Haemodynamic effects of umbilical cord milking in premature sheep during the neonatal transition

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Abstract

Objective

Umbilical cord milking (UCM) at birth may benefit preterm infants, but the physiological effects of UCM are unknown. We compared the physiological effects of two UCM strategies with immediate umbilical cord clamping (UCC) and physiological-based cord clamping (PBCC) in preterm lambs.

Methods

At 126 days’ gestational age, fetal lambs were exteriorised, intubated and instrumented to measure umbilical, pulmonary and cerebral blood flows and arterial pressures. Lambs received either (1) UCM without placental refill (UCMwoPR); (2) UCM with placental refill (UCMwPR); (3) PBCC, whereby ventilation commenced prior to UCC; or (4) immediate UCC. UCM involved eight milks along a 10 cm length of cord, followed by UCC.

Results

A net volume of blood was transferred into the lamb during UCMwPR (8.8 mL/kg, IQR 8–10, P=0.01) but not during UCMwoPR (0 mL/kg, IQR −2.8 to 1.7) or PBCC (1.1 mL/kg, IQR −1.3 to 4.3). UCM had no effect on pulmonary blood flow, but caused large fluctuations in mean carotid artery pressures (MBP) and blood flows (CABF). In UCMwoPR and UCMwPR lambs, MBP increased by 12%±1% and 8%±1% and CABF increased by 32%±2% and 15%±2%, respectively, with each milk. Cerebral oxygenation decreased the least in PBCC lambs (17%, IQR 13–26) compared with UCMwoPR (26%, IQR 23–25, P=0.03), UCMwPR (35%, IQR 27–44, P=0.02) and immediate UCC (34%, IQR 28–41, P=0.02) lambs.

Conclusions

UCMwoPR failed to provide placental transfusion, and UCM strategies caused considerable haemodynamic disturbance. UCM does not provide the same physiological benefits of PBCC. Further review of UCM is warranted before adoption into routine clinical practice.

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Most cited references 35

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Early CPAP versus surfactant in extremely preterm infants.

Neil N Finer, Waldemar A Carlo, Michele C Walsh … (2010)

There are limited data to inform the choice between early treatment with continuous positive airway pressure (CPAP) and early surfactant treatment as the initial support for extremely-low-birth-weight infants. We performed a randomized, multicenter trial, with a 2-by-2 factorial design, involving infants who were born between 24 weeks 0 days and 27 weeks 6 days of gestation. Infants were randomly assigned to intubation and surfactant treatment (within 1 hour after birth) or to CPAP treatment initiated in the delivery room, with subsequent use of a protocol-driven limited ventilation strategy. Infants were also randomly assigned to one of two target ranges of oxygen saturation. The primary outcome was death or bronchopulmonary dysplasia as defined by the requirement for supplemental oxygen at 36 weeks (with an attempt at withdrawal of supplemental oxygen in neonates who were receiving less than 30% oxygen). A total of 1316 infants were enrolled in the study. The rates of the primary outcome did not differ significantly between the CPAP group and the surfactant group (47.8% and 51.0%, respectively; relative risk with CPAP, 0.95; 95% confidence interval [CI], 0.85 to 1.05) after adjustment for gestational age, center, and familial clustering. The results were similar when bronchopulmonary dysplasia was defined according to the need for any supplemental oxygen at 36 weeks (rates of primary outcome, 48.7% and 54.1%, respectively; relative risk with CPAP, 0.91; 95% CI, 0.83 to 1.01). Infants who received CPAP treatment, as compared with infants who received surfactant treatment, less frequently required intubation or postnatal corticosteroids for bronchopulmonary dysplasia (P<0.001), required fewer days of mechanical ventilation (P=0.03), and were more likely to be alive and free from the need for mechanical ventilation by day 7 (P=0.01). The rates of other adverse neonatal outcomes did not differ significantly between the two groups. The results of this study support consideration of CPAP as an alternative to intubation and surfactant in preterm infants. (ClinicalTrials.gov number, NCT00233324.) 2010 Massachusetts Medical Society

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Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes.

Heike Rabe, José Díaz-Rossello, Lelia Duley … (2012)

Optimal timing for clamping the umbilical cord at preterm birth is unclear. Early clamping allows for immediate transfer of the infant to the neonatologist. Delaying clamping allows blood flow between the placenta, the umbilical cord and the baby to continue. The blood which transfers to the baby between birth and cord clamping is called placental transfusion. Placental transfusion may improve circulating volume at birth, which may in turn improve outcome for preterm infants. To assess the short- and long-term effects of early rather than delaying clamping or milking of the umbilical cord for infants born at less than 37 completed weeks' gestation, and their mothers. We searched the Cochrane Pregnancy and Childbirth Group Trials Register (31 May 2011). We updated this search on 26 June 2012 and added the results to the awaiting classification section. Randomised controlled trials comparing early with delayed clamping of the umbilical cord and other strategies to influence placental transfusion for births before 37 completed weeks' gestation. Three review authors assessed eligibility and trial quality. Fifteen studies (738 infants) were eligible for inclusion. Participants were between 24 and 36 weeks' gestation at birth. The maximum delay in cord clamping was 180 seconds. Delaying cord clamping was associated with fewer infants requiring transfusions for anaemia (seven trials, 392 infants; risk ratio (RR) 0.61, 95% confidence interval (CI) 0.46 to 0.81), less intraventricular haemorrhage (ultrasound diagnosis all grades) 10 trials, 539 infants (RR 0.59, 95% CI 0.41 to 0.85) and lower risk for necrotising enterocolitis (five trials, 241 infants, RR 0.62, 95% CI 0.43 to 0.90) compared with immediate clamping. However, the peak bilirubin concentration was higher for infants allocated to delayed cord clamping compared with immediate clamping (seven trials, 320 infants, mean difference 15.01 mmol/L, 95% CI 5.62 to 24.40). For most other outcomes (including the primary outcomes infant death, severe (grade three to four) intraventricular haemorrhage and periventricular leukomalacia) there were no clear differences identified between groups; but for many there was incomplete reporting and wide CIs. Outcome after discharge from hospital was reported for one small study; there were no significant differences between the groups in mean Bayley II scores at age seven months (corrected for gestation at birth (58 children)).No studies reported outcomes for the women. Providing additional placental blood to the preterm baby by either delaying cord clamping for 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion, better circulatory stability, less intraventricular haemorrhage (all grades) and lower risk for necrotising enterocolitis. However, there were insufficient data for reliable conclusions about the comparative effects on any of the primary outcomes for this review.

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Helping Babies Breathe: global neonatal resuscitation program development and formative educational evaluation.

Nalini Singhal, Jocelyn Lockyer, Herta Fidler … (2012)

To develop an educational program designed to train health care providers in resource limited settings to carry out neonatal resuscitation. We analyzed facilitator and learner perceptions about the course, examined skill performance, and assessed the quality of instruments used for learner evaluation as part of the formative evaluation of the educational program Helping Babies Breathe. Multiple stakeholders and a Delphi panel contributed to program development. Training of facilitators and learners occurred in global field test sites. Course evaluations and focus groups provided data on facilitator and learner perceptions. Knowledge and skill assessments included pre/post scores from multiple choice questions (MCQ) and post-training assessment of bag and mask skills, as well as 2 objective structured clinical evaluations (OSCE). Two sites (Kenya and Pakistan) trained 31 facilitators and 102 learners. Participants expressed high satisfaction with the program and high self-efficacy with respect to neonatal resuscitation. Assessment of participant knowledge and skills pre/post-program demonstrated significant gains; however, the majority of participants could not demonstrate mastery of bag and mask ventilation on the post-training assessment without additional practice. Participants in a program for neonatal resuscitation in resource-limited settings demonstrated high satisfaction, high self-efficacy and gains in knowledge and skills. Mastery of ventilation skills and integration of skills into case management may not be achievable in the classroom setting without additional practice, continued learning, and active mentoring in the workplace. These findings were used to revise program structure, materials and assessment tools. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

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Author and article information

Journal

Journal ID (nlm-ta): Arch Dis Child Fetal Neonatal Ed

Journal ID (iso-abbrev): Arch. Dis. Child. Fetal Neonatal Ed

Journal ID (hwp): fetalneonatal

Journal ID (publisher-id): fnn

Title: Archives of Disease in Childhood. Fetal and Neonatal Edition

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Print): 1359-2998

ISSN (Electronic): 1468-2052

Publication date (Print): November 2018

Publication date (Electronic): 5 December 2017

Volume: 103

Issue: 6

Pages: F539-F546

Affiliations

[1 ] departmentNewborn Research , The Royal Women’s Hospital , Parkville, Victoria, Australia

[2 ] departmentThe Ritchie Centre , Hudson Institute of Medical Research, Monash University , Clayton, Victoria, Australia

[3 ] departmentDepartment of Neonatology , Royal North Shore Hospital and University of Sydney , New South Wales, Australia

[4 ] departmentCentre for Neonatal Research and Education , University of Western Australia , Perth, Australia

Author notes

[Correspondence to ] Dr Douglas A Blank, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, Victoria 3168, Australia; blankdouglas@ 123456gmail.com

Article

Publisher ID: fetalneonatal-2017-314005

DOI: 10.1136/archdischild-2017-314005

PMC ID: 6278653

PubMed ID: 29208663

SO-VID: 0a4899d4-5140-41fd-b315-3ea42fd74faa

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

History

Date received : 24 August 2017

Date revision received : 31 October 2017

Date accepted : 05 November 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100000925, National Health and Medical Research Council;

Funded by: FundRef http://dx.doi.org/10.13039/501100000991, Faculty of Medicine, Nursing and Health Sciences, Monash University;

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ScienceOpen disciplines: Neonatology

Keywords: fetal medicine,neonatology,umbilical cord milking,delayed cord clamping,premature

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ScienceOpen disciplines: Neonatology

Keywords: fetal medicine, neonatology, umbilical cord milking, delayed cord clamping, premature

Haemodynamic effects of umbilical cord milking in premature sheep during the neonatal transition

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Abstract

Objective

Methods

Results

Conclusions

Related collections

Animal models of intrauterine growth restriction (IUGR)

Most cited references 35

Early CPAP versus surfactant in extremely preterm infants.

Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes.

Helping Babies Breathe: global neonatal resuscitation program development and formative educational evaluation.

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