Comparison of Three Different Cord Clamping Techniques Regarding Oxidative-antioxidative Capacity in Term Newborns

Objective As newborns are exposed to oxidative stress during delivery, cord clamping techniques play significant role on antioxidant status. In this study, we aimed to show the relationship between early cord clamping (ECC), delayed cord clamping (DCC) and cut umblical cord milking (C-UCM) techniques with total oxidant capacity (TOC), total antioxidant capacity (TAC) and peroxynitrite levels. Study Design Sixty-nine term infants were selected with APGAR score of 7 and above in the first and fifth minutes. The mothers of all infants had uncomplicated pregnancy, had no congenital anomaly, and delivered by cesarean section. Newborns were randomised to one of three groups: ECC (n: 23), DCC (n: 23) or C-UCM (n: 23). After all newborn babies were taken under radiant heater, blood samples were collected from the umbilical cord. The plasma samples were then frozen and stored at -80 °C until analysis and TOC, TAC and peroxynitrite levels were studied. Results The ages of the mothers participating in the study were between 17 and 42, with an average of 29.14 ± 6.28. 30 (43.5%) of the babies were girls and 39 (56.5%) were boys. The 5th minute APGAR score of the babies in early cord clamping group was significantly lower than the babies in delayed cord clamping and cut cord milking group (p = 0.034; p = 0.034; p <0.05). The TOC, OSI and Peroxynitrite measurements of three groups did not differ statistically. The TAC value of the C-UCM group was significantly higher than the patients with the ECC and DCC group (p = 0.002; p = 0.019; p <0.05). Conclusion C-UCM and DCC would be feasible methods by increasing antioxidant status and providing protective effect on the future health of the term newborns,

Oxygen saturation and heart rate in healthy term and late preterm infants with delayed cord clamping

Blood oxygen in the fetus is substantially lower than in the newborn infant. In the minutes after birth, arterial oxygen saturation rises from around 50–60% to 90–95%. Initial respiratory efforts generate negative trans-thoracic pressures that drive liquid from the airways into the lung interstitium facilitating lung aeration, blood oxygenation, and pulmonary artery vasodilatation. Consequently, intra- (foramen ovale) and extra-cardiac (ductus arteriosus) shunting changes and the sequential circulation switches to a parallel pulmonary and systemic circulation. Delaying cord clamping preserves blood flow through the ascending vena cava, thus increasing right and left ventricular preload. Recently published reference ranges have suggested that delayed cord clamping positively influenced the fetal-to-neonatal transition. Oxygen saturation in babies with delayed cord clamping plateaus significantly earlier to values of 85–90% than in babies with immediate cord clamping. Delayed cord clamping may also contribute to fewer episodes of brady-or-tachycardia in the first minutes after birth, but data from randomized trials are awaited. Impact Delaying cord clamping during fetal to neonatal transition contributes to a significantly earlier plateauing of oxygen saturation and fewer episodes of brady-and/or-tachycardia in the first minutes after birth. We provide updated information regarding the changes in SpO2 and HR during postnatal adaptation of term and late preterm infants receiving delayed compared with immediate cord clamping. Nomograms in newborn infants with delayed cord clamping will provide valuable reference ranges to establish target SpO2 and HR in the first minutes after birth.

Not Everything Is Cordless Today—Case Report of Acute Intestinal Obstruction in a Neonate Due to Cord Clamping

We report a case of a 2-day-old neonate with bilious vomiting and abdominal distension. A small bowel obstruction with ileal perforation due to a misplaced clamping of the umbilical cord was apparent before laparotomy. This complication was a sequala after clamping the cord too close to the abdominal wall in a case where there was a hernia into the cord with intestinal content. A herniation of abdominal contents due to an omphalocele minor or a hernia must be taken into consideration during the inspection of the umbilical cord before clamping.

Maintaining Normothermia in Preterm Babies during Stabilisation with an Intact Umbilical Cord

Background: We had experienced an increase in admission hypothermia rates during implementation of deferred cord clamping (DCC) in our unit. Our objective was to reduce the number of babies with a gestation below 32 weeks who are hypothermic on admission, whilst practising DCC and providing delivery room cuddles (DRC). Method: A 12 month quality improvement project set, in a large Neonatal Intensive Care Unit, from January 2020 to December 2020. Monthly rates of admission hypothermia (<36.5 °C) for all eligible babies, were tracked prospectively. Each hypothermic baby was reviewed as part of a series of Plan, Do, Study Act (PDSA) cycles, to understand potential reasons and to develop solutions. Implementation of these solutions included the dissemination of the learning through a variety of methods. The main outcome measure was the proportion of babies who were hypothermic (<36.5 °C) on admission compared to the previous 12 months. Results: 130 babies with a gestation below 32 weeks were admitted during the study period. 90 babies (69.2%) had DCC and 79 babies (60%) received DRC. Compared to the preceding 12 months, the rate of hypothermia decreased from 25/109 (22.3%) to 13/130 (10%) (p = 0.017). Only 1 baby (0.8%) was admitted with a temperature below 36 °C and 12 babies (9.2%) were admitted with a temperature between 36 °C and 36.4 °C. Continued monitoring during the 3 months after the end of the project showed that the improvements were sustained with 0 cases of hypothermia in 33 consecutive admissions. Conclusions: It is possible to achieve low rates of admission hypothermia in preterm babies whilst providing DCC and DRC. Using a quality improvement approach with PDSA cycles is an effective method of changing clinical practice to improve outcomes.

Metoclopramide and Propofol to Prevent Nausea and Vomiting during Cesarean Section under Spinal Anesthesia: A Randomized, Placebo-Controlled, Double-Blind Trial

Background: Intra-operative nausea, vomiting and retching (NVR) are frequently associated with subarachnoid anesthesia (SA) in women undergoing cesarean section (CS). In this study performed in women undergoing CS under SA with a risk factor control strategy, we compared saline (placebo), propofol, metoclopramide and both drugs to prevent NVR. Methods: We recorded NVR events in 110 women undergoing CS who were randomized after umbilical cord clamping to receive saline (S; n = 27), metoclopramide 10 mg (M; n = 28), propofol 1 mg/kg/h (P; n = 27) or both drugs (PM; n = 28). Results: The proportion of women with intra-operative nausea was: S: 17/27 (63%); P: 15/27 (56%); M: 13/28 (46%); PM: 6/28 (21%) (p = 0.012, Cramér’s V = 0.31 (large effect). The proportion of women with intra-operative vomiting/retching was: S: 9/27 (33%); M: 7/27 (25%); P: 3/28 (11%); PM 2/28 (7%) (p = 0.049, Cramér’s V = 0.26 (medium effect). Post-hoc multiple comparisons revealed a significant reduction in NVR episodes and NRS scores between the PM group and control. Sedation scores did not differ among groups. Conclusion: In women undergoing CS under SA with a risk factor control strategy, combined propofol and metoclopramide reduce nausea and vomiting.

Large Hemoglobin Differences at Birth in Monochorionic Twins with a Placental Chorangioma and Delayed Cord Clamping

We report a case of a monochorionic diamniotic twin with an uncomplicated pregnancy, but with an unexpected large intertwin hemoglobin (Hb) difference at birth. Twin 1 was delivered vaginally and had an uneventful neonatal course. The umbilical cord of Twin 1 was clamped approximately 5 min after birth. After the birth of Twin 1, Twin 2 developed severe bradycardia and showed limited cardiac output on ultrasound, for which an emergency cesarean section was performed. A full blood count revealed an Hb of 20.1 g/dL for Twin 1 and 10.2 g/dL for Twin 2 (intertwin difference 9.9 g/dL). Reticulocyte counts were similar, 40‰ and 38‰, respectively. Placental examination revealed 10 vascular anastomoses, including one arterio-arterial anastomosis with a diameter of 1.4 mm. Additionally, a large chorangioma was present on the placental surface of Twin 2. There was no color difference on the maternal side of the placenta. Based on the reticulocyte count ratio and the placental characteristics, twin anemia polycythemia sequence was ruled out as the cause of the large intertwin Hb difference. In this report, we discuss the various potential causes that could explain the large intertwin Hb difference including the role of delayed cord clamping in Twin 1, and the role of a large chorangioma, which may have attracted blood from the fetal circulation of Twin 2.

Single versus continuous sustained inflations during chest compressions and physiological-based cord clamping in asystolic lambs

BackgroundThe feasibility and benefits of continuous sustained inflations (SIs) during chest compressions (CCs) during delayed cord clamping (physiological-based cord clamping; PBCC) are not known. We aimed to determine whether continuous SIs during CCs would reduce the time to return of spontaneous circulation (ROSC) and improve post-asphyxial blood pressures and flows in asystolic newborn lambs.MethodsFetal sheep were surgically instrumented immediately prior to delivery at ~139 days’ gestation and asphyxia induced until lambs reached asystole. Lambs were randomised to either immediate cord clamping (ICC) or PBCC. Lambs then received a single SI (SIsing; 30 s at 30 cmH2O) followed by intermittent positive pressure ventilation, or continuous SIs (SIcont: 30 s duration with 1 s break). We thus examined 4 groups: ICC +SIsing, ICC +SIcont, PBCC +SIsing, and PBCC +SIcont. Chest compressions and epinephrine administration followed international guidelines. PBCC lambs underwent cord clamping 10 min after ROSC. Physiological and oxygenation variables were measured throughout.ResultsThe time taken to achieve ROSC was not different between groups (mean (SD) 4.3±2.9 min). Mean and diastolic blood pressure was higher during chest compressions in PBCC lambs compared with ICC lambs, but no effect of SIs was observed. SIcont significantly reduced pulmonary blood flow, diastolic blood pressure and oxygenation after ROSC compared with SIsing.ConclusionWe found no significant benefit of SIcont over SIsing during CPR on the time to ROSC or on post-ROSC haemodynamics, but did demonstrate the feasibility of continuous SIs during advanced CPR on an intact umbilical cord. Longer-term studies are recommended before this technique is used routinely in clinical practice.

Increment in Phototherapy After Adopting Delayed Cord Clamping Practice

Introduction: World Health Organization (WHO) in 2014 recommended delayed cord clamping (DCC) in all babies who cry immediately after birth. Despite many benefits, there are concerns of increased rate of phototherapy in babies receiving DCC. This study was done to determine the increment in the rate of phototherapy required in infants managed with DCC vs infants managed with early cord clamping (ECC). Methods: A retrospective observational study was conducted in a tertiary care hospital in Pune, India. All the infants born between January 2018 and July 2018, for whom ECC was done, were compared with infants who were born between January 2019 and July 2019, after DCC policy was adopted. All the infants with birth weight ≥2 kg and gestation ≥35 weeks, who were with their mother, were included. Baseline characteristics were compared for both the groups. American Academy of Pediatrics guidelines for treatment of neonatal jaundice were used to determine the need for phototherapy. Number of infants in both the groups who required phototherapy were compared. Results: The ECC group had 565 infants while DCC group had 731 infants. There was no difference in the baseline characteristics of the 2 groups. Jaundice requiring phototherapy was noted in 31% of infants in the ECC group, compared to 45% in infants in the DCC group (relative risk: 1.47 [1.27-1.71] [ P < .001]). Conclusion: In this study, DCC increased the need for phototherapy by 47% in late preterm and term infants. Randomized control trials with larger sample size are required to confirm this finding.