Effects of delayed versus immediate umbilical cord clamping in reducing death or major disability at 2 years corrected age among very preterm infants (APTS): a multicentre, randomised clinical trial

Robledo, Kristy; Tarnow‐Mordi, William; Rieger, Ingrid; Suresh, Preeti K.; Martin, Andrew; Yeung, Carbo; Ghadge, Alpana; Liley, Helen; Osborn, David A; Morris, Jonathan M.; Hague, Wendy; Kluckow, Martin; Lui, Kei; Soll, Roger F.; Cruz, Melinda; Keech, Anthony; Kirby, Adrienne; Simes, John

doi:10.1016/s2352-4642(21)00373-4

Cited by 30 publications

(15 citation statements)

References 38 publications

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“…Benefits for term neonates include higher hemoglobin levels, less iron deficiency in infancy, improved brain myelin volume out to 12 months, and better motor and social development at 4 years of age especially in boys [41][42][43]. For preterm infants, benefits include less intraventricular hemorrhage, fewer gastrointestinal issues, lower transufusion requirements, and decreased mortality by 30% in the NICU and out to two years of age [1,44,45]. Perhaps the benefit most familiar with clinicians is the prevention of iron deficiency and anemia in infancy.…”

Section: Benefits For Term and Preterm Infantsmentioning

confidence: 99%

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What does the evidence tell us? Revisiting optimal cord management at the time of birth

Rabe

Mercer

2022

Eur J Pediatr

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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.

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Section: Benefits For Term and Preterm Infantsmentioning

confidence: 99%

“…Unfortunately, failure to adopt beneficial practices in a timely fashion may lead to unnecessary harm to the newborn [71][72][73]. Mounting evidence, especially a decrease of mortality in preterm infants, supports the benefits of DCC [45]. This has led to a greater willingness for hospital settings to adopt DCC.…”

Section: Implementing a Protocolmentioning

confidence: 99%

What does the evidence tell us? Revisiting optimal cord management at the time of birth

Rabe

Mercer

2022

Eur J Pediatr

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“…On the other hand, a large multicenter RCT for 1566 preterm infants found that delayed cord clamping did not result in a lower incidence of death or major morbidity at 36 weeks of gestation when compared to immediate cord clamping [ 36 ]. While in their long-term follow-up analysis of this mega multicenter RCT revealed that clamping the umbilical cord ≥ 60 s after birth resulted in a 30% reduction in relative mortality without affecting the major disability [ 37 ]. In the current study, there were no differences regarding predischarge mortality among the study groups, but the DCC group had lower days to death than the other 2 groups.…”

Section: Discussionmentioning

confidence: 99%

The effect of placental transfusion on hemodynamics in premature newborns: a randomized controlled trial

et al. 2022

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Despite of growing evidence of the beneficial effects of placental transfusion techniques, there is no available sufficient data about their effects on vulnerable hemodynamics and myocardium of premature infants. The purpose of this work is to study ventricular functions and hemodynamics after applying different placental transfusion techniques, delayed cord clamping (DCC), cut cord milking (C-UCM), and intact cord milking (I-UCM). Sixty-four infants delivered whether by C-section or vaginal delivery were randomly assigned to undergo C-UCM (20–30 cm), I-UCM (3–4 strippings), and DCC (30–60 s). Functional echocardiography was done on day 1 and day 3 of life for 57 infants. Primary outcome variable was superior vena cava flow measurement in infants having placental transfusion in the first 24 h of life and between 64 and 72 h. Secondary outcomes were other echocardiographic and clinical hemodynamic parameters, and biventricular functions in those infants. Of a total 196 preterm infants ≤ 32 weeks delivered in the study period, from January 2021 to August 2021, 57 infants were eligible and survived till the second examination. They were randomly assigned to the three groups. Neonates randomly assigned to DCC had significantly higher superior vena cava flow and lower right ventricular systolic function in the first 24 h of life. This finding vanished at day 3. Neonates undergone different methods of placental transfusions had similar hemoglobin, admission temperature, and mean blood pressure in the first 24 h of life.Conclusion: Despite their potential benefits, placental transfusions have shown to alter the hemodynamics and adversely affect myocardial function of premature neonates.Trial registration: This trial was registered in the clinical trial gov NCT04811872. What is Known:• Placental transfusion techniques might have benefits regarding prematurity- related morbidities and mortality. What is New:• Placental transfusion might adversely affect the myocardium and alter hemodynamics in premature infants.

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“…In many cases, the newborns received immediate or early cord clamping, a non-evidence-based intervention [2]. Waiting to clamp the umbilical cord at birth results in a 30% decreased incidence of death for preterm infants [3][4][5][6]. Enhanced blood volume from placental transfusion may be the most important factor that prevents death in these infants [7].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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

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Effects of delayed versus immediate umbilical cord clamping in reducing death or major disability at 2 years corrected age among very preterm infants (APTS): a multicentre, randomised clinical trial

Cited by 30 publications

References 38 publications

What does the evidence tell us? Revisiting optimal cord management at the time of birth

What does the evidence tell us? Revisiting optimal cord management at the time of birth

The effect of placental transfusion on hemodynamics in premature newborns: a randomized controlled trial

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

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