][225][226]228,229 For all other outcomes evaluated, results were similarly inconclusive. ...
... 196,[224][225][226][227][228][229] For the critical outcome of survival to discharge, moderate-certainty evidence from 5 trials involving 1000 infants could not exclude benefit or harm from later cord clamping. [224][225][226]228,229 For all other outcomes evaluated, results were similarly inconclusive. ...
... I 2 =23%). 196,224,225,228 There was only 1 small study on cut-cord milking. ...
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
... The SysRev identified 7 trials (1073 infants) for this comparison. 196,[224][225][226][227][228][229] For the critical outcome of survival to discharge, moderate-certainty evidence from 5 trials involving 1000 infants could not exclude benefit or harm from later cord clamping. [224][225][226]228,229 For all other outcomes evaluated, results were similarly inconclusive. ...
... 196,[224][225][226][227][228][229] For the critical outcome of survival to discharge, moderate-certainty evidence from 5 trials involving 1000 infants could not exclude benefit or harm from later cord clamping. [224][225][226]228,229 For all other outcomes evaluated, results were similarly inconclusive. ...
... I 2 =23%). 196,224,225,228 There was only 1 small study on cut-cord milking. ...
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
... The pairwise IPD meta-analysis 472 identified 15 trials including 1655 infants. 485,487,492,[517][518][519][520][521][522][523][524][525][526][527][528] The median study sample size was 44 (IQR, . The median gestational age at birth was 30 (IQR, 28-33) weeks. ...
... The NMA 476 and the IPD meta-analysis identified 47 eligible studies including 6094 infants. [481][482][483][484][485][487][488][489][490][491][492][493][494][495][496][497][498][499]501,502,[504][505][506]508,510,511,516,[518][519][520][521][522][523][524][525]528,[531][532][533][534][535][536][537][538][539][540] The median study sample size was 60 infants (IQR, . The median gestational age at birth was 29.6 weeks (IQR, 27.6-33.3). ...
This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.
... Previous studies [8,13,33] documented no difference in CrSO 2 in neonates < 32 weeks exposed to either UCM or DCC at birth. We found comparable MAP after either intervention, whereas the effect of UCM on systemic blood pressure remains variable in literature [8,34]. Though the mean hematocrit was significantly higher in our UCM group, the incidence of polycythemia was comparable. ...
... Though the mean hematocrit was significantly higher in our UCM group, the incidence of polycythemia was comparable. Previous trials showed either similar [34,35] or increased hematocrit levels [9] without a higher incidence of polycythemia after UCM. Differences could be attributed to variable GA, length of the umbilical cord milked, and age of hematocrit assessment. ...
Recommendations for umbilical cord management in intrauterine growth-restricted (IUGR) neonates are lacking. The present randomized controlled trial compared hemodynamic effects of umbilical cord milking (UCM) with delayed cord clamping (DCC) in IUGR neonates > 28 weeks of gestation, not requiring resuscitation. One hundred seventy IUGR neonates were randomly allocated to intact UCM (4 times squeezing of 20 cm intact cord; n = 85) or DCC (cord clamping after 60 s; n = 85) immediately after delivery. The primary outcome variable was superior vena cava (SVC) blood flow at 24 ± 2 h. Secondary outcomes assessed were anterior cerebral artery (ACA) and superior mesenteric artery (SMA) blood flow indices, right ventricular output (RVO), regional cerebral oxygen saturation (CrSO2) and venous hematocrit at 24 ± 2 h, peak total serum bilirubin (TSB), incidences of in-hospital complications, need and duration of respiratory support, and hospital stay. SVC flow was significantly higher in UCM compared to DCC (111.95 ± 33.54 and 99.49 ± 31.96 mL/kg/min, in UCM and DCC groups, respectively; p < 0.05). RVO and ACA/SMA blood flow indices were comparable whereas CrSO2 was significantly higher in UCM group. Incidences of polycythemia and jaundice requiring phototherapy were similar despite significantly higher venous hematocrit and peak TSB in UCM group. The need for non-invasive respiratory support was significantly higher in UCM group though the need and duration of mechanical ventilation and other outcomes were comparable.
Conclusions: UCM significantly increases SVC flow, venous hematocrit, and CrSO2 compared to DCC in IUGR neonates without any difference in other hemodynamic parameters and incidences of polycythemia and jaundice requiring phototherapy; however, the need for non-invasive respiratory support was higher with UCM.
Trial registration: Clinical trial registry of India (CTRI/2021/03/031864).
What is Known:
• Umbilical cord milking (UCM) increases superior vena cava blood flow (SVC flow) and hematocrit without increasing the risk of symptomatic polycythemia and jaundice requiring phototherapy in preterm neonates compared to delayed cord clamping (DCC).
• An association between UCM and intraventricular hemorrhage in preterm neonates < 28 weeks of gestation is still being investigated.
What is New:
• Placental transfusion by UCM compared to DCC increases SVC flow, regional cerebral oxygenation, and hematocrit without increasing the incidence of symptomatic polycythemia and jaundice requiring phototherapy in intrauterine growth-restricted neonates.
• UCM also increases the need for non-invasive respiratory support compared to DCC.
... Several randomized controlled trials have demonstrated preterm infants delivered by C-section undergoing UCM vs. DCC had better systemic blood flow, blood pressure, hemoglobin levels, and urine output in the first 72 h of life (33)(34)(35). UCM has been found to be feasible in term infants born by C-section and did not result in higher incidence of phototherapy, symptomatic polycythemia, NICU hospitalizations, or readmissions for phototherapy (36). ...
... Whether prior animal data is translatable in these infants is unclear, however there is biological plausibility that the additional blood volume provided by UCM may not be as well tolerated in the extremely preterm infant who lack cerebral autoregulation and have a very fragile germinal matrix which may lead to hemorrhage (8). Unfortunately, most of the literature on preterm infants comes from small studies or mostly mature infants (34,90,94,95). Recent meta-analyses of these studies may also only provide false assurance of safety (56). ...
The most common methods for providing additional placental blood to a newborn are delayed cord clamping (DCC) and umbilical cord milking (UCM). However, DCC carries the potential risk of hypothermia due to extended exposure to the cold environment in the operating room or delivery room, as well as a delay in performing resuscitation. As an alternative, umbilical cord milking (UCM) and delayed cord clamping with resuscitation (DCC-R) have been studied, as they allow for immediate resuscitation after birth. Given the relative ease of performing UCM compared to DCC-R, UCM is being strongly considered as a practical option in non-vigorous term and near-term neonates, as well as preterm neonates requiring immediate respiratory support. However, the safety profile of UCM, particularly in premature newborns, remains a concern. This review will highlight the currently known benefits and risks of umbilical cord milking and explore ongoing studies.
... UCM can be done in 2 ways: (1) before clamping the cord (whole length), to allow for passage of more blood from the placental unit, and (2) after clamping the cord (cut cord, a relatively short length). In our study, we followed the latter technique, while in Rabe et al's 19 and Hosono et al's 3 studies, UCM was done before cord clamping. ...
... So, practitioners should not refrain from cord milking in a preterm delivery because of the occurrence of neonatal hyperviscosity.In our study, after delivery, we kept the neonates at the uterus level in vaginal deliveries and at the mothers' thigh level in cesarean delivery while the cord was cut and clamped. Rabe et al19 placed the neonates 20 cm below the mother's level, which could lead to a gravity-dependent flow of blood from the mother to the neonate. However, according to Vain et al,20 the position of the neonate before clamping the cord does not appear to influence the volume of placental transfusion. ...
... The stripped segment was approximately 20 cm, with a speed of 20 cm over 2 s and 2 s between each stripping, keeping the baby at the level of the placenta. These maneuvers were adapted from earlier similar studies [12,13]. The allocation sequence cards, including the random number sequence and the requested intervention, were masked using sealed separate envelopes. ...
... The least required sample size for both parameters was 196 subjects, and the authors decided to collect 200 participants for the study. The proposed difference in primary outcomes used in the calculation was indirectly determined through the estimated differences in the hematocrit value between both the DCC and UCM groups in comparison to immediate cord clamping, as stated in earlier studies [13][14][15]. ...
Background
The hematological impact of umbilical cord milking (UCM) was compared to that of delayed cord clamping (DCC) as a faster placental transfusion technique for preterm neonates (between 24 and 34 + 6 weeks gestation). A comparison of important neonatal morbidities was also made.
Methods
This was an open-label randomized trial conducted from June 8, 2017, to April 22, 2019. Two hundred patients with preterm deliveries (24 and 34 + 6 weeks gestation) were assigned to the DCC or UCM group at random at a ratio of 1:1. The study power was 80% for a difference in the hematocrit value of 3% and Hb value of one gram, and an alpha error of 0.05.
Results
The following variables were analyzed in the comparison of UCM vs. DCC: first draw hemoglobin: 17.0 ± 1.9 vs. 16.8 ± 1.8 gm/dl (95% CI -0.75–0.29, P 0.383); first draw hematocrit: 55.6 ± 6.4 vs. 55.2 ± 6.4% (95% CI -2.18–1.38, P 0.659); peak hematocrit: 56.9 ± 6.4 vs. 56.3 ± 6.7% (95% CI -2.41–1.26, P 0.537); the need for respiratory assistance (47% vs. 30%, P 0.020), inotropes (16% vs. 6%, P 0.040), and blood transfusion (26% vs. 12%, P 0.018); and the occurrence of intraventricular hemorrhage (9% vs. 5%, P 0.407), necrotizing enterocolitis (6% vs. 2%, P 0.279), sepsis (25% vs. 15%, P 0.111), and neonatal death (13% vs. 4%, P 0.40).
Conclusion
UCM facilitated a rapid transfer of placental blood equivalent to that of DCC for premature neonates. However, it resulted in increased rates of interventions and morbidities, especially in extremely preterm neonates.
Trial registration
The clinical trial was registered on May 10, 2017, with registration number (NCT03147846).
... Cord clamping immediately after birth is potentially harmful in a new born with compromised cardiovascular and respiratory functions. 5,6 In Europe 26% and in low income countries 100%, children of preschool going age group suffer from Iron deficiency. 7 Iron deficiency causes anaemia and in early childhood can cause irreversible adverse effects on neurodevelopment. ...
... Jaiswal et al, did not exclusively study the effect on term infants delivered by caesarean delivery rather they included new borns delivered by caesareans as well as vaginal delivery. Rabe et al, 5 compared the umbilical cord milking with delayed cord clamping in preterm infants and their results showed no significant difference in haemoglobin levels (p=71) and haematocrit levels (p=0.65) one hour after birth. ...
Objective: To assess the feasibility of umbilical cord milking as an alternative to delayed cord clamping during caserean section by comparing neonatal outcomes. Study Design: Quasi experimental study. Place and Duration of Study: Department of Anesthesiology, Combined Military Hospital, Okara, from Mar to Oct 2018. Methodology: A total of 384 cases (n=192 in each group) were included in our study. In group A, the half-length of umbilical cord was milked thrice by the operating surgeon before clamping and cutting it. In group B the umbilical cord was cut 90 second after delivery of the baby. The outcomes were: APGAR score at one and five minutes after delivery, haemglobin and haematocrit 4 hours after delivery of baby. Requirement of oxygen and ventilatory support during the 24 hours after birth were also noted. Results: Our two study groups didn’t vary in their demographic profile. The difference between the APGAR score at one and five minutes was not statistically significant, (p>0.05). The diffrence in haemoglobin and haematocrit levels of the neonates 4 hours after delivery were insignificant (p-value 0.27 and 0.14 respectively). Conclusion: Milking of the umbilical cord can be used as an alternative to the recommended technique of delayed umbilical cord clamping, especially when immediate resuscitation of the newborn is needed.
... Совершенствование профилактических и терапевтических аспектов медицинской помощи способствует улучшению результатов лечения как доношенных, так и недоношенных пациентов. В целях профилактики анемии недоношенных проводятся сцеживание или отсроченное пережатие пуповины при рождении, а также терапия рекомбинантным человеческим эритропоэтином (рчЭПО), железосодержащими препаратами [1][2][3][4]. По данным систематического обзора, опубликованного в 2020 г., было продемонстрировано, что отсроченное пережатие пуповины в группе недоношенных новорожденных с экстремально низкой массой тела (ЭНМТ) снижает частоту заболеваемости и смертности [5]. В обзоре 18 рандомизированных контролируемых исследований было показано, что отсроченное пережатие пуповины на 30 с и более снижает риск смертности у недоношенных новорожденных на 32%, а также частоту внутрижелудочковых кровоизлияний, некротизирующего энтероколита и сепсиса, потребность в проведении трансфузий эритроцитсодержащих компонентов (ЭСК) крови, улучшает запасы железа в возрасте 3 и 6 месяцев жизни и показатели неврологического развития в возрасте 2 лет [1,6,7]. ...
... Европейским обществом по перинатальной медицине также рекомендуется проведение отсроченного пережатия пуповины в течение 60 с и более после рождения ребенка [17]. Отсроченное пережатие пуповины на 30 с и более снижает риск смертности у недоношенных новорожденных на 32%, а также значимо увеличивает объем циркулирующей крови новорожденного [18], снижает частоту развития анемии у новорожденных [1,2,19], гемотрансфузий ЭСК крови, повышает запасы железа в возрасте 3 и 6 месяцев жизни, снижает частоту НЭК, сепсиса и ВЖК, частоту проведения кардиотонической терапии, а также улучшает показатели неврологического развития в возрасте 2 лет [1,3,17,[20][21][22][23]. ...
Anemia of prematurity is one of the most common and serious problems of neonatology. The main focus is to prevent of anemia in preterm infants. The aim of the study was to assess effectiveness of umbilical cord milking/delayed cord clamping and erythropoietin therapy in reducing red blood cell transfusions in extremely and very low birth weight infants. This clinical study was approved by the Commission on ethics of biomedical research (Protocol No. 12 November 17, 2016) and approved by the Scientific Council of National Medical Research Center for obstetrics, gynecology and perinatology named academician V.I. Kulakov of the ministry of Healthcare of the Russian Federation (Protocol No. 19 of November 29, 2016). Analysis of 482 extremely and very low birth weight infants was conducted (from 2008 to 2018). Umbilical cord milking or delayed umbilical cord clamping, both, and in combination with recombinant human erythropoietin therapy, decreasing the phlebotomy losses significantly reduces the need for transfusions of red blood cells in extremely and very low birth weight infants. The effectiveness of erythropoietin therapy, time of its start and various treatment schemes remain controversial, therefore further researches are necessary.
... were almost similar. Rabe et al. (2011) concluded that milking the cord four times achieved similar placenta-fetal blood transfusion as delaying clamping the cord [10] . ...
... were almost similar. Rabe et al. (2011) concluded that milking the cord four times achieved similar placenta-fetal blood transfusion as delaying clamping the cord [10] . ...
... This was consistent with a previous similar randomized control trial. 27 The reason for this could be that the effect of the extra volume of whole blood transfused from the placenta to the neonate might not have been reflected in the DCC group then, at birth, when the haemoglobin levels were measured. Usually, after receiving red blood cells, haematocrit equilibration takes place gradually, leading to a stable packed cell volume. ...
Objective
To compare the effects of early and delayed cord clamping on the haemoglobin levels of neonates delivered at term.
Methods
This randomized controlled trial enrolled pregnant women during the second stage of labour. They were randomized into either the early cord clamping (ECC) group or the delayed cord clamping (DCC) group in the ratio of 1:1. Following delivery of the baby, the umbilical cords of participants in the ECC group were clamped within 30 s of delivery of the neonate while those of participants in the DCC group were clamped after 2 min from the delivery of the neonate. The primary outcome measure was the effect of ECC and DCC on the haemoglobin levels of neonates delivered at term.
Results
A total of 270 pregnant women were enrolled in the study. Their baseline sociodemographic and clinical characteristics were similar in both groups. There was no significant difference in the mean haemoglobin level between ECC and DCC groups at birth. The mean haemoglobin level of the neonates at 48 h postpartum was significantly higher in the DCC group than the ECC group.
Conclusion
DCC at birth was associated with a significant increase in neonatal haemoglobin levels at 48 h postpartum when compared with ECC.
Trial Registration: The trial was registered at Pan African Clinical Trial Registry with approval number PACTR202206735622089.
... The amount of placento-fetal blood transfusion obtained by milking the cord four times was comparable to that obtained by delaying clamping the cord for 30 seconds. 9 The hematocrit does not rise when cord stripping is added to the delayed cord clamp. 10 Although there was no increase in staff workload due to delayed cord clamping, it was a procedure adjustment for the nurses and doctors. ...
The yolk sac and the allantois give rise to and are preserved in the umbilical cord. By the fifth week of development, it has formed and is the embryo's new source of nutrition, taking the place of the yolk sac. The cord joins the placenta, which transports substances to and from the mother's blood without allowing them to directly mix, rather than being directly attached to the mother's circulatory system. The umbilical cord can be clamped at various times, although postponing it until at least one minute after delivery improves results, provided that the minor risk of jaundice can be treated if it does occur. Clamping is followed by a painless cord cutting procedure because there are no nerves present. Out of those 20 studies, only 5 studies discuss the risk associated with delayed cord clamping, 2 studies discuss the benefit associated with good nutritional status, 2 studies discuss the benefit associated with good neurodevelopment, and the remaining studies discuss the increase in hemoglobin due to delayed cord clamping.
... The infants randomized to the intact cord milking arm had higher Hb levels, required less cardiorespiratory assistance in the delivery room, and experienced fewer cases of moderate-to-severe hypoxicischemic encephalopathy [18]. The results in our study are consistent with those observed in previous studies on cord milking which had reported on hematological outcomes at 48 h or 6 weeks either as primary or secondary outcomes in babies born at different gestational age [8,10,19,20]. Majority of the studies did not include the preterm neonates requiring resuscitation at birth. This is the most vulnerable group of population at highest risk of anaemia and its adverse outcomes. ...
Routine practice of delayed cord clamping (DCC) is the standard of care in vigorous neonates. However there is no consensus on the recommended approach to placental transfusion in non-vigorous neonates. In this trial, we tried to examine the effect of cut umbilical cord milking (C-UCM) as compared to early cord clamping (ECC) on hematological and clinical hemodynamic parameters in non-vigorous preterm neonates of 30–35 weeks gestation. The primary outcome assessed was venous hematocrit (Hct) at 48 (± 4) hours of postnatal age. The important secondary outcomes assessed were serum ferritin at 6 weeks of age, mean blood pressure in the initial transitional phase along with important neonatal morbidities and potential complications. In this single centre randomized controlled trial, 134 non vigorous neonates of 30–35 weeks gestation were allocated in a 1:1 ratio to either C-UCM (n = 67) or ECC (n = 67). For statistical analysis, unpaired Student t and Chi square or Fisher’s exact test were used. The mean Hct at 48 h was higher in the C-UCM group as compared to the control group, 50.24(4.200) vs 46.16(2.957), p < .0001. Also significantly higher was the mean Hct at 12 h, 6 weeks and mean serum ferritin at 6 weeks of age in the milked group (p < .0001). Mean blood pressure at 1 h and 6 h was also significantly higher in the milked arm. Need for transfusion and inotropes was less in the milked group but not statistically significant. No significant difference in potential complications was observed between the groups.
Conclusion: C-UCM stabilizes initial blood pressure and results in higher hematocrit and improved iron stores. It can be an alternative to DCC in non-vigorous preterm neonates of 30–35 weeks’ gestation. Further large multicentric studies are needed to fully establish its efficacy and safety.
Trial registration: CTRI/2021/12/038606; registration date December 14, 2021.What is Known:
• DCC is the routinely recommended method of placental transfusion for vigorous neonates but no consensus exist for neonates requiring resuscitation at birth.
• C-UCM is easier to perform in non-vigorous neonates but there is paucity of studies in the preterm population.
What is New:
• C-UCM is effective as well as safe in non-vigorous preterm neonates of 30–35 weeks gestational age.
• C-UCM holds promise as an alternative to DCC, especially in resource limited settings and in situations where the later is not feasible.
... More recently, Upadhyay et al. (21) found higher Hb levels and iron status after performing cut-cord milking in a large randomized controlled trial including 200-term infants. Rabe et al. (22) also recorded more favorable hematological parameters for UCM. The higher hemoglobin levels reported by the latter may have been attributed to the implementation of the ICM technique compared to the CCM technique (20,23). ...
Background: Deferring the umbilical cord clamping produces more satisfactory neurological and hematological outcomes. Another alternative for the deferred umbilical cord clamping is the umbilical cord milking. Objectives: This study aimed to evaluate different placental transfusion techniques in terms of hematological parameters for term neonates. Methods: This observational study included 120 term infants assigned to groups of deferred cord clamping for 60 seconds (DCC), cut cord milking for four times with a speed of 10 cm/second (CCM), intact cord milking for four times (ICM), and a historical control group of immediate cord clamping (ICC). The primary outcome of this study was hematological parameters at birth and 24th hours. Hyperbilirubinemia, polycythemia, or respiratory distress were secondary outcomes. Results: The median gestational ages and birth weights of neonates were 39 (37 - 40) weeks and 3270 (2365 - 4850) grams, respectively. Umbilical cord hemoglobin (Hb) and hematocrit (Hct) levels were significantly higher in the ICM group (P < 0.01). Hemoglobin and Hct levels at 24th hours of life were similar in DCC, CCM, and ICM groups and significantly higher than those in the ICC group (P < 0.01). No significant difference was found among the groups in terms of hyperbilirubinemia, polycythemia, and respiratory distress. Conclusions: To the best of our knowledge, this study was one of the most comprehensive studies evaluating the effects of different placental transfusion strategies on hematological parameters in term infants and the first study exploring intact cord milking in term infants. Intact cord milking was suggested to be associated with higher hemoglobin levels at birth. All DCC, ICM, and CCM techniques were found to be more effective than ICC in terms of early hematological parameters.
... In preterm infants, umbilical cord milking (UCM) has the same benefits as DCC in terms of red blood cell (RBC) transfusion requirements [10,11]. A meta-analysis suggests that DCC or UCM both have advantages over immediate cord clamping regarding decreased blood transfusion incidence, decreased overall mortality, and lower risk of intraventricular hemorrhage [12]. ...
Background:
Preterm infants often have long hospital stays and frequent blood tests; they often develop anemia requiring multiple blood transfusions. Placental transfusion via delayed cord clamping (DCC) or umbilical cord milking (UCM) helps increase blood volume. We hypothesized umbilical cord milking (UCM), together with DCC, would be superior in reducing blood transfusions.
Objectives:
To compare the effects of DCC and DCC combined with UCM on hematologic outcomes among preterm infants.
Methods:
One hundred twenty singleton preterm infants born at 280/7- 336/7 weeks of gestation at Thammasat University Hospital were enrolled in an open-label, randomized, controlled trial. They were placed into three groups (1:1:1) by a block-of-three randomization: DCC for 45 s, DCC with UCM performed before clamping (DCM-B), and DCC with UCM performed after clamping (DCM-A). The primary outcomes were hematocrit levels and number of infants receiving blood transfusions during the first 28 days of life. Intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) were secondary outcomes. Analyses were performed with an intent-to-treat approach.
Results:
One hundred twenty preterm infants were randomized. There was no statistically significant difference in neonatal outcomes; hematocrit on admission 54.0 ± 5.5, 53.3 ± 6.0, and 54.3 ± 5.8 (p = 0.88), receiving blood transfusions 25%, 20%, and 12.5% (p = 0.24), incidence of NEC 7.5, 0 and 10% (p = 0.78) in the DCC, DCM-B and DCM-A groups, respectively. There were no preterm infants with severe IVH, polycythemia, maternal or neonatal death.
Conclusion:
The placental transfusion techniques utilized, DCC and DCC combined with UCM, provided the same benefits for preterm infants born at GA 28 and 33 weeks in terms of reducing the need for RBC transfusions, severities of IVH and incidence of NEC without increasing comorbidity.
Trial registration:
TCTR20190131002 . Registered 31 January 2019-Retrospectively registered.
... In more recent studies included in this review, which compared UCM to DCC in TNB and PTNB, similar levels of hemoglobin, hematocrit and serum ferritin were found between the two groups (14,27,33,65) . It should be noted that, at term birth, the newborn has an iron reserve of 75 mg/ kg and, when submitted to DCC, an additional 40 mg occurs in one minute and 50 mg in three minutes. ...
Objective: To map the available evidence on umbilical cord milking in newborns. Material and Method: Scoping Review based on the protocol proposed by the Joanna Briggs Institute. A search for full-text articles published in MEDLINE, SCOPUS, WOS and CINAHL was carried out using the following keywords: infant, newborn, umbilical cord milking, placental transfusion and umbilical cord blood. Results: The results indicated umbilical cord milking has superior benefits to the immediate cord clamping, among the main ones are higher levels of Hemoglobin, Hematocrit and Serum Ferritin, and reduction of complications in preterm newborns, such as intraventricular hemorrhage and the need for blood transfusion. When compared to delayed cord clamping, it has similar benefits, but milking is considered a faster method of placental blood transfusion. Conclusions: Umbilical cord milking has similar potential to delayed cord clamping. Therefore, it can be an alternative for obstetric nurses and midwives when delayed cord clamping cannot be performed in order to ensure the benefits of placental transfusion to the neonate.
... When the umbilical cord is clamped right after birth, a significant proportion of fetal blood stays in the placenta, resulting in a reduced red blood cell (RBC) count in the newborn. The two basic placental transfusion procedures used in the delivery room to enhance the RBC count in newborns are delayed cord clamping (DCC) and umbilical cord milking (UCM) (5). Physiologic-based cord clamping (PBCC) entails delayed umbilical cord clamping until the infant has started breathing or has received respiratory support, and the lung has been aerated (6). ...
Background
The role of umbilical cord management in placental transfusion in cesarean section (CS) requires clarification. The spontaneous first breath may be more important than the timing of cord clamping for placental transfusion in neonates born by CS.
Objective
This study aimed to evaluate the impact of cord clamping after the first spontaneous breath on placental transfusion in neonates born by CS.
Methods
We recruited women with a live singleton pregnancy at ≥37.0 weeks of gestation admitted for CS. The interventions performed, such as physiologic-based cord clamping (PBCC), intact-umbilical cord milking (I-UCM), 30-s delay in cord clamping (30-s DCC), and 60-s delay in cord clamping (60-s DCC), were noted and placed in a sealed envelope. The sealed envelope was opened immediately before delivery to perform randomization.
Results
A total of 123 infants were eligible for evaluation. Of these, 31, 30, 32, and 30 were assigned to the PBCC, I-UCM, 30-s DCC, and 60-s DCC groups, respectively. The mean hemoglobin (Hb) and mean hematocrit (Hct) were significantly higher in the 60-s DCC group than in the PBCC group ( p = 0.028 and 0.019, respectively), but no difference was noted among the I-UCM, 30-s DCC, and PBCC groups at 36 h of age. Further, no significant differences were observed in the mean Hb and mean Hct among the I-UCM, 60-s DCC, and 30-s DCC groups. Peak total serum bilirubin (TSB) levels were higher in the 60-s DCC group than in the I-UCM and PBCC groups ( p = 0.017), but there was no difference between the 60-s DCC and 30-s DCC groups during the first week of life. The phototherapy requirement was higher in 60-s DCC than in IUCM and 30-sDCC ( p = 0.001).
Conclusions
Our findings demonstrated that PBCC, 30-s DCC, and I-UCM in neonates born by CS had no significant differences from each other on placental transfusion. The Hb and Hct in the neonates were higher after 60-s DCC than after PBCC.
... There were concerns that performing DCC may delay neonatal resuscitation, therefore umbilical cord milking (UCM) is an alternative placental transfusion technique. In preterm infants, UCM has the same bene ts as DCC in terms of red blood cell (RBC) transfusion requirements 9,10 . A meta-analysis suggests that DCC or UCM both have advantages over immediate cord clamping regarding decreased blood transfusion incidence, decreased overall mortality, and lower risk of intraventricular hemorrhage 11 . ...
Background: Premature babies often have long hospital stays and frequent blood tests; they often develop anemia requiring multiple blood transfusions. Placental transfusion via delayed cord clamping (DCC) or umbilical cord milking (UCM) helps increase blood volume. We hypothesized umbilical cord milking (UCM), together with DCC, would be a superior in reducing blood transfusions.
Objectives: To compare the effects of DCC and DCC combined with UCM on hematologic outcomes among preterm infants.
Methods: 120 singleton preterm infants born at 280/7- 336/7 weeks of gestation at Thammasat University Hospital were enrolled in a randomized controlled, open label, trial. They were placed into three groups (1:1:1) by a block-of-three randomization: DCC for 45 seconds, DCC with UCM performed before clamping (DCM-B), and DCC with UCM performed after clamping (DCM-A). The primary outcomes were hematocrit levels and number of infants receiving blood transfusions during the first 28 days of life. Intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) were secondary outcomes. Analysis were performed with an intent-to-treat approach.
Results: 120 preterm infants were randomized. There was no statistically significant difference in neonatal outcomes; hematocrit on admission 54.0 ± 5.5, 53.3 ± 6.0, and 54.3 ± 5.8, receiving blood transfusions 25%, 20% and 12.5%, incidence of NEC 7.5, 0 and 10% in the DCC, DCM-B and DCM-A groups, respectively. There were no preterm infants with severe IVH, polycythemia, maternal or neonatal death.
Conclusion: Although it was not significantly different, preterm infants in DCM-B and DCM-A groups requiring blood transfusion were less than those in DCC group. All three placental transfusion techniques provided the same benefit in preterm infants in reducing the incidence of severe IVH and NEC without increasing complication and comorbidity.
Trial Registration: TCTR20190131002
Registered 31 January 2019 - Retrospectively registered
http://www.thaiclinicaltrials.org/show/TCTR20190131002
... Although it is not physiologic, milking the umbilical cord two to four times towards the baby has been studied as an alternative to waiting for at least 60 s before clamping the cord [37,38]. Meta-analyses of studies using UCM show similar benefits to waiting for 60 s, with increased survival by 27% compared to ICC with no difference in major comorbidities of prematurity [3,39,40]. ...
A newborn who receives a placental transfusion at birth from delayed cord clamping (DCC) obtains about 30% more blood volume than those with immediate cord clamping (ICC). Benefits for term neonates include higher hemoglobin levels, less iron deficiency in infancy, improved myelination out to 12 months, and better motor and social development at 4 years of age especially in boys. For preterm infants, benefits include less intraventricular hemorrhage, fewer gastrointestinal issues, lower transfusion requirements, and less mortality in the neonatal intensive care unit by 30%. Ventilation before clamping the umbilical cord can reduce large swings in cardiovascular function and help to stabilize the neonate. Hypovolemia, often associated with nuchal cord or shoulder dystocia, may lead to an inflammatory cascade and subsequent ischemic injury. A sudden unexpected neonatal asystole at birth may occur from severe hypovolemia. The restoration of blood volume is an important action to protect the hearts and brains of neonates. Currently, protocols for resuscitation call for ICC. However, receiving an adequate blood volume via placental transfusion may be protective for distressed neonates as it prevents hypovolemia and supports optimal perfusion to all organs. Bringing the resuscitation to the mother’s bedside is a novel concept and supports an intact umbilical cord. When one cannot wait, cord milking several times can be done quickly within the resuscitation guidelines. Cord blood gases can be collected with optimal cord management. Conclusion: Adopting a policy for resuscitation with an intact cord in a hospital setting takes a coordinated effort and requires teamwork by obstetrics, pediatrics, midwifery, and nursing.
What is Known:
• Placental transfusion through optimal cord management benefits morbidity and mortality of newborn infants.
• The World Health Organisation has recommended placental transfusion in their guidance.
What is New:
• Improved understanding of transitioning to extrauterine life has been described.
• Resuscitation of newborn infants whilst the umbilical cord remains intact could improve the postpartum adaptation.
... There is a need to compare the two methods, to evaluate whether they are equally effective in improving hematological parameters during infancy. There are very few trials directly comparing umbilical cord milking and delayed cord clamping in both term 15,16 and preterm 11,12 babies. In a country where a child may not come in contact with the health system for prolonged periods, a method which increases the iron reserves in the neonate will go a long way in preventing IDA. ...
Iron stores at birth can be affected by transplacental transfer of iron and blood from the placenta and cord at the time of delivery. To enhance their transfer from placenta and umbilical cord to baby, interventions like umbilical cord milking and delayed cord clamping have received a lot of scientific attention. Therefore, the present study was conducted with the aim to compare the effect of delayed cord clamping (DCC) and umbilical cord milking (UCM) on hematological parameters in healthy term neonates. This single centered Randomized Control Trial (RCT) was conducted in term neonates (37-41 weeks) born either vaginally or by lower segment cesarean section at Guru Gobind Singh Medical College and Hospital, Faridkot , Punjab, India for the period of one and a half year. Statistically, it has been analyzed that newborns who underwent DCC and UCM, there was an insignificant difference in the level of hemoglobin (Hb) and haematocrit (HCT) at 30 minutes, 24 hours and 48 hours after birth. Similarly, the insignificant results were observed for hematological parameters in the two treatment groups at six weeks of age. Our study demonstrated that both Delayed Cord Clamping (DCC) and Umbilical Cord Milking (UCM) have comparable benefits in improving hematological status at six weeks of age. Both the methods of placental transfusion do not alter the hemodynamic status of the child and do not result in any significant adverse neonatal outcomes in the first 48 hours of life.
... There is a need to compare the two methods, to evaluate whether they are equally effective in improving hematological parameters during infancy. There are very few trials directly comparing umbilical cord milking and delayed cord clamping in both term 15,16 and preterm 11,12 babies. In a country where a child may not come in contact with the health system for prolonged periods, a method which increases the iron reserves in the neonate will go a long way in preventing IDA. ...
... Of the preterm infant studies, five studies had no extractable data but these studies were included in the review as they had BP related comments within the text for comparative purposes [40,42,58,60,61]. Two papers were based on the same original cohort but the second paper reported additional data [55,56]. ...
Objective
A comprehensive understanding of the factors contributing to perinatal blood pressure is vital to ensure optimal postnatal hemodynamic support. The objective of this study was to review existing literature on maternal and perinatal factors influencing blood pressure in neonates up to 3 months corrected age.
Methods
A systematic search of published literature in OVID Medline, OVID Embase and the COCHRANE library identified publications relating to maternal factors affecting blood pressure of neonates up to corrected age of 3 months. Summary data were extracted and compared (PROSPERO CRD42018092886).
Results
Of the 3683 non-duplicate publications identified, 44 were eligible for inclusion in this review. Topics elicited were sociodemographic factors, maternal health status, medications, smoking during pregnancy, and cord management at birth. Limited data were available for each factor. Results regarding the impact of these factors on neonatal blood pressure were inconsistent across studies.
Conclusions
There is insufficient evidence to draw definitive conclusions regarding the impact of various maternal and perinatal factors on neonatal blood pressure. Future investigations of neonatal cardiovascular therapies should account for these factors in their study design. Similarly, studies on maternal diseases and perinatal interventions should include neonatal blood pressure as part of their primary or secondary analyses.
... First, leaving the cord intact and gradually "milking" 20 cm of the umbilical cord over 1 to 2 seconds, and releases the umbilical cord after each milk to allow the cord to refill with blood. This process is repeated 2 to 4 times prior to UCC [34,36,38,42,43,45]. The second method is called the "cutumbilical cord milking" when the cord is clamped close to the placenta the residual volume of blood is milked towards the infant [46][47][48][49][50]. ...
Delayed cord clamping has been shown to be beneficial in both preterm and term babies. Practice guidelines have not been consistent between centers and the practice of delayed cord clamping has not been standardized. The concept of physiologic-based cord clamping emerged into practice as well. Cord milking has different physiological effect and might be harmful in preterm babies.
The transplantation of CD34⁺ hematopoietic stem-progenitor cells (HSPCs) derived from cord blood serves as the standard treatment for selected hematological, oncological, metabolic, and immunodeficiency disorders, of which the dose is pivotal to the clinical outcome. Based on numerous maternal and neonatal parameters, we evaluated the predictive power of mathematical pipelines to the proportion of CD34⁺ cells in the final cryopreserved cord blood product adopting both parametric and non-parametric algorithms. Twenty-four predictor variables associated with the cord blood processing of 802 processed cord blood units randomly sampled in 2020–2022 were retrieved and analyzed. Prediction models were developed by adopting the parametric (multivariate linear regression) and non-parametric (random forest and back propagation neural network) statistical models to investigate the data patterns for determining the single outcome (i.e., the proportion of CD34⁺ cells). The multivariate linear regression model produced the lowest root-mean-square deviation (0.0982). However, the model created by the back propagation neural network produced the highest median absolute deviation (0.0689) and predictive power (56.99%) in comparison to the random forest and multivariate linear regression. The predictive model depending on a combination of continuous and discrete maternal with neonatal parameters associated with cord blood processing can predict the CD34⁺ dose in the final product for clinical utilization. The back propagation neural network algorithm produces a model with the highest predictive power which can be widely applied to assisting cell banks for optimal cord blood unit selection to ensure the highest chance of transplantation success.
Background: Placental insufficiency is one of the highly prevalent clinical concerns in obstetrics. It is becoming increasingly obvious that its presence significantly affects fetus and placenta, with ramifications on the metabolic, cardiovascular, and neurological development until adulthood. Purpose: To assess the effect of umbilical cord milking (UCM) on selected maternal and premature neonatal outcomes among women with placental insufficiency. Design: Quasi experimental design. Setting: Obstetrics and Neonatal Intensive Care Units (NICU) in Menoufia University Hospital at Shebin El-Koom. Sampling: A purposive sample of 80 pregnant women diagnosed with placental insufficiency and their premature neonates was included. Instruments: For data collection three instruments were used. Instrument one: Characteristics of pregnant women and premature neonates' assessment sheet. Instrument two: maternal health outcomes assessment sheet. Instrument three: preterm neonates' health outcomes assessment sheet. Results: Premature neonates in the study group had elevated CD34 (1.13 ± 0 .65 VS 0 .40 ± 0 .20), hematocrit percentage (48.25 ± 5.71 VS 40.47 ± 3.37), and hemoglobin (Hb) (17.37 ±.0.95 VS 14.18 ± 0.78) within 24 h of life than premature neonates in the control group. No statistical significant differences were found between studied women in relation to duration of third stage of labor or occurrence of postpartum hemorrhage (PPH). Conclusion: Performing UCM for premature neonates elevated CD34 percentage and Hb levels (at birth and at 2 months), reduced their need for PRBCs transfusion and reduced the duration of oxygen management. However, it did not influence the length of third stage of labor or maternal PPH. Recommendations: UCM procedure should be implemented in all Obstetrics & Gynecology departments to improve hematological and clinical outcomes of prematures. Nurses should also be trained to perform UCM.
Delayed cord clamping (DCC) is an established practice in perinatology with multiple benefits. However, in instances where the implementation of DCC is not viable, it needs alternatives, especially during caesarean deliveries. A non-inferiority randomized, non-blinded, trial was conducted at a tertiary care referral unit in South India among the preterm newborns (28–36 weeks) randomized to DCC as opposed to intact-umbilical cord milking (UCM). The primary objective was to compare the mean haemoglobin values between the two groups, and the secondary outcome was to compare death and/or major IVH (> Grade II). Of the 132 eligible newborn infants, 99 were randomized to two study groups. Of the 59 and 40 randomised to UCM and DCC, 54 and 36 received the allocated intervention respectively. Preterm infants who underwent UCM had significantly higher haemoglobin (19.97 ± 1.44) as compared to DCC group (18.62 ± 0.98) p-0.0001. The rates of mortality and/or major IVH were comparable between the two groups.
Conclusion: UCM may be a feasible alternative to DCC especially in settings where the latter is not achievable, without increasing the risk of adverse effects to the preterm infants, this finding needing further confirmation with larger sample.
Trial registration: CTRI (Clinical Trial Registry—India) registration number: CTRI/2020/04/024566 (registered prospectively on 13/04/2020). What is Known:
• Delayed cord clamping (DCC) is recommended as a standard of care for all the stable term and preterm newborn babies at birth.
What is New:
• Intact umbilical cord milking may be a reasonable choice of cord management when DCC is unsuccessful, without increasing adverse effects for the new born.
Background: Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth.
Methods: We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640.
Findings: We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality.
Interpretation: This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations.
The first 60 min after birth, called “golden Hour,” is a critical period for both mother and newborn, who moved from the internal to the external uterine environment. Monitoring trends of vital signs is important to predict clinical worsening and improve their outcome.This chapter is divided in two sections: the first section is about mothers’ cardiac dysfunctions and hemorrhages (screening, primary prevention especially in women affected by genetic coagulation disorders and treatment protocols in postpartum hemorrhages); the second section is about newborns treatment protocols in critical emergencies.The “Golden Hour” in obstetric is crucial for women and neonates during the first hour after childbirth. The main objective of golden hour is to use timely and effective interventions to improve the outcome.KeywordsPostpartum hemorrhagesHemodynamic monitoringThromboelastographyCardiac disease
Delayed clamping and cutting of the umbilical cord at birth is standard practice for management for all newborns. Preterm infants may additionally benefit from a combination of ventilation and oxygen provision during intact cord resuscitation. This review highlights both the potential benefits of such a combined approach and the need for further rigorous studies, including randomized controlled trials, of delivery room management in this population.
Importance:
Interventions to reduce severe brain injury risk are the prime focus in neonatal clinical trials.
Objective:
To evaluate multiple perinatal interventions across clinical settings for reducing the risk of severe intraventricular hemorrhage (sIVH) and cystic periventricular leukomalacia (cPVL) in preterm neonates.
Data sources:
MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception until September 8, 2022, using prespecified search terms and no language restrictions.
Study selection:
Randomized clinical trials (RCTs) that evaluated perinatal interventions, chosen a priori, and reported 1 or more outcomes (sIVH, cPVL, and severe brain injury) were included.
Data extraction and synthesis:
Two co-authors independently extracted the data, assessed the quality of the trials, and evaluated the certainty of the evidence using the Cochrane GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Fixed-effects pairwise meta-analysis was used for data synthesis.
Main outcomes and measures:
The 3 prespecified outcomes were sIVH, cPVL, and severe brain injury.
Results:
A total of 221 RCTs that assessed 44 perinatal interventions (6 antenatal, 6 delivery room, and 32 neonatal) were included. Meta-analysis showed with moderate certainty that antenatal corticosteroids were associated with small reduction in sIVH risk (risk ratio [RR], 0.54 [95% CI, 0.35-0.82]; absolute risk difference [ARD], -1% [95% CI, -2% to 0%]; number needed to treat [NNT], 80 [95% CI, 48-232]), whereas indomethacin prophylaxis was associated with moderate reduction in sIVH risk (RR, 0.64 [95% CI, 0.52-0.79]; ARD, -5% [95% CI, -8% to -3%]; NNT, 20 [95% CI, 13-39]). Similarly, the meta-analysis showed with low certainty that volume-targeted ventilation was associated with large reduction in risk of sIVH (RR, 0.51 [95% CI, 0.36-0.72]; ARD, -9% [95% CI, -13% to -5%]; NNT, 11 [95% CI, 7-23]). Additionally, early erythropoiesis-stimulating agents (RR, 0.68 [95% CI, 0.57-0.83]; ARD, -3% [95% CI, -4% to -1%]; NNT, 34 [95% CI, 22-67]) and prophylactic ethamsylate (RR, 0.68 [95% CI, 0.48-0.97]; ARD, -4% [95% CI, -7% to 0%]; NNT, 26 [95% CI, 13-372]) were associated with moderate reduction in sIVH risk (low certainty). The meta-analysis also showed with low certainty that compared with delayed cord clamping, umbilical cord milking was associated with a moderate increase in sIVH risk (RR, 1.82 [95% CI, 1.03-3.21]; ARD, 3% [95% CI, 0%-6%]; NNT, -30 [95% CI, -368 to -16]).
Conclusions and relevance:
Results of this study suggest that a few interventions, including antenatal corticosteroids and indomethacin prophylaxis, were associated with reduction in sIVH risk (moderate certainty), and volume-targeted ventilation, early erythropoiesis-stimulating agents, and prophylactic ethamsylate were associated with reduction in sIVH risk (low certainty) in preterm neonates. However, clinicians should carefully consider all of the critical factors that may affect applicability in these interventions, including certainty of the evidence, before applying them to clinical practice.
Recently, the survival of the high-risk population of preterm infants has steadily improved, and the severity of prematurity is a growing threat of gestational-age-related fatal conditions. Posthemorrhagic hydrocephalus (PHH) is the most common but serious neurological complication in premature infants, which can have life-threatening consequences during the acute phase in the neonatal period and life-long psychomotor and cognitive sequelae in their later life. Although neonatologists, pediatric neurologists, and pediatric neurosurgeons have investigated a diversified strategy for several decades, a consensus on the best management of PHH in premature infants still must be reached. Several approaches have tried to reduce the incidence of intraventricular hemorrhage (IVH) and mitigate the effect of IVH-related hydrocephalus. This paper reviews and discusses the clinical feature of PHH in premature infants, general/nonsurgical management of prematurity for IVH prevention, and posthemorrhagic management, and how and when to intervene.
Introduction
Placental transfusion is additional volume of blood transferred to the baby during birth. A newborn who receives placental transfusion at birth obtains 30% more blood volume than the newborn whose cord is cut immediately. Receiving an adequate blood volume from placental transfusion at birth may be protective for the distressed neonates. It provides sufficient iron reserves for the first 3 to 6 months of life there by preventing or delaying iron deficiency anemia until the use of iron fortified food is implemented. There are 2 ways of placental transfusion, they are delayed cord clamping and umbilical cord milking. Delayed cord clamping (defined as clamping till cessation of pulsations or up to 60-180 s) leads to improvement in levels of hemoglobin and hematocrit at 6 weeks of age. However, universal application is limited due to concerns for the risk of hypothermia, and delay in initiation of resuscitation if required. Umbilical cord milking involves milking the entire contents of the umbilical cord towards the baby with in 20 s. Umbilical cord milking can be used in deliveries where delayed cord clamping is not feasible.
Objective
Comparison of hematological parameters (cord hemoglobin at birth, hemoglobin, hematocrit, and bilirubin levels in term neonates at 48 h with umbilical cord milking and delayed cord clamping).
Methods and Analysis
In this study all the term neonates delivered by vaginal delivery and lower segment caesarean section born to nonanemic mothers were considered eligible. All newborns with no risk factors underwent delayed cord clamping (n = 148) and those term neonates in whom delayed cord clamping was not feasible and/or currently WHO guidelines recommend for immediate cord clamping were allocated for umbilical cord milking (n = 121). Cord hemoglobin at birth, hemoglobin, hematocrit, and bilirubin (direct and indirect) were sent at 48 h. These parameters were compared between 2 groups.
Results
At birth cord hemoglobin was 15.36 and 15.46 (mean difference = 0.1) in DCC and UCM, respectively. At 48 hours, mean hemoglobin was 18.73 and 18.95 (mean difference = 0.22, P = .3591). Mean hematocrit was 52.22 and 53.28 (mean difference = 1.06, P = .0989), and mean total bilirubin levels was 11.24 and 10.56 (mean difference = 0.69, P = .466).
Conclusion
There were no statistically significant differences in the hematological parameters in full term neonates at 48 h, between delayed cord clamping and umbilical cord milking groups.
Cord management in non-vigorous newborns remains up for debate, as limited studies have validated strategies in this high-risk population. While multiple national and international governing bodies now recommend the routine practice of delayed cord clamping (DCC) in vigorous neonates, these organizations have not reached a consensus on the appropriate approach in non-vigorous neonates. Benefits of placental transfusion are greatly needed amongst non-vigorous neonates who are at risk of asphyxiation-associated mortality and morbidities, but the need for immediate resuscitation complicates matters. This chapter discusses the physiological benefits of placental transfusion for non-vigorous neonates and reviews the available literature on different umbilical cord management strategies for this population.
Neonatal anaemia is a very frequent clinical condition that may be due to apparent or not evident blood loss, decreased red blood cells (RBCs) production, or increased destruction of RBCs. RBCs transfusion criteria are clearly defined by several national and locally agreed guidelines. However, it is not possible to define a unique cut-off to guide clinicians' transfusion practice, which needs a multiparametric analysis of demographic variables (gestational age, postnatal age, birth weight), clinical evaluation, conventional and new generation monitoring (such as echocardiography and near-infrared spectroscopy). Unfortunately, few tools are available in the delivery room to help neonatologists in the management of newborn with acute anaemia. Early volume replacement with cristalloids and RBCs transfusion could be life-saving in the delivery room when a hypovolaemic shock is suspected, but the use of un-crossmatched whole is not risk-free nor easily available in clinical practice. Placental transfusion could be an extremely effective and inexpensive method to increase haemoglobin (Hb), to improve oxygen delivery, and to increase cardiac output with a reduced need for RBCs transfusions, a reduced risk of intraventricular haemorrhages, and an improved survival of the newborn.
See Bonus NeoBriefs videos and downloadable teaching slides
The body of literature supporting different umbilical management strategies has increased over the past decade as the role of cord management in neonatal transition is realized. Multiple international governing bodies endorse delayed cord clamping, and this practice is now widely accepted by obstetricians and neonatologists. Although term and preterm neonates benefit in some ways from delayed cord clamping, additional research on variations in this practice, including resuscitation with an intact cord, aim to find the optimal cord management practice that reduces mortality and major morbidities.
Literature supporting various umbilical management strategies have increased substantially over the past decade. Delayed cord clamping and umbilical cord milking are increasing embraced by obstetricians and neonatologists, and multiple international governing bodies now endorse these practices. This review summarizes the benefits and limitations of the different umbilical cord management strategies for term, near-term, and preterm neonates. Additional studies are underway to elucidate the safety profile of these practices, long term outcomes, and variations within these strategies that could potentially augment the benefits.
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause.
The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
Background:Delayed cord clamping (DCC) is currently recommended for preterm infants to improve blood volume and decrease the rate of blood transfusion. Umbilical cord milking (CM) had similar advantages without interrupting neonatal resuscitation. However, the differences in neonatal outcomes between DCC and CM are not well elucidated. Objective:To compare neonatal outcomes between DCC and CM among preterm infants. Method:Infants born at 25-34 weeks of gestation were randomly allocated to one of two groups; group 1 received DCC for 60 seconds whereas group 2 received CM. Initial hemoglobin value was measured, while blood pressure and urine output were monitored. Neonatal complications and the rate of blood transfusion were recorded. Results: Twenty-two infants were enrolled in each group. No differences were observed regarding sex, gestational age, birth weight, mode of delivery, Apgar scores and rate of resuscitation between groups. The initial hemoglobin level of the DCC group [median 17.1 (13.1, 21.3) g/dL] did not differ from that of the CM group [median 17.1 (14.0, 22.5) g/dL], p=0.963. During the first 24 hours, no significant differences were observed regarding blood pressure and urine output between the groups. No differences were found in the rates of hypothermia, hyperbilirubinemia, intraventricular hemorrhage, necrotizing enterocolitis and rate of blood transfusion. Conclusion:We demonstrated no different effects on neonatal outcomes between DCC and CM among preterm infants. CM can be applied as an alternative to DCC especially in emergency situations. However, larger studies are warranted to determine the effects and safety of CM among preterm infants.
Objective Delayed cord clamping (DCC) and 21 to 30% O2 resuscitation is recommended for preterm infants but is commonly associated with low pulmonary blood flow (Qp) and hypoxia. 100% O2 supplementation during DCC for 60 seconds followed by 30% O2 may increase Qp and oxygen saturation (SpO2).
Study Design Preterm lambs (125–127 days of gestation) were resuscitated with 100% O2 with immediate cord clamping (ICC, n = 7) or ICC + 30% O2, and titrated to target SpO2 (n = 7) or DCC + 100% O2 for 60 seconds, which followed by cord clamping and 30% O2 titration (n = 7). Seven preterm (23–27 weeks of gestation) human infants received continuous positive airway pressure (CPAP) + 100% O2 for 60 seconds during DCC, cord clamping, and 30% O2 supplementation after cord clamping.
Results Preterm lambs in the ICC + 100% O2 group resulted in PaO2 (77 ± 25 mmHg), SpO2 (77 ± 11%), and Qp (27 ± 9 mL/kg/min) at 60 seconds. ICC + 30% O2 led to low Qp (14 ± 3 mL/kg/min), low SpO2 (43 ± 26%), and PaO2 (19 ± 7 mmHg). DCC + 100% O2 led to similar Qp (28 ± 6 mL/kg/min) as ICC + 100% O2 with lower PaO2. In human infants, DCC + CPAP with 100% O2 for 60 seconds, which followed by weaning to 30% resulted in SpO2 of 92 ± 11% with all infants >80% at 5 minutes with 100% survival without severe intraventricular hemorrhage.
Conclusion DCC + 100% O2 for 60 seconds increased Qp probably due to transient alveolar hyperoxia with systemic normoxia due to “dilution” by umbilical venous return. Larger translational and clinical studies are warranted to confirm these findings.
Key Points
Importance: It is unclear which umbilical cord management strategy is the best for preventing mortality and morbidities in preterm infants.
Objective: To systematically review and conduct a network meta-analysis comparing 4 umbilical cord management strategies for preterm infants: immediate umbilical cord clamping (ICC), delayed umbilical cord clamping (DCC), umbilical cord milking (UCM), and UCM and DCC.
Data sources: PubMed, Embase, CINAHL, and Cochrane CENTRAL databases were searched from inception until September 11, 2020.
Study selection: Randomized clinical trials comparing different umbilical cord management strategies for preterm infants were included.
Data extraction and synthesis: Data were extracted for bayesian random-effects meta-analysis to estimate the relative treatment effects (odds ratios [OR] and 95% credible intervals [CrI]) and surface under the cumulative ranking curve values.
Main outcomes and measures: The primary outcome was predischarge mortality. The secondary outcomes were intraventricular hemorrhage, severe intraventricular hemorrhage, need for packed red blood cell transfusion, and other neonatal morbidities. Confidence in network meta-analysis software was used to assess the quality of evidence and grade outcomes.
Results: Fifty-six studies enrolled 6852 preterm infants. Compared with ICC, DCC was associated with lower odds of mortality (22 trials, 3083 participants; 7.6% vs 5.0%; OR, 0.64; 95% CrI, 0.39-0.99), intraventricular hemorrhage (25 trials, 3316 participants; 17.8% vs 15.4%; OR, 0.73; 95% CrI, 0.54-0.97), and need for packed red blood cell transfusion (18 trials, 2904 participants; 46.9% vs 38.3%; OR, 0.48; 95% CrI, 0.32-0.66). Compared with ICC, UCM was associated with lower odds of intraventricular hemorrhage (10 trials, 645 participants; 22.5% vs 16.2%; OR, 0.58; 95% CrI, 0.38-0.84) and need for packed red blood cell transfusion (9 trials, 688 participants; 47.3% vs 32.3%; OR, 0.36; 95% CrI, 0.23-0.53), with no significant differences for other secondary outcomes. There was no significant difference between UCM and DCC for any outcome.
Conclusions and relevance: Compared with ICC, DCC was associated with the lower odds of mortality in preterm infants. Compared with ICC, DCC and UCM were associated with reductions in intraventricular hemorrhage and need for packed red cell transfusion. There was no significant difference between UCM and DCC for any outcome. Further studies directly comparing DCC and UCM are needed.
Optimal timing for clamping of the umbilical cord at birth is unclear. Early clamping allows for immediate resuscitation of the newborn. Delaying clamping may facilitate transfusion of blood between the placenta and the baby.
To delineate the short- and long-term effects for infants born at less than 37 completed weeks' gestation, and their mothers, of early compared to delayed clamping of the umbilical cord at birth.
We searched the Cochrane Pregnancy and Childbirth Group trials register (2 February 2004), the Cochrane Neonatal Group trials register (2 February 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), PubMed (1966 to 2 February 2004) and EMBASE (1974 to 2 February 2004).
Randomized controlled trials comparing early with delayed (30 seconds or more) clamping of the umbilical cord for infants born before 37 completed weeks' gestation.
Three reviewers assessed eligibility and trial quality.
Seven studies (297 infants) were eligible for inclusion. The maximum delay in cord clamping was 120 seconds. Delayed cord clamping was associated with a higher hematocrit four hours after birth (four trials, 134 infants; weighted mean difference 5.31, 95% confidence interval (CI) 3.42 to 7.19), fewer transfusions for anaemia (three trials, 111 infants; relative risk (RR) 2.01, 95% CI 1.24 to 3.27) or low blood pressure (two trials, 58 infants; RR 2.58, 95% CI 1.17 to 5.67) and less intraventricular haemorrhage (five trials, 225 infants; RR 1.74, 95% CI 1.08 to 2.81) than early clamping.
Delaying cord clamping by 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion and less intraventricular haemorrhage. There are no clear differences in other outcomes.
To investigate whether it was possible to promote placental blood transfer to infants at preterm delivery by (1) delaying cord clamping, (2) holding the infant below the placenta, and (3) administering an oxytocic agent to the mother, we measured the infants' blood volumes.
Randomized study.
Forty-six preterm infants (gestational age: 24[0/7] to 32[6/7] weeks) were assigned randomly to either placental blood transfer promotion (delayed cord clamping [DCC] group, ie, > or =30 seconds from moment of delivery) or early cord clamping (ECC) with conventional management (ECC group). Eleven of 23 and 9 of 23 infants assigned randomly to DCC and ECC, respectively, were delivered through the vaginal route. The study was conducted at a tertiary perinatal center, the Queen Mother's Hospital (Glasgow, United Kingdom).
The infants' mean blood volume in the DCC group (74.4 mL/kg) was significantly greater than that in the ECC group (62.7 mL/kg; 95% confidence interval for advantage: 5.8-17.5). The blood volume was significantly increased by DCC for infants delivered vaginally. The infants in the DCC group delivered through cesarean section had greater blood volumes (mean: 70.4 mL/kg; range: 45-83 mL/kg), compared with the ECC group (mean: 64.0 mL/kg; range: 48-77 mL/kg), but this was not significant. Additional analyses confirmed the effect of DCC (at least 30 seconds) to increase average blood volumes across the full range of gestational ages studied.
The blood volume was, on average, increased in the DCC group after at least a 30-second delay for both vaginal and cesarean deliveries. However, on average, euvolemia was not attained with the third stage management methods outlined above.
The optimal timing of clamping the umbilical cord in preterm infants at birth is the subject of continuing debate. Objective: To investigate the effects of a brief delay in cord clamping on the outcome of babies born prematurely.
A retrospective meta-analysis of randomised trials in preterm infants was conducted. Data were collected from published studies identified by a structured literature search in EMBASE, PubMed, CINAHL and the Cochrane Library. All infants born below 37 weeks gestation and enrolled into a randomised study of delayed cord clamping (30 s or more) versus immediate cord clamping (less than 20 s) after birth were included. Systematic search and analysis of the data were done according to the methodology of the Cochrane collaboration.
Ten studies describing a total of 454 preterm infants were identified which met the inclusion and assessment criteria. Major benefits of the intervention were higher circulating blood volume during the first 24 h of life, less need for blood transfusions (p = 0.004) and less incidence of intraventricular hemorrhage (p = 0.002).
The procedure of a delayed cord clamping time of at least 30 s is safe to use and does not compromise the preterm infant in the initial post-partum adaptation phase.
We have performed brain scanning by computed tomography on 46 consecutive live-born infants whose birth weights were less than 1,500 gm; 20 of them had evidence of cerebral intraventricular hemorrhage. Nine of the 29 infants who survived had IVH. Four grades of IVH were identified. Grade I and II lesions resolved spontaneously, but there was prominence of the interhemispheric fissue on CT of the infants at six months of age. Hydrocephalus developed in infants with Grade III and IV lesions. Seven of the surviving infants with IVH did not have clinical evidence of hemorrhage. There were no significant differences between the infants with and without IVH in birth weight, gestational age, one- and five-minute Apgar scores, or the need for resuscitation at birth or for subsequent respiratory assistance.
The results from our previous trial revealed that infants with delayed cord clamping (DCC) had significantly lesser intraventricular hemorrhage (IVH) and late-onset sepsis (LOS) than infants with immediate cord clamping (ICC). A priori, we hypothesized that infants with DCC would have better motor function by 7 months corrected age.
Infants between 24 and 31 weeks were randomized to ICC or DCC and follow-up evaluation was completed at 7 months corrected age.
We found no differences in the Bayley Scales of Infant Development (BSID) scores between the DCC and ICC groups. However, a regression model of effects of DCC on motor scores controlling for gestational age, IVH, bronchopulmonary dysplasia, sepsis and male gender suggested higher motor scores of male infants with DCC.
DCC at birth seems to be protective of very low birth weight male infants against motor disability at 7 months corrected age.
To investigate the effects of umbilical cord milking on cardiopulmonary adaptation in very low birth weight infants.
This study was the secondary analysis of a randomised control study of the effect of umbilical cord milking in premature infants. Forty singleton infants born between 24 and 28 weeks' gestation were randomly assigned to groups in which the umbilical cord was clamped either immediately after birth (control group, n = 20) or after umbilical cord milking (milked group, n = 20). Blood pressure, heart rate, urine output, fluid intake, and ventilatory index values in both groups were measured during the first 120 h after birth.
There were no significant differences in gestational age or birth weight between the two groups. The initial haemoglobin value was higher in the milked group (mean (SD) 16.5 (1.4) g/dl in the milked vs 14.1 (1.6) g/dl in the control; p<0.01). During the first 12 h, blood pressure was significantly higher in the milked group. Urine output in the milked group was higher than that in the control group during the first 72 h. There were no significant differences in heart rate, water intake, or ventilatory index values between the groups.
Umbilical cord milking may facilitate early stabilisation of both blood pressure and urine output in very low birth weight infants.
Very-low-birth-weight (VLBW) infants often require blood transfusions for anemia. Studies have investigated the preventative effect of delayed cord clamping, high-dose iron, and costly recombinant erythropoietin. As part of our unit clinical governance framework to improving patient care, we audited the effect of a preventative management guideline that combines delayed cord clamping for 30 seconds with early protein intake and early oral iron supplementation (6 mg/kg from days 7 to 10 of life, if milk feeds 60 mL/kg/d) combined with a restrictive transfusion policy in infants < 32 weeks' gestation and < 1500 g birth weight. Data on blood transfusions in VLBW infants during the first 6 weeks of life collected before the start of the new regimen (period I) were compared with data in consecutively born VLBW infants after the introduction of the management guideline (period II). Age (in days) when milk feeds and oral iron supplements were introduced was recorded. Statistical analysis used Wilcoxon signed-rank test. VLBW infants in period I ( N = 18, median birth weight 1001 g [727; 1158]) received a median of four transfusions (0.75; 9) compared with 1.5 (0.75; 5, P = 0.01) VLBW infant transfusions in period II ( N = 22, median birth weight 967 g [792; 1131]). Milk feeds of 60 mL/kg/d were achieved on median day 12 (6; to 16), and iron was introduced on median day 38 (21; to 44) in period I compared with milk feeds on day 9 (7; 15, P = 0.05) and oral iron on day 16 (11; 21, P < 0001) in period II. The combination of a 30-second delay in cord clamping, early protein and iron, and a change of transfusion thresholds reduced the number of blood transfusions by half.
We have performed brain scanning by computed tomography on 46 consecutive live-born infants whose birth weights were less than 1,500 gm; 20 of them had evidence of cerebral intraventricular hemorrhage. Nine of the 29 infants who survived had IVH. Four grades of IVH were identified. Grade I and II lesions resolved spontaneously, but there was prominence of the interhemispheric fissue on CT of the infants at six months of age. Hydrocephalus developed in infants with Grade III and IV lesions. Seven of the surviving infants with IVH did not have clinical evidence of hemorrhage. There were no significant differences between the infants with and without IVH in birth weight, gestational age, one- and five-minute Apgar scores, or the need for resuscitation at birth or for subsequent respiratory assistance.
A method of clinical staging for infants with necrotizing enterocolitis (NEC) is proposed. On the basis of assigned stage at the time of diagnosis, 48 infants were treated with graded intervention. For Stage I infants, vigorous diagnostic and supportive measures are appropriate. Stage II infants are treated medically, including parenteral and gavage aminoglycoside antibiotic, and Stage III patients require operation. All Stage I patients survived, and 32 of 38 Stage II and III patients (85%) survived the acute episode of NEC. Bacteriologic evaluation of the gastrointestinal microflora in these neonates has revealed a wide range of enteric organisms including anaerobes. Enteric organisms were cultured from the blood of four infants dying of NEC. Sequential cultures of enteric organisms reveal an alteration of flora during gavage antibiotic therapy. These studies support the use of combination antimicrobial therapy in the treatment of infants with NEC.
S ummary Peripheral haematocrit (PCV) is the traditional target and monitor in many transfusion regimens. Without negating the importance of PCV as a determinant of whole blood viscosity, the present article outlines two important reasons why the red cell volume (RCV) should replace PCV in the central target role during blood transfusion in intensive care and other emergency situations:
1. PCV reflects both RCV and plasma volume (PV) and is therefore not directly proportional to the total blood oxygen carrying capacity. At best, the relationship between PCV and RCV is hyperbolic and this is often overlooked when relating the two parameters in practice. At worst, the hyperbolic relationship is unreliable because PV and RCV can vary independently and the PCV is a fluctuating ratio of variable numbers.
2. PCV is not a good indicator of blood volume (BV), which is another important determinant of oxygen delivery to tissues and a crucial parameter in intensively managed patients. BV is directly proportional to RCV and this relationship also is often overlooked in clinical practice.
The recommended values for RCV are 30 ml/kg in men, 25 ml/kg in women and between 30 ml/kg and 45 ml/kg in neonates within the first week of life.
To assess: (i) the size of placental transfusion following a 30 s delay in cord clamping following vaginal and Caesarean births; and (ii) the feasibility of delaying cord clamping in the labour ward and particularly in the operating theatre.
Fourty-six infants born at 26-33 weeks gestation were randomized to having the umbilical cord clamped either immediately or 30 s after birth. The venous haematocrit was measured at 1 and at 4 h of age.
There were trends towards higher mean haematocrits in the infants following delayed clamping, but these were not significant either at 1 h (55 +/- 7.7 vs 52.9 +/- 7) or at 4 h of age (55 +/- 7 vs 52.5 +/- 7). The trends were more marked in the infants born by Caesarean section, and in those born at 26-29 weeks gestation.
A 30 s delay in cord clamping is feasible at both vaginal and Caesarean births, but does not lead to the predicted difference in infant haematocrit. Although physiological studies suggest that a placental transfusion of 15-20 mL/kg occurs within 30 s of delivery, these data suggest that future trials should either delay cord clamping for more than 30 s, or should alter the position of the infant in relation to the uterus in order to facilitate the transfusion. Delayed cord clamping is feasible at Caesarean section.
Almost 65% of all premature neonates with a birth weight <1,500 g receive at least one erythrocyte transfusion during their first weeks of life. In the present study, we examined the feasibility of autologous transfusions in neonates, using placental blood. Placental blood was obtained from 131 of 141 preterm and term infants using a special placental blood collecting system. Approximately 20 ml of placental blood per kilogram body weight could be harvested, irrespective of birth weight. One placental blood sample was contaminated with maternal erythrocytes; aerobe or anaerobe contamination was observed in any of the stored placental blood products (n = 119) after 35 days of storage. 19 of the 141 newborns needed allogeneic erythrocyte transfusions during the first 12 weeks of life. In 5 of these 19 patients, the amount of placental blood collected would have been enough to dispense with further allogeneic blood transfusions. After completion of the preclinical study, we transfused a total of 22 children, using autologous placental blood. 8 of the 10 infants with a birth weight between 1,000 and 2,000 g and 3 of 5 infants requiring surgical intervention directly after birth needed no further allogeneic blood transfusions. We, therefore, conclude that the collection and preparation of placental blood is feasible for clinical use. The target groups of neonates who are most likely to benefit are infants with a birth weight between 1,000 and 2,000 g and neonates requiring surgical intervention directly after birth.
This study compared the effects of immediate (ICC) and delayed (DCC) cord clamping on very low birth weight (VLBW) infants on 2 primary variables: bronchopulmonary dysplasia (BPD) and suspected necrotizing enterocolitis (SNEC). Other outcome variables were late-onset sepsis (LOS) and intraventricular hemorrhage (IVH).
This was a randomized, controlled unmasked trial in which women in labor with singleton fetuses <32 weeks' gestation were randomly assigned to ICC (cord clamped at 5-10 seconds) or DCC (30-45 seconds) groups. Women were excluded for the following reasons: their obstetrician refused to participate, major congenital anomalies, multiple gestations, intent to withhold care, severe maternal illnesses, placenta abruption or previa, or rapid delivery after admission.
Seventy-two mother/infant pairs were randomized. Infants in the ICC and DCC groups weighed 1151 and 1175 g, and mean gestational ages were 28.2 and 28.3 weeks, respectively. Analyses revealed no difference in maternal and infant demographic, clinical, and safety variables. There were no differences in the incidence of our primary outcomes (BPD and suspected NEC). However, significant differences were found between the ICC and DCC groups in the rates of IVH and LOS. Two of the 23 male infants in the DCC group had IVH versus 8 of the 19 in the ICC group. No cases of sepsis occurred in the 23 boys in the DCC group, whereas 6 of the 19 boys in the ICC group had confirmed sepsis. There was a trend toward higher initial hematocrit in the infants in the DCC group.
Delayed cord clamping seems to protect VLBW infants from IVH and LOS, especially for male infants.
To determine whether extremely low birth weight infants (ELBW) transfused at lower hemoglobin thresholds versus higher thresholds have different rates of survival or morbidity at discharge.
Infants weighing <1000 g birth weight were randomly assigned within 48 hours of birth to a transfusion algorithm of either low or high hemoglobin transfusion thresholds. The composite primary outcome was death before home discharge or survival with any of either severe retinopathy, bronchopulmonary dysplasia, or brain injury on cranial ultrasound. Morbidity outcomes were assessed, blinded to allocation.
Four hundred fifty-one infants were randomly assigned to low (n = 223) or high (n = 228) hemoglobin thresholds. Groups were similar, with mean birth weight of 770 g and gestational age of 26 weeks. Fewer infants received one or more transfusions in the low threshold group (89% low versus 95% high, P = .037). Rates of the primary outcome were 74.0% in the low threshold group and 69.7% in the high (P = .25; risk difference, 2.7%; 95% CI -3.7% to 9.2%). There were no statistically significant differences between groups in any secondary outcome.
In extremely low birth weight infants, maintaining a higher hemoglobin level results in more infants receiving transfusions but confers little evidence of benefit.
To investigate the effects of umbilical cord milking on the need for red blood cell (RBC) transfusion and morbidity in very preterm infants.
40 singleton infants born between 24 and 28 weeks' gestation were randomly assigned to receive umbilical cord clamped either immediately (control group, n = 20) or after umbilical cord milking (milked group, n = 20). Primary outcome measures were the probability of not needing transfusion, determined by Kaplan-Meier analysis, and the total number of RBC transfusions. Secondary outcome variables were haemoglobin value and blood pressure at admission.
There were no significant differences in gestational age and birth weight between the two groups. The milked group was more likely not to have needed red cell transfusion (p = 0.02) and had a decreased number (mean (SD)) of RBC transfusions (milked group 1.7 (3.0) vs controls 4.0 (4.2); p = 0.02). The initial mean (SD) haemoglobin value was higher in the milked group (165 (14) g/l) than in the controls (141 (16) g/l); p<0.01). Mean (SD) blood pressure at admission was significantly higher in the milked group (34 (9) mm Hg) than in the controls 28 (8) mm Hg; p = 0.03). There was no significant difference in mortality between the groups. The milked group had a shorter duration of ventilation or supplemental oxygen than the control group.
Milking the umbilical cord is a safe procedure, reducing the need for RBC transfusions, and the need for circulatory and respiratory support in very preterm infants.
Most neonates less than 1.0 kg birth weight need red blood cell (RBC) transfusions. Delayed clamping of the umbilical cord 1 minute after delivery transfuses the neonate with autologous placental blood to expand blood volume and provide 60 percent more RBCs than after immediate clamping. This study compared hematologic and clinical effects of delayed versus immediate cord clamping.
After parental consent, neonates not more than 36 weeks' gestation were randomly assigned to cord clamping immediately or at 1 minute after delivery. The primary endpoint was an increase in RBC volume/mass, per biotin labeling, after delayed clamping. Secondary endpoints were multiple clinical and laboratory comparisons over the first 28 days including Score for Neonatal Acute Physiology (SNAP).
Problems with delayed clamping techniques prevented study of neonates of less than 30 weeks' gestation, and 105 neonates 30 to 36 weeks are reported. Circulating RBC volume/mass increased (p = 0.04) and weekly hematocrit (Hct) values were higher (p < 0.005) after delayed clamping. Higher Hct values did not lead to fewer RBC transfusions (p > or = 0.70). Apgar scores after birth and daily SNAP scores were not significantly different (p > or = 0.22). Requirements for mechanical ventilation with oxygen were similar. More (p = 0.03) neonates needed phototherapy after delayed clamping, but initial bilirubin levels and extent of phototherapy did not differ.
Although a 1-minute delay in cord clamping significantly increased RBC volume/mass and Hct, clinical benefits were modest. Clinically significant adverse effects were not detected. Consider a 1-minute delay in cord clamping to increase RBC volume/mass and RBC iron, for neonates 30 to 36 weeks' gestation, who do not need immediate resuscitation.
Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm
- L A Papile
- J Burstein
- R Burstein
- H Koffler
Papile LA, Burstein J, Burstein R, Koffler H. Incidence and
evolution of subependymal and intraventricular hemorrhage: a
study of infants with birth weights less than 1,500 gm. J Pediatr
1978;92:529 -34.
Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm.
- Papile