Immediate Cord Clamping Group Research Articles

Effect of delayed cord clamping on cerebral hemodynamics in preterm infants

BackgroundUnstable cerebral hemodynamics is an important cause of intracranial hemorrhage in premature infants. The increased blood flow of delayed cord clamping (DCC) compared to immediate cord clamping (ICC) is equivalent to 1/3-1/4 of newborn blood volume. Our objective was to assess whether the increased blood flow causes fluctuations in cerebral blood flow and how. MethodsThis experiment was a prospective, observational study. Neonatologists selected preterm infants eligible for inclusion and exclusion, and divided them into DCC group and ICC group according to the way of umbilical cord ligation performed by obstetrics department, and matched them 1:1 according to gestational age. The peak systolic velocity （PSV) ，end diastolic velocity (EDV)，and resistance index (RI) of middle cerebral artery was measured by Mindray M9 color ultrasonic diagnostic instrument within 1 h, 24±1 h, 48±1 h, 72±1 h, respectively. ResultsThere was no significant difference in PSV, EDV and RI in middle cerebral artery between DCC group and ICC group (P > 0.05). There were no significant differences between groups and time (P > 0.05). The hemoglobin and hematocrit in DCC group were higher than those in ICC group within 2 h after birth (P < 0.05). (P > 0.05). ConclusionDCC can increase hemoglobin and hematocrit in preterm infants, but does not cause cerebral blood flow fluctuation within a certain range. DCC is a safe method of placental transfusion.

Effect of delayed cord clamping on maternal and neonatal outcome in twin pregnancies: a retrospective cohort study

The objective of this study was to compare the maternal and neonatal outcomes following delayed cord clamping (DCC) versus immediate cord clamping (ICC) in twin pregnancies. This was a retrospective cohort study of 705 twin pregnancies who delivered at ≥ 24 weeks of gestation. Maternal and neonatal hemoglobin levels, blood transfusion, and neonatal outcomes were compared between DCC (n = 225) and ICC (n = 480) groups. Mean maternal predelivery and postpartum hemoglobin levels and the rate of postpartum hemoglobin drop ≥ 20% or maternal blood transfusion were comparable between the two groups. The DCC group had a significantly higher mean neonatal hemoglobin level (DCC vs. ICC: 17.4 ± 3.5 vs. 16.6 ± 2.7 g/dl, P = 0.010) but significantly lower rates of neonatal blood transfusion (DCC vs. ICC: 3.3% vs. 8.8%, P < 0.001) and respiratory distress syndrome (DCC vs. ICC: 6.7% vs. 15.2%, P < 0.001) than the ICC group. In conclusion, DCC compared with ICC in twin pregnancy was not associated with an increase of maternal postpartum bleeding complications, but it was associated with higher neonatal hemoglobin level and lower risks of neonatal blood transfusion and respiratory distress syndrome.

Effect of Novel Placental Transfusion Technique—Gravity-Aided Cord Blood Transfusion at Birth on Hemoglobin Levels in Preterm Infants Born Less than 30 Weeks: A Randomized Controlled Trial

Introduction Delayed cord clamping (DCC) is considered standard of practice in very preterm deliveries but could not be practiced in more than 50%, as they need resuscitation measures. We studied the effect of a novel technique of placental transfusion, gravity aided cord blood transfusion (GCT) in comparison to standard care in preterm &lt;30 weeks of gestation on hemoglobin levels at 24 hours of life. Methods This randomized noninferiority trial was conducted in a tertiary care unit from September 2020 to June 2021 in South India. Preterm infants with gestational age (GA) &lt;30 weeks were randomized to either GCT or standard care. GCT was performed by clamping the cord with maximal length immediately after birth, shifting the baby to radiant warmer and holding the whole length of the umbilical cord attached to the baby vertically upwards, allowing blood to drain by gravity while the steps of resuscitation were being performed simultaneously. Standard care was either DCC in vigorous babies and immediate cord clamping (ICC) in nonvigorous babies. Primary outcome was hemoglobin levels at 24 hours of birth. The study was terminated in view of slow recruitment due to covid pandemic. Results Twenty two babies were included. Nine babies were in the GCT group. The median (IQR) hemoglobin at 24 hours of life was 16.9 (16.3-18.9) in the GCT group and 16.4 (14.8-17.8) in standard care; the difference was not statistically significant ( P = .4). Higher hemoglobin at 24 hours of life was observed in GCT group with median (IQR) of 16.9 (16.3-18.9) compared to the ICC group with median (IQR) of 15.55 (14.5-17.1), though not statistically significant ( P = .095). Conclusion The novel placental transfusion strategy, namely GCT, is feasible in preterm neonates. Hemoglobin level at 24 hours was not significantly different between GCT and standard care groups. There is a need for large RCT to assess the effect of GCT on other important clinical outcomes in preterm neonates.

Delayed versus immediate cord clamping in dichorionic twins

Objectives Strong evidence imply that delayed cord clamping (DCC) provides significant benefits for singleton neonates. However, there is little information about the safety or efficacy of DCC in twins to recommend for or against DCC in twins in guidelines. We aimed to determine the effect of DCC on dichorionic twins born at <32 weeks of gestation. Study design This is a retrospective cohort study comparing the neonatal and maternal outcomes of immediate cord clamping (ICC) [<15 second (s)] versus DCC (at 60 s). Generalized estimating equations models were performed accounting for twin correlation. Results A total of 82 pairs of twins (DCC: 41; ICC: 41) were included in analysis. The primary outcome of death before discharge occurred in 3.66% of twins in the DCC group and 7.32% in the ICC group, without a significant difference between the groups. Compared to ICC group, DCC was associated with increased hemoglobin levels [β1 coefficient 6.51; 95% confidence interval (CI) 0.69–12.32. β2 coefficient 5.80; 95% CI 0.07–11.54] at 12–24 h of life. There were no significant differences between the groups in neonatal death, neonatal major morbidities and maternal bleeding complications, although DCC was associated with higher estimated maternal blood loss in the cesarean section group (p = .005). Conclusions DCC for 60 s in dichorionic twins born at <32 weeks of gestation was associated with increased neonatal hemoglobin levels, when compared with ICC. The finding of a higher estimated maternal blood loss by cesarean section in the DCC group calls for further trials to assess maternal safety of this procedure in this patient population.

Different Placental Transfusion Strategies and Their Effects on Short - Term Hematological Parameters in Term Infants

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 &lt; 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 &lt; 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.

Effects of Umbilical Cord Management Strategies on Stem Cell Transfusion, Delivery Room Adaptation, and Cerebral Oxygenation in Term and Late Preterm Infants.

Background:The umbilical cord blood contains a high concentration of stem cells. There is not any published study evaluating the amount of stem cells that have the potential to be transferred to the infant through placental transfusion methods as delayed cord clamping (DCC) and umbilical cord milking (UCM). The aim of this study is to measure the concentrations of endothelial progenitor cell (EPC) and CD34+ hematopoietic stem cell (HSC) in the placental residual blood volume (PRBV), and evaluate the delivery room adaptation and cerebral oxygenation of these infants.MethodsInfants with ≥36 gestational weeks were randomized to receive DCC (120 s), UCM, or immediate cord clamping (ICC). EPC and CD34+ HSC were measured by flow cytometry from the cord blood. PRBV was collected in the setup. The cord blood gas analysis and complete blood count were performed. The heart rate (HR), oxygen saturation (SpO2), and cerebral regional oxygen saturation (crSO2) were recorded.ResultsA total of 103 infants were evaluated. The amount of PRBV (in ml and ml/kg) was higher in the ICC group (p < 0.001). The number of EPCs in the PRBV content (both ml and ml/kg) were the highest in the ICC group (p = 0.002 and p = 0.001, respectively). The number of CD34+ HSCs in PRBV content (ml and ml/kg) was similar in all groups, but nonsignificantly higher in the ICC group. The APGAR scores at the first and fifth min were lower in the ICC group (p < 0.05). The mean crSO2 values were higher at the 3rd and 10th min in the DCC group (p = 0.042 and p = 0.045, respectively). cFOE values were higher at the 3rd and 10th min in the ICC group (p = 0.011 and p < 0.001, respectively).ConclusionThis study showed that placental transfusion methods, such as DCC and UCM, provide both higher blood volume, more stem cells transfer to the infant, and better cerebral oxygenation in the first minutes of life, whereas many lineages of stem cells is lost to the placenta by ICC with higher residual blood volume. These cord management methods rather than ICC do not require any cost or technology, and may be a preemptive therapeutic source for diseases of the neonatal period.

The haemodynamic effects of umbilical cord milking in term infants: a randomised controlled trial.

Umbilical cord milking (UCM) is a method that allows for postnatal placental transfusion. The benefits of UCM have been demonstrated in some studies, but knowledge about its haemodynamic effects in term infants is limited. The aim of this study was to evaluate the haemodynamic effects of UCM in term infants. In this prospective, randomised controlled study, 149 healthy term infants with a birth week of ≥37 weeks were randomly assigned to either the UCM or immediate cord clamping (ICC) group. Blinded echocardiographic evaluations were performed in all the neonates in the first 2-6 h. Superior vena cava (SVC) flow measurements were higher in the UCM group compared to the ICC group (132.47 ± 37.0 vs. 126.62 ± 34.3 mL/kg/min), but this difference was not statistically significant. Left atrial diameter (12.23 ± 1.99 vs. 11.43 ± 1.78 mm) and left atrium-to-aorta diastolic diameter ratio (1.62 ± 0.24 vs. 1.51 ± 0.22) were significantly higher in the UCM group. There were no significant differences in other echocardiographic parameters between the two groups. We found no significant difference in the SVC flow measurements in term infants who underwent UCM versus those who underwent ICC. This lack of significant difference in SVC flow may be explained by the mature cerebral autoregulation mechanism in term neonates.

Effect of later cord clamping on umbilical cord blood gas in term neonates of diabetic mothers: a randomized clinical trial

ObjectiveTo evaluate the effect of later cord clamping (LCC) on umbilical arterial blood gas in neonates of diabetic mothers.MethodsThis prospective study included a group of 160 diabetic mothers (DM) whose neonates were randomized to immediate cord clamping (ICC) (≤ 15 s after birth) or LCC (≥ 30 s after birth), and a group of 208 non-diabetic mothers (NDM) whose neonates were randomized to ICC or LCC as a reference. Cord arterial pH, base excess (BE), bicarbonate (HCO3−), partial pressure of carbon dioxide (pCO2), partial pressure of oxygen (pO2), lactate, hemoglobin, hematocrit and glucose were compared among groups.ResultsIn neonates of DM, there was no significant difference in cord arterial pH between the ICC and LCC group. LCC of ≥ 30 s decreased umbilical arterial HCO3− and BE and increased lactate (ICC versus LCC, HCO3−: 24.3 (22.7, 25.8) versus 23.7 (22.3, 24.7) mmol/L, P = 0.01; BE: -2.70 (-4.80, -1.50) versus − 3.72 (-5.66, -2.36) mmol/L, P = 0.006; lactate: 2.1 (1.6, 3.7) versus 2.7 (2.1, 4.3) mmol/L, P = 0.005), without the alterations of pCO2, pO2, hemoglobin, hematocrit and glucose. Similar results were found in neonates of NDM (ICC versus LCC, HCO3−: 24.3 (23.1, 25.7) versus 23.5 (22.3, 24.8) mmol/L, P = 0.01; BE: -2.39 (-3.73, -1.51) versus − 3.40 (-4.73, -1.91) mmol/L, P = 0.001; lactate: 2.2 (1.9, 3.3) versus 2.5 (2.0, 4.3) mmol/L, P = 0.01), except for the higher level of hemoglobin in the LCC group. The majority of diabetic mothers (ICC: 92.0%; LCC: 91.8%) had good blood glucose control. No differences were observed in acid-base status and glucose between neonates of DM and neonates of NDM in both ICC and LCC, but hemoglobin and hematocrit were elevated after ICC in neonates of DM compared to neonates of NDM.ConclusionsLater cord clamping of ≥ 30 s resulted in a tendency towards metabolic acidosis of umbilical arterial blood in neonates of DM and NDM. Umbilical arterial blood gas parameters at birth were similar in neonates of DM and NDM.Trial registrationClinicalTrials.gov: NCT04369313; date of registration: 30/04/2020 (retrospectively registered).

The effects of placental transfusion on mothers

Objective While there is ample evidence supporting delayed cord clamping (DCC) in neonates, the data on the maternal outcomes related to DCC are relatively sparse. Moreover, the outcomes, such as postpartum hemorrhage (PPH), were mostly reported for uncomplicated term vaginal deliveries. The objective of this study was to present the two primary maternal outcomes, incidence of PPH and change in hematocrit pre- and post-delivery in complex situations of preterm deliveries and term cesarean sections. Study design Maternal data were collected prospectively since the placental transfusion process was implemented in a step-wise fashion in our delivery hospitals, starting August, 2013. These data on very preterm singleton, moderate preterm, very preterm twin gestation, late preterm deliveries and term cesarean sections with DCC or umbilical cord milking (UCM) were compared with respective retrospective cohorts of deliveries in which immediate cord clamping (ICC) was performed. Results Comparing very preterm singleton deliveries, the incidence of PPH was similar between the ICC and DCC groups (2.3% vs. 1.7%). There was no significant difference in mean hematocrit change pre- and postdelivery (3.06 ± 1.32 vs. 3.47 ± 1.52). When 45 s DCC cohort was compared with 60 s DCC cohort, there were no significant differences in the incidence of PPH (1.7% vs. 4.8%) or the hematocrit change pre- and postdelivery (3.47 ± 1.52 vs. 4.32 ± 1.88). PPH was not observed in either group when comparing retrospective ICC cohort with prospective DCC cohort with 60 s delay in very preterm twin gestation deliveries. There was no significant difference between the mean hematocrit change pre- and postdelivery (5.5 ± 3.3 vs. 5.8 ± 3.9). When moderate and early late preterm deliveries between 32° to 346 weeks of gestation were compared, there were no differences between the incidence of PPH (0.9% vs. 0%) or hematocrit change pre- and postdelivery (4.2 ± 2.3 vs. 4.8 ± 2.9). Comparing late preterm deliveries between 35° and 366 weeks of gestation, there was no significant difference in the incidence of PPH (13% vs. 11.4%) or the mean hematocrit change pre- and postdelivery (5.0 ± 3.0 vs. 5.1 ± 2.8). In term cesarean deliveries, the incidence of PPH was 2.2% in the retrospective ICC group and 1.4% in the prospective UCM group. There was no difference in mean hematocrit change pre- and postdelivery (5.9 ± 3.7 vs. 6.2 ± 2.8). Conclusion DCC or UCM was not associated with the increased risk for PPH or significant change in maternal hematocrit pre- and postdelivery in very preterm singleton, moderate preterm, very preterm twin gestation, late preterm deliveries and term cesarean sections.

Umbilical Cord Milking in Late Preterm Neonates and its Effects on Haematological and Haemodynamical ParametersA Randomised Controlled Study

Introduction: Delayed Cord Clamping (DCC) is a procedure, in which the cord is clamped after a short delay (30s to 180s) after birth. This improves iron status, reduce chances of anaemia and need for blood transfusion. However, DCC method compromised the success of resuscitation and induced various consequences, especially in neonates in need of emergency resuscitation. Umbilical Cord Milking (UCM), which is likewise a procedure of transporting additional blood from the umbilical cord to the newborn by milking or stripping the umbilical cord toward the baby, is an alternative to this approach. This study was conducted due to a lack of data on the use of umbilical cord milking in late preterm newborns. Aim: To study the effect of UCM on haematological and haemodynamical parameters in late preterm neonates. Materials and Methods: This single centre randomised controlled study was conducted, from November 2017 to August 2019 in the Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India. Total 200 late preterm neonates fulfilling the inclusion criteria were randomised into cases (UCM group) and controls (Immediate cord clamping group). In UCM group, just after delivery, umbilical cord was milked towards the baby. In ICC group, cord was clamped and cut immediately. Primary outcomes included Haemoglobin (Hb), Haematocrit (Hct) and haemodynamic parameters (heart rate, respiratory rate and mean blood pressure), were noted at 48 hours of age. Clinical parameters (respiratory distress, need for oxygen, polycythemia and jaundice requiring phototherapy) were also noted. Student's t-test, Chi-square/fisher-exact test were used to find out the significance of study parameters. Results: There was a significant higher Hb in UCM group (19.27±2.64 gm/dL) than Immediate Cord Clamping (ICC) group (16.32±2.09 gm/dL) with p-value=0.012 and higher Hct in UCM group (55.41±5.07%) than the ICC group (48.99±5.57%) with a p-value &lt;0.001. Hence, there was higher placental transfusion in UCM group as shown by higher Hb and Hct in UCM group. There was also higher systolic, diastolic and mean blood pressure in the UCM group as compared to ICC group. Difference for mean arterial blood pressure was about 3 mmHg and was statistically significant (p-value &lt;0.001). Hence, UCM leads to a higher mean arterial pressure at 48 hours of life. Conclusion: Umbilical cord milking provides a greater placental transfusion, as demonstrated by higher Hb, higher Hct, higher blood pressure, and lesser requirement for inotropes and blood transfusions.

A 20-cm cut umbilical cord milking may not benefit the preterm infants < 30 week's gestation: A randomized clinical trial

To evaluate whether a shorter length (20cm) of C-UCM has potential benefits, compared to immediate cord clamping (ICC), in very preterm babies. Inborn preterm infants less than 30 weeks of gestational age (GA) were randomly assigned to the 20-cm C-UMC and ICC groups. The primary outcome was the need for packed red blood cell (pRBC) transfusion before the 21st day of life. The secondary outcomes were short- and long-term outcomes related to premature birth. Seventy-six neonates were randomized to the two groups. GA were 27.2±1.8 and 27.5±1.7 weeks (p=0.389) and birth weights were 987±269 and 1023±313g (p=0.601) in the 20-cm C-UCM and ICC groups, respectively. There was no significant difference between the groups in terms of the need for pRBC transfusion before the 21st day of life (59.4% versus 71.8%, adjusted odds ratio [aOR] 0.311, 95% confidence interval [CI] 0.090-1.079). An increased prevalence of late-onset sepsis was observed in the 20-cm C-UCM group compared to the ICC group (21.6% versus 5.1%, aOR 5.434, 95% CI 1.033-23.580). The mortality rates were 13.5% and 2.6% in the 20-cm C-UCM and ICC groups, respectively (aOR 5.339, 95% CI 0.563-50.626). The neurodevelopmental outcomes at 2 years of corrected age between the groups were also not statistically significant. A 20-cm C-UCM showed no effect on reducing the incidence of pRBC transfusion in preterm babies with GA less than 30 weeks compared with ICC in this small-scale randomized controlled trial.

Umbilical Cord Management in Late Preterm and Term Infants: A Randomized Controlled Trial

The study aimed to compare the effects of three different methods of umbilical cord management on hematological parameters in term and late-preterm infants. A randomized controlled trial comparing intact-umbilical cord milking (I-UCM) with cut-umbilical cord milking (C-UCM) and immediate cord clamping (ICC) in neonates born >35 weeks' gestation. A total of 587 infants were evaluated. Of these, 197 were assigned to I-UCM, 190 to C-UCM, and 200 to ICC. Mean hemoglobin and hematocrit levels at 48 hours of age were higher in I-UCM group compared with the ICC group (p = 0.002 and p = 0.010, respectively). These findings suggest that I-UCM is more beneficial choice. Further trials are needed to assess the various long- and short-term effects of different cord milking methods. · This is the first study comparing these three methods (I-UCM, C-UCM, and ICC) concurrently.. · I-UCM is more beneficial choice.. · Although the terms I-UCM and C-UCM are often used interchangeably, these are different procedures..

Delayed cord clamping for prevention of intraventricular hemorrhage in preterm neonates: a randomized control trial

Background Intraventricular hemorrhage (IVH) is a common condition in preterm neonates and is responsible for substantial adverse neurodevelopmental outcome in preterm neonates. Prevention of IVH is an important intervention for better neurological outcome in these preterm neonates. Aims and objective This study aimed to determine whether delayed cord clamping (DCC) was superior to immediate cord clamping (ICC) for the prevention of IVH in preterm neonates. Patients and methods In this two centered prospective double-blind randomized controlled trial, eligible neonates with gestational age from 26 to 34 weeks were randomized to receive either ICC (cord clamped in 10–15 s) or DCC (cord clamped in 30–45 s) groups. The grading and severity of IVH were evaluated by cranial ultrasound scan done on the 3–4th and 7–10th days after birth. Results Among the 148 enrolled neonates, 79 were in the ICC group and 69 were in the DCC group. There was no difference in maternal and neonatal baseline characteristics except the neonates in the DCC group weighed more (ICC 1528.77 ± 365.5 g vs. DCC 1658.11 ± 419.52 g; p = .047) at birth. There was no significant difference in the incidence of any grade of IVH in both groups (ICC 12.8% vs. DCC 14.5%; p = .745). There was a significantly higher incidence of grade I IVH (ICC 2.5% vs. DCC 13%; p = .024) in the DCC group. The incidence of grade II IVH (ICC 5.1% vs. DCC 0%; p = .123); grade III IVH (ICC 3.8% vs. DCC 1.4%; p = .623); and grade IV IVH (ICC 1.3% vs. DCC 0%; p>.999) were comparable between the two groups. The incidence of a significant IVH (grades II, III, and IV) was significantly less in the DCC group (ICC 10.1% vs. DCC 1.4%, p = .036). The mean initial hemoglobin levels were significantly higher in neonates enrolled in DCC (15.41 ± 2.1 vs. 16.46 ± 2.45 g/dL; p = .007). There was a significant reduction in the number of days of hospital stay (ICC 18.78 ± 15.42 vs. DCC 13.21 ± 16.16; p = .002). There was no difference in initial hematocrit, platelet count, maximum bilirubin level, and Apgar score (p>.05). Conclusions Although there was no reduction in any grade of IVH, the incidence of significant IVH (grades II, III, and IV) was significantly decreased with the use of DCC in preterm neonates. Delayed cord clamping also resulted in a significant increase in birth weight, higher hemoglobin levels, and shorter hospital stays without any increase in the risks of hyper-bilirubinemia, low Apgar score, and neonatal mortality. Trial registry IRCT2014031116936N1, https://www.irct.ir/trial/15707.

Umbilical Cord Milking in Extremely Preterm Infants: A Randomized Controlled Trial Comparing Cord Milking with Immediate Cord Clamping.

This study aimed to assess potential benefits of umbilical cord milking (UCM) when compared with immediate cord clamping (ICC) in extremely preterm infants. This is a single-center, randomized controlled trial of infants 240/7 to 276/7 weeks' gestation who received UCM versus ICC. In the experimental group, 18 cm of the umbilical cord was milked three times. The primary aim was to assess the initial hemoglobin and to assess the number of blood transfusions received in the first 28 days after birth. Secondary outcomes were also assessed, including intraventricular hemorrhage (IVH). A priori, neurodevelopmental follow-up was planned at 15 to 18 months corrected gestational age (CGA). Baseline characteristics for 56 enrolled infants were similar in both groups with a mean gestational age of 26.1 ± 1.2 weeks and a mean birth weight of 815 ± 204 g. There were no differences in the mean initial hemoglobin in the UCM group when compared with the ICC group, 13.7 ± 2.0 and 13.8 ± 2.6 g/dL, respectively (p = 0.95), with no differences in median number of blood transfusions after birth between the ICC group and the UCM group, 2 (interquartile range [IQR]: 1-4) versus 2.5 (IQR: 1-5) (p = 0.40). There was also no difference in the rate of severe IVH. At 15 to 18 months CGA, there were no differences in death or disability in the ICC group compared with the UCM group (26 vs. 22%; p = 1.0) and no differences in neurodevelopmental outcomes. In a randomized trial of ICC versus UCM in extremely preterm infants, no differences were seen in initial hemoglobin or number of blood transfusions. · Umbilical cord milking may be an alternative to delayed cord clamping, but its safety and efficacy are not established in extremely premature infants.. · There are minimal available published data on the longer term neurodevelopmental outcomes in extremely premature infants who receive umbilical cord milking compared with immediate clamping.. · We did not find a significant difference in the primary outcomes of initial hemoglobin and blood transfusions between the groups, nor did we find a difference in severe IVH with umbilical cord milking..

Cardiopulmonary Resuscitation of Asystolic Newborn Lambs Prior to Umbilical Cord Clamping; the Timing of Cord Clamping Matters!

Background: Current guidelines recommend immediate umbilical cord clamping (UCC) for newborns requiring chest compressions (CCs). Physiological-based cord clamping (PBCC), defined as delaying UCC until after lung aeration, has advantages over immediate UCC in mildly asphyxiated newborns, but its efficacy in asystolic newborns requiring CC is unknown. The aim of this study was to compare the cardiovascular response to CCs given prior to or after UCC in asystolic near-term lambs. Methods: Umbilical, carotid, pulmonary, and femoral arterial flows and pressures as well as systemic and cerebral oxygenation were measured in near-term sheep fetuses [139 ± 2 (SD) days gestation]. Fetal asphyxia was induced until asystole ensued, whereupon lambs received ventilation and CC before (PBCC; n = 16) or after (n = 12) UCC. Epinephrine was administered 1 min after ventilation onset and in 3-min intervals thereafter. The PBCC group was further separated into UCC at either 1 min (PBCC1, n = 8) or 10 min (PBCC10, n = 8) after return of spontaneous circulation (ROSC). Lambs were maintained for a further 30 min after ROSC. Results: The duration of CCs received and number of epinephrine doses required to obtain ROSC were similar between groups. After ROSC, we found no physiological benefits if UCC was delayed for 1 min compared to immediate cord clamping (ICC). However, if UCC was delayed for 10 min after ROSC, we found significant reductions in post-asphyxial rebound hypertension, cerebral blood flow, and cerebral oxygenation. The prevention of the post-asphyxial rebound hypertension in the PBCC10 group occurred due to the contribution of the placental circulation to a low peripheral resistance. As a result, left and right ventricular outputs continued to perfuse the placenta and were evidenced by reduced mean pulmonary blood flow, persistence of right-to-left shunting across the ductus arteriosus, and persistence of umbilical arterial and venous blood flows. Conclusion: It is possible to obtain ROSC after CC while the umbilical cord remains intact. There were no adverse effects of PBCC compared to ICC; however, the physiological changes observed after ROSC in the ICC and early PBCC groups may result in additional cerebral injury. Prolonging UCC after ROSC may provide significant physiological benefits that may reduce the risk of harm to the cerebral circulation.

Umbilical Cord Clamping Timing in Preterm Infants Delivered by Cesarean Section

Background: The timing of umbilical cord clamping may affect the need to bloodtransfusion and other morbidities of preterm infants. This study aimed to compare three different cord clamping timing (immediate cord clamping, delayed cord clamping and umbilical cord milking) in preterm infants delivered by cesarean section (CS). Materials and Methods A controlled randomized clinical trial was done in preterm infants with gestation age less than 32 weeks delivered by CS in AlZahra hospital, Tabriz, Iran from June 2018 up to the end of January 2019. They were randomly allocated in three groups consisted of 30 neonates in each group. Umbilical cord was clamped within 10 seconds after infant delivery in immediate cord clamping (ICC) group, 60 seconds after delivery in delayed cord clamping (DCC) group. Cord was milked toward the infant three times over two seconds duration in umbilical cord milking (UCM) group. All patients were followed until discharge for needing the blood transfusion, bronchopulmonary dysplasia and mortality. Results: A total of 20 neonates of 90 studied neonates needed blood transfusion during hospital stay, of which, 4 neonates (13.3%) were in UCM group, 7 neonates (23.3%) in DCC group and 9 patients (30%) in ICC group (P= 0.27). The mean hemoglobin was significantly higher in UCM group at admission and 30 days after birth (P<0.05). Conclusion UCM may be as effective as DCC to increase hemoglobin in preterm infants delivered by CS. Although the hemoglobin of infants with DCC and UCM was significantly higher than infants with ICC, the rate of blood transfusion was not significantly decreased during hospital stay.

Effects of Umbilical Cord Milking on Term Infants Delivered by Cesarean Section.

Umbilical cord milking (UCM) is an efficient way to achieve optimal placental transfusion in term infants born by cesarean section (CS). However, it is not frequently performed due to concern for short-term adverse effects of increased blood volume, such as polycythemia and hyperbilirubinemia. The aim of this study is to evaluate the short-term effects of UCM on term infants delivered by CS. We conducted a pre- and postimplementation cohort study comparing term infants delivered by CS who received UCM five times (141 infants, UCM group) during a 6-month period (August 1, 2017 to January 31, 2018) to those who received immediate cord clamping (ICC) during the same time period (105 infants, postimplementation ICC) and during a 3-month period (October1, 2016 to December 31, 2016) prior to the implementation of UCM (141 infants, preimplementation ICC). Mothers were older in UCM group compared with both ICC groups. There were no significant differences in other maternal or neonatal characteristics. Although this study was not powered to detect differences in outcomes, the occurrence of hyperbilirubinemia needing phototherapy, symptomatic polycythemia, NICU admissions, or readmissions for phototherapy was similar between the groups. UCM intervention was not associated with increased incidence of phototherapy or symptomatic polycythemia in term infants delivered by CS.

The “DUC” trial: a pilot randomized controlled trial of immediate versus delayed cord clamping in preterm infants born between 24 and 32 weeks gestation

Purpose To determine the feasibility of a randomized controlled trial of delayed umbilical cord clamping in preterm infants. Methods Following informed consent, women between 24 to 32 weeks gestation experiencing imminent preterm birth were randomly assigned to either an immediate cord clamping (ICC) or delayed cord clamping (DCC) group. Umbilical cord clamping directions were 0–15 s for the ICC group and 30–45 s for the DCC group. Information regarding recruitment rate and trial compliance was collected. Neonatal outcomes of intraventricular hemorrhage (IVH), sepsis, anemia, and hyperbilirubinemia were also compared between the two groups. This trial was registered at https://clinicaltrials.gov/. (ClinicalTrials.gov Identifier: NCT00562536). Results Thirty-eight women were recruited in total, 19 each to the ICC and DCC groups respectively. The study recruitment rate was 33% and study compliance rate was 97%. The average time for cord clamping was 5.4 s in the ICC group and 39.7 s in the DCC group (p < .05). The incidence of IVH and sepsis was the same in both groups (16 and 11% respectively). Thirty-seven percent of the ICC group and 21% of the DCC group required a blood transfusion. Hyperbilirubinemia requiring phototherapy occurred in 37% of the ICC group and 26% of the DCC group. Conclusion This study demonstrates that a trial of a short delay in umbilical cord clamping (30–45 s) is feasible for women and physicians. Larger scale studies of long term outcomes are warranted.

Blunted sympathoadrenal activation accompanies hemodynamic stability after early ventilation and delayed cord clamping at birth in preterm lambs

As surges in circulating norepinephrine and epinephrine have chronotropic, pressor, and inotropic effects, we tested the hypothesis that blunted rises in these catecholamines during preterm birth accompanied hemodynamic stability observed after early ventilation and delayed cord clamping (DCC), with findings compared to immediate cord clamping (ICC) and a non-asphyxial cord clamp-to-ventilation interval. Anesthetized preterm fetal lambs were instrumented with arterial micromanometers to obtain pressure and the maximal rate of pressure rise (dP/dtmax) as a surrogate of ventricular contractility and an aortic catheter to obtain blood samples for catecholamine assay. Fetuses were delivered and mechanically ventilated before cord clamping ∼1.5 min later (DCC, n = 9) or subjected to ICC with ventilation started ∼40 s later (n = 8). Perinatal hemodynamics were stable after DCC, with greater fluctuations evident following birth after ICC (P ≤ 0.05). With DCC, circulating norepinephrine and epinephrine were unchanged after early ventilation but rose following cord clamping (P ≤ 0.01), with concentrations below the threshold for hemodynamic effects. Norepinephrine was higher in the ICC group after cord clamping and immediately after ventilation (P < 0.025), but catecholamine levels were otherwise similar between groups. Hemodynamic stability at birth after DCC is accompanied by sub-threshold rises in circulating norepinephrine and epinephrine and thus blunted sympathoadrenal activation.

Delayed cord clamping is associated with improved dynamic cerebral autoregulation and decreased incidence of intraventricular hemorrhage in preterm infants.

Delayed cord clamping (DCC) improves neurologic outcomes in preterm infants through a reduction in intraventricular hemorrhage (IVH) incidence. The mechanism behind this neuroprotective effect is not known. Infants born <28 wk gestation were recruited for longitudinal monitoring. All infants underwent 72 h of synchronized near-infrared spectroscopy (NIRS) and mean arterial blood pressure (MABP) recording within 24 h of birth. Infants with DCC were compared with control infants with immediate cord clamping (ICC), controlling for severity of illness [clinical risk index for babies (CRIB-II) score], chorioamnionitis, antenatal steroids, sedation, inotropes, and delivery mode. Autoregulatory dampening was calculated as the transfer function gain coefficient between the MABP and NIRS signals. Forty-five infants were included (DCC; n = 15, paired 2:1 with ICC controls n = 30). ICC and DCC groups were similar including gestational age (25.5 vs. 25.2 wk, P = 0.48), birth weight (852.3 vs. 816.6 g, P = 0.73), percent female (40 vs. 40%, P = 0.75), and dopamine usage (27 vs. 23%, P = 1.00). There was a significant difference in IVH incidence between the DCC and ICC groups (20 vs. 50%, P = 0.04). Mean MABP was not different (35.9 vs. 35.1 mmHg, P = 0.44). Compared with the DCC group, the ICC group had diminished autoregulatory dampening capacity (-12.96 vs. -15.06 dB, P = 0.01), which remained significant when controlling for confounders. Dampening capacity was, in turn, strongly associated with decreased risk of IVH (odds ratio = 0.14, P < 0.01). The results of this pilot study demonstrate that DCC is associated with improved dynamic cerebral autoregulatory function and may be the mechanism behind the decreased incidence of IVH. NEW & NOTEWORTHY The neuroprotective mechanism of delayed cord clamping in premature infants is unclear. Delayed cord clamping was associated with improved cerebral autoregulatory function and a marked decrease in intraventricular hemorrhage (IVH). Improved dynamic cerebral autoregulation may decrease arterial baroreceptor sensitivity, thereby reducing the risk of IVH.