Rethinking Placental Transfusion and Cord Clamping Issues

A brief delay in clamping the umbilical cord results in a placental transfusion that supplies the infant with a major source of iron during the first few months of life. Cord circulation continues for several minutes after birth and placental transfusion results in approximately 30% more blood volume. Gravity influences the amount of placental transfusion that an infant receives. Placing the infant skin-to-skin requires a longer delay of cord clamping (DCC) than current recommendations. Uterotonics are not contraindicated with DCC. Cord milking is a safe alternative to DCC when one must cut the cord prematurely. Recent randomized controlled trials demonstrate benefits for term and preterm infants from DCC. The belief that DCC causes hyperbilirubinemia or symptomatic polycythemia is unsupported by the available research. Delay of cord clamping substantively increases iron stores in early infancy. Inadequate iron stores in infancy may have an irreversible impact on the developing brain despite oral iron supplementation. Iron deficiency in infancy can lead to neurologic issues in older children including poor school performance, decreased cognitive abilities, and behavioral problems. The management of the umbilical cord in complex situations is inconsistent between birth settings. A change in practice requires collaboration between all types of providers who attend births

Cardiac asystole at birth: Is hypovolemic shock the cause?

A birth involving shoulder dystocia can rapidly deteriorate—from a fetus with a reassuring tracing in the minutes before birth, to a neonate needing aggressive resuscitation. Infants experiencing a traumatic birth involving shoulder dystocia may be severely compromised, even when the preceding labor was uncomplicated. This paper presents two cases in which infants had normal heart beats recorded 5–10 min before birth and were born with cardiac asystole following shoulder dystocia. Often, in cases of shoulder dystocia, infants shift blood to the placenta due to the tight compressive squeeze of the body in the birth canal (along with cord compression) and thereby may be born hypovolemic. Our hypothesis is that the occurrence of sudden cardiac asystole at birth is due to extreme hypovolemic shock secondary to the loss of blood. At birth, the sudden release of pressure on the infant’s body results in hypoperfusion resulting in low central circulation and blood pressure. Severe hypovolemic shock from these effects leads to sudden cardiac arrest. Immediate cord clamping maintains the hypovolemic state by preventing the physiologic and readily available placental blood from returning to the infant. Loss of this blood initiates an inflammatory response leading to seizures, hypoxic-ischemic encephalopathy, and brain damage or death. Animal studies have shown that human umbilical stem cells injected into a rat’s abdomen after induced brain damage, can protect the rat’s brain from developing permanent injury. To prevent damage to newborns, the infant must receive the blood volume and stem cells lost at the time of descent and immediate cord clamping. Recommended countermeasures for research include: (1) resuscitation at the perineum with intact cord; or (2) milking the cord before clamping; or (3) autologous transfusion of placenta blood after the birth; or (4) rapid transfusion of O negative blood after birth and before seizures begin

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

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

Seven-month developmental outcomes of very low birth weight infants enrolled in a randomized controlled trial of delayed versus immediate cord clamping

Objective: 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. Study Design: Infants between 24 and 31 weeks were randomized to ICC or DCC and follow-up evaluation was completed at 7 months corrected age. Result: 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. Conclusion: DCC at birth seems to be protective of very low birth weight male infants against motor disability at 7 months corrected age

Prescription Opioid Use among Pregnant Women Enrolled in Rhode Island Medicaid

Objective: Our objective was to identify the patterns of opioid use among pregnant women enrolled in RI Medicaid. Methods: This study used linked RI Medicaid and RI Birth Certificate data from 01/01/2006 to 12/31/2016. We examined temporal trends of prescription opioid dispensings and identified risk factors associated with opioids use during pregnancy. Results: Among 25,500 RI Medicaid enrolled pregnant women who delivered a live baby from 2008 to 2016, 1,914 (7.5%) received at least one prescription for an opioid medication during pregnancy, 810 (3.2%) were during the first trimester, 633 (2.5%) during the second trimester, and 866 (3.4%) during the third trimester. Of these, 213 (0.8%) women received 3 or more opioids during pregnancy. The prevalence of prescription opioids dispensed in pregnant women increased from 4.9% in 2008 to 9.6% in 2015 (β SD: 0.66 0.28, P=0.05). Conclusions: Prescription opioid use during pregnancy has increased among women enrolled in RI Medicaid

Effects of Placental Transfusion on Neonatal and 18 Month Outcomes in Preterm Infants: A Randomized Controlled Trial

Objective: To assess the effect of delayed cord clamping (DCC) vs immediate cord clamping (ICC) on intraventricular hemorrhage (IVH), late onset sepsis (LOS), and 18-month motor outcomes in preterm infants. Study Design: Women (n = 208) in labor with singleton fetuses (\u3c32 weeks gestation) were randomized to either DCC (30-45 seconds) or ICC (\u3c10 seconds). The primary outcomes were IVH, LOS, and motor outcomes at 18-22 months corrected age. Intention-to-treat was used for primary analyses. Results: Cord clamping time was 32 ± 16 (DCC) vs 6.6 ± 6 (ICC) seconds. Infants in the DCC and ICC groups weighed 1203 ± 352 and 1136 ± 350 g and mean gestational age was 28.3 ± 2 and 28.4 ± 2 weeks, respectively. There were no differences in rates of IVH or LOS between groups. At 18-22 months, DCC was protective against motor scores below 85 on the Bayley Scales of Infant Development, Third Edition (OR 0.32, 95% CI 0.10-0.90, P = .03). There were more women with preeclampsia in the ICC group (37% vs 22%, P = .02) and more women in the DCC group with premature rupture of membranes/preterm labor (54% vs 75%, P = .002). Preeclampsia halved the risk of IVH (OR 0.50, 95% CI 0.2-1.0) and premature rupture of membranes/preterm labor doubled the risk of IVH (OR 2.0, 95% CI 1.2-4.3). Conclusions: Although DCC did not alter the incidence of IVH or LOS in preterm infants, it improved motor function at 18-22 months corrected age

Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial

Objective To evaluate whether placental transfusion influences brain myelination at 4 months of age. Study design A partially blinded, randomized controlled trial was conducted at a level III maternity hospital in the US. Seventy-three healthy term pregnant women and their singleton fetuses were randomized to either delayed umbilical cord clamping (DCC, \u3e5 minutes) or immediate clamping (ICC, \u3c20 \u3eseconds). At 4 months of age, blood was drawn for ferritin levels. Neurodevelopmental testing (Mullen Scales of Early Learning) was administered, and brain myelin content was measured with magnetic resonance imaging. Correlations between myelin content and ferritin levels and group-wise DCC vs ICC brain myelin content were completed. Results In the DCC and ICC groups, clamping time was 172 ± 188 seconds vs 28 ± 76 seconds (P \u3c .002), respectively; the 48-hour hematocrit was 57.6% vs 53.1% (P \u3c .01). At 4 months, infants with DCC had significantly greater ferritin levels (96.4 vs 65.3 ng/dL, P = .03). There was a positive relationship between ferritin and myelin content. Infants randomized to the DCC group had greater myelin content in the internal capsule and other early maturing brain regions associated with motor, visual, and sensory processing/function. No differences were seen between groups in the Mullen testing. Conclusion At 4 months, infants born at term receiving DCC had greater ferritin levels and increased brain myelin in areas important for early life functional development. Endowment of iron-rich red blood cells obtained through DCC may offer a longitudinal advantage for early white matter development

Is It Time to Rethink Cord Management When Resuscitation Is Needed?

A newborn who receives a placental transfusion at birth, either from cord milking or delayed cord clamping, obtains about 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 neonate as it prevents hypovolemia and can support optimal perfusion to all organs. New research shows that ventilating before clamping the umbilical cord can reduce large swings in cardiovascular function and help to stabilize the newborn. 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 these neonates. Current protocols for resuscitation imply immediate cord clamping and the care of the newborn away from the mother\u27s bedside. We suggest that an intrapartum care provider can achieve placental transfusion for the distressed neonate by milking the cord several times or resuscitating the neonate at the perineum with an intact cord. Milking the cord can be done quickly within the current Neonatal Resuscitation Program guidelines. Cord blood gases can be collected with delayed cord clamping. Bringing the resuscitation to the mother\u27s bedside is a novel concept and supports an intact cord. Adopting a policy for resuscitation with an intact cord in a hospital setting will take concentrated effort and team work by obstetrics, pediatrics, midwifery, and nursing