Heike Rabe

A Systematic Review and Meta-Analysis of a Brief Delay in Clamping the Umbilical Cord of Preterm Infants

Background: The optimal timing of clamping the umbilical cord in preterm infants at birth is the subject of continuing debate. Objective: To investigate the effects of a brief delay in cord clamping on the outcome of babies born prematurely. Methods: A retrospective meta-analysis of randomised trials in preterm infants was conducted. Data were collected from published studies identified by a structured literature search in EMBASE, PubMed, CINAHL and the Cochrane Library. All infants born below 37 weeks gestation and enrolled into a randomised study of delayed cord clamping (30 s or more) versus immediate cord clamping (less than 20 s) after birth were included. Systematic search and analysis of the data were done according to the methodology of the Cochrane collaboration. Results: Ten studies describing a total of 454 preterm infants were identified which met the inclusion and assessment criteria. Major benefits of the intervention were higher circulating blood volume during the first 24 h of life, less need for blood transfusions (p = 0.004) and less incidence of intraventricular hemorrhage (p = 0.002). Conclusions: The procedure of a delayed cord clamping time of at least 30 s is safe to use and does not compromise the preterm infant in the initial post-partum adaptation phase.

Milking Compared With Delayed Cord Clamping to Increase Placental Transfusion in Preterm Neonates: A Randomized Controlled Trial

OBJECTIVE: To compare two strategies to enhance placento-fetal blood transfusion in preterm neonates before 33 weeks of gestation. METHODS: We recruited women at risk for singleton preterm deliveries. All delivered before 33 completed weeks of gestation. In this single-center trial, women were randomized to either standard treatment (clamping the cord for 30 seconds after delivery) or repeated (four times) milking of the cord toward the neonate. Exclusion criteria included inadequate time to obtain consent before delivery, known congenital abnormalities of the fetus, Rhesus sensitization, or fetal hydrops. RESULTS: Of 58 neonates included the trial, 31 were randomized to cord clamping and 27 were randomized to repeated milking of the cord. Mean birth weight was 1,263±428 g in the clamping group and 1,235±468 g in the milking group, with mean gestational age of 29.2±2.3 weeks and 29.5±2.7 weeks, respectively. Mean hemoglobin values for each group at 1 hour after birth were 17.3 g/L for clamping and 17.5 g/L for milking (P=.71). There was no significant difference in number of neonates undergoing transfusion (clamping group, 15; milking group, 17; P=.40) or the median number of transfusions within the first 42 days of life (median [range]: clamping group 0 [0–7]; milking group 0 [0–20]; P=.76). CONCLUSION: Milking the cord four times achieved a similar amount of placento-fetal blood transfusion compared with delaying clamping the cord for 30 seconds. CLINICAL TRIAL REGISTRATION: National Research Register UK, www.nihr.ac.uk/Pages/default.aspx, N0051177741. LEVEL OF EVIDENCE: I

Measures of satisfaction with care during labour and birth: a comparative review

BackgroundSatisfaction is the one of the most frequently reported outcome measures for quality of care. Assessment of satisfaction with maternity services is crucial, and psychometrically sound measures are needed if this is to inform health practices. This paper comparatively reviews current measures of satisfaction with care during labour and birth.MethodsA review of the literature was conducted. Studies were located through computerised databases and hand searching references of identified articles and reviews. Inclusion criteria were that the questionnaire was a multi-item scale of satisfaction with care during labour and birth, and some form of psychometric information (either information about questionnaire construction, or reliability, or validity) had to be reported.ResultsNine questionnaires of satisfaction with care during labour and birth were identified. Instruments varied in psychometric properties and dimensions. Most described questionnaire construction and tested some form of reliability and validity. Measures were generally not based on the main theoretical models of satisfaction and varied in scope and application to different types of samples (e.g. satisfaction following caesarean section). For an in-depth measure of satisfaction with intrapartum care, the Intrapartal-Specific Quality from the Patient’s Perspective questionnaire (QPP-I) is recommended. Brief measures with good reliability and validity are provided by the Six Simple Questions (SSQ) or Perceptions of Care Adjective Checklist (PCACL-R).ConclusionsDespite the interest in measures of satisfaction there are only a small number of validated measures of satisfaction with care during labour and birth. It is important that brief, reliable and valid measures are available for use in general and specific populations in order to assist research and inform practice.

Effects of placental transfusion in extremely low birthweight infants: meta-analysis of long- and short-term outcomes.

Risks and benefits of increasing placental transfusion in extremely preterm infants (extremely low birthweight [ELBW], <1000 g) are ill defined. We performed a meta‐analysis to compare long‐ and short‐term outcomes of ELBW infants in trials of enhanced placental transfusion regimens.

Acute and protracted effects of intratracheal surfactant application on internal carotid blood flow velocity, blood pressure and carbondioxide tension in very low birth weight infants

As a part of a multicentre clinical trial of prophylattic treatment with bovine surfactant (SF-RI 1) given to immature infants below 31 gestational weeks, short term and protracted effects on cerebral haemodynamics were assessed by Dopplersonographic measurements of the right internal carotid artery. Measurements were performed every 10 min for 1h after intratracheal application of the surfactant in ten treated infants. The results of additional measurements every 12h up to the age of 100h were compared with a control group. In single cases there were changes of time averaged mean maximum velocity (Vmax) of as much as 100% immediately after intratracheal surfactant application, although the mean short term and protracted variability of Vmax was the same as the protracted variability in the control group. Variability of mean arterial blood pressure and transcutaneous carbondioxide tension (tcpCO2) was even less. With proper adjustment of ventilatory settings intratracheal treatment with surfactant does not affect variability or absolute values of internal carotid Vmax, mean arterial blood pressure and transcutaneous pCO2 in low birth weight infants within 100h after application.

Parents’ first moments with their very preterm babies: a qualitative study

Objectives To assess parents’ first experiences of their very preterm babies and the neonatal intensive care unit (NICU). Design Qualitative study using semistructured interviews. Participants 32 mothers and 7 fathers of very preterm babies (<32 weeks gestation). Setting Three neonatal units in tertiary care hospitals in South East England. Results Five themes were identified. The first describes parents’ blurred recall of the birth. The second shows the anticipation of seeing and touching their baby for the first time was characterised by contrasting emotions, with some parents feeling scared and others excited about the event. The third theme describes parents’ first sight and touch of their babies and their ‘rollercoaster’ of emotions during this time. It also highlights the importance of touch to trigger and strengthen the parent–baby bond. However, some parents were worried that touching or holding the baby might transmit infection or interfere with care. The fourth theme captures parents’ impressions of NICU and how overwhelming this was particularly for parents who had not toured NICU beforehand or whose first sight of their baby was on NICU. The final theme captures unique experiences of fathers, in particular that many felt excluded and confused about their role. Conclusions This study informs family-centred care by providing insight into the experiences of parents of very preterm infants at a time when they are most in need of support. Clinical implications include the importance of offering parents preparatory tours of the NICU and including fathers.

Parents’ views on care of their very premature babies in neonatal intensive care units: a qualitative study

BackgroundThe admission of a very premature infant to the neonatal intensive care unit (NICU) is often a difficult time for parents. This paper explores parents’ views and experiences of the care for their very premature baby on NICU.MethodsParents were eligible if they had a baby born before 32 weeks gestation and cared for in a NICU, and spoke English well. 32 mothers and 7 fathers were interviewed to explore their experiences of preterm birth. Although parents’ evaluation of care in the NICU was not the aim of these interviews, all parents spoke spontaneously and at length on this topic. Results were analysed using thematic analysis.ResultsOverall, parents were satisfied with the care on the neonatal unit. Three major themes determining satisfaction with neonatal care emerged: 1) parents’ involvement; including looking after their own baby, the challenges of expressing breast milk, and easy access to their baby; 2) staff competence and efficiency; including communication, experience and confidence, information and explanation; and 3) interpersonal relationships with staff; including sensitive and emotional support, reassurance and encouragement, feeling like an individual.ConclusionsDeterminants of positive experiences of care were generally consistent with previous research. Specifically, provision of information, support for parents and increasing their involvement in the care of their baby were highlighted by parents as important in their experience of care.

Management of congenital cytomegalovirus infection: an evidence-based approach

Despite cytomegalovirus being the most common congenital infection leading to psychomotor impairment and sensori‐neural hearing loss, little is known about early identification and management of congenitally infected neonates. This article reviews the literature and devises an algorithm for identification and management of these neonates.

Short-term outcome of very-low-birthweight infants with arterial hypotension in the first 24 h of life

Objective To evaluate lowest mean arterial blood pressure during the first 24 h of life (minMAP24) in very-low-birthweight (VLBW) infants and to identify associations between hypotension and short-term outcome. Design Retrospective cohort analysis of the minMAP24 of 4907 VLBW infants with a gestational age <32 weeks in correlation with clinical data. Hypotension was defined as minMAP24 being lower than the median value of all patients of the same gestational age. Results MinMAP24 values correlated with gestational age. Median minMAP24 values of VLBW infants ≤29 weeks’ gestation were 1–2 mm Hg lower than gestational age in completed weeks. Hypotensive infants had a higher rate of intraventricular haemorrhage (IVH, 20.3% vs 15.9%, p<0.001), bronchopulmonary dysplasia (BPD, 19.2% vs 15.1%, p<0.001) and death (5.2% vs 3.0%, p<0.001). Multivariate logistic regression analyses, including potential confounders, confirmed these data. MinMAP24 was an independent risk factor for IVH (OR 0.97/mm Hg, 95% CI 0.96 to 0.99, p=0.003), BPD (OR 0.96/mm Hg, 95% CI 0.94 to 0.98, p<0.001) and mortality (OR 0.94/mm Hg, 95% CI 0.90 to 0.98, p=0.003). Conclusions Hypotension during the first 24 h of life is associated with adverse outcomes in VLBW infants. This underlines the need for randomised controlled trials on the use of vasoactive drugs in this vulnerable patient cohort.

Placental transfusion: a review

Recently there have been a number of studies and presentations on the importance of providing a placental transfusion to the newborn. Early cord clamping is an avoidable, unphysiologic intervention that prevents the natural process of placental transfusion. However, placental transfusion, although simple in concept, is affected by multiple factors, is not always straightforward to implement, and can be performed using different methods, making this basic procedure important to discuss. Here, we review three placental transfusion techniques: delayed cord clamping, intact umbilical cord milking and cut-umbilical cord milking, and the evidence in term and preterm newborns supporting this practice. We will also review several factors that influence placental transfusion, and discuss perceived risks versus benefits of this procedure. Finally, we will provide key straightforward concepts and implementation strategies to ensure that placental-to-newborn transfusion can become routine practice at any institution.