Debra A. Erickson-Owens

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.

Umbilical cord milking in term infants delivered by cesarean section: a randomized controlled trial

Objective:The studys objective was to compare hematocrit (Hct) levels at 36 to 48 h of age in term infants delivered by cesarean section exposed to immediate cord clamping or umbilical cord milking (UCM).Study Design:In this randomized controlled trial, 24 women scheduled for elective cesarean section were randomized to either immediate clamping (<10 s) or UCM (milked × 5 by the obstetrical provider) at birth.Result:All subjects received their allocated intervention. The milking group had a smaller placental residual blood volume (13.2±5.6 vs 19.2±5.4 ml kg–1, P=0.01) and higher Hct levels at 36 to 48 h (57.5±6.6 vs 50.0±6.4 %, P=0.01). Five infants (42%) in the immediate group had a Hct of ⩽47%, indicative of anemia.Conclusion:UCM results in placental transfusion in term infants at the time of elective cesarean section with higher Hct levels at 36 to 48 h of age.

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.

Delayed cord clamping increases infants' iron stores

It is startling to see how a seemingly insubstantial change in practice might affect long-term results for infants. When a medical text recommended immediate cord clamping in 1913 science was in its infancy and expert opinion guided practice. Today we have the benefit of scientific evidence to advise our actions. The article in todays Lancet by Camila Chaparro and colleagues provides additional weight to the growing evidence that our haste to clamp the umbilical cord and pass the baby off is ill-advised. The mounting evidence that delayed cord clamping benefits both term and preterm infants continues to build. (excerpt)

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 (<32 weeks gestation) were randomized to either DCC (30-45 seconds) or ICC (<10 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. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: NCT00818220 and NCT01426698.

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 5-10min 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 infants 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 rats abdomen after induced brain damage, can protect the rats 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.

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 mothers 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 mothers 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.

Development of an educational/support group for pregnant women in prison

It is estimated that 6–10% of women are pregnant when they enter the prison system. The majority have had little, if any, prenatal care and/or childbirth education. Given economic constraints, the educational and support needs of this population are often not met. In response to these needs, an educational/support group was developed and led by a social worker, a mental health clinical nurse specialist, and a nurse midwife in a womens correctional facility in the Northeast. Women in various stages of pregnancy and early postpartum voluntarily attended. The need for education and psychosocial support was overwhelming. This group fostered a safe space for women to discuss real-life issues in a supportive environment. Meeting the educational and support needs of incarcerated women is paramount.

Effects of delayed cord clamping on residual placental blood volume, hemoglobin and bilirubin levels in term infants: a randomized controlled trial

Objective:The objective of the study was to measure the effects of a 5-min delay (DCC) versus immediate cord clamping (ICC) on residual placental blood volume (RPBV) at birth, and hemoglobin and serum bilirubin at 24 to 48 h of age.Study Design:In this prospective randomized controlled trial, 73 women with term (37 to 41 weeks) singleton fetuses were randomized to DCC (⩾5 min; n=37) or ICC (<20 s; n=36).Results:Maternal and infant demographics were not different between the groups. Mean cord clamping time was 303±121 (DCC) versus 23±59 (ICC) s (P<0.001) with 10 protocol violations. Cord milking was the proxy for DCC (n=11) when the provider could not wait. Infants randomized to DCC compared with ICC had significantly less RPBV (20.0 versus 30.8 ml kg−1, P<0.001), higher hemoglobin levels (19.4 versus 17.8 g dl−1, P=0.002) at 24 to 48 h, with no difference in bilirubin levels.Conclusion:Term infants had early hematological advantage of DCC without increases in hyperbilirubinemia or symptomatic polycythemia.

The Evolution of Individual Maternity Care Providers to Delayed Cord Clamping: Is It the Evidence?

INTRODUCTION Studies of organizational strategies to incorporate evidence into practice and change provider behavior have shown limited success. The majority of existing research centers on influencing participants to change practice versus understanding what occurs when providers have successfully shifted to an evidence-based practice on their own. This study sought to explore the dynamics involved when individual midwives and physicians transitioned from a practice less based on the evidence to one with more scientific support. Delayed cord clamping was selected as the exemplar practice for the study. METHODS A qualitative grounded theory approach was used. Seventeen providers were interviewed throughout the United States. This included 5 physicians and 12 midwives from a variety of practice configurations and birth settings including the home, birth center, and hospital. RESULTS Five themes arose from the stories of the participants: 1) trusting colleagues, 2) believing the evidence, 3) honoring mothers and families, 4) knowing personal certainty, and 5) protecting the integrity of the mother and the baby. The themes served as drivers of change for the providers in what emerged as an evolution toward change rather than a decision to change. From the themes, the model for individual evolution to evidence-based practice was developed. DISCUSSION Important findings included the significant role that colleagues play in an individuals journey toward a new practice, the fact that the evidence alone was never a sole driver of change, and the emergence of a discourse: Who owns the baby? The model developed as a result of this study provides a new framework for both future research and potential strategies to support the incorporation of evidence into practice.