Umbilical cord milking in nonvigorous infants: a cluster-randomized crossover trial

Katheria, Anup; Clark, Erin A.S.; Yoder, Bradley A.; Schmölzer, Georg M.; Law, Brenda Hiu Yan; El-Naggar, Walid; Rittenberg, D.; Sheth, Sheetal; Mohamed, Mohamed A.; Martin, Courtney; Vora, Farha; Lakshminrusimha, Satyan; Underwood, Mark A.; Mazela, Jan; Kaempf, Joseph W.; Tomlinson, Mark; Gollin, Yvonne; Fulford, Kevin; Goff, Yvonne; Wozniak, Paul R.; Baker, Keith; Rich, Wade; Morales, Ana; Varner, Michael W.; Poeltler, Debra; Vaucher, Yvonne E.; Mercer, Judith S.; Finer, Neil N.; ghormli, Laure El; Rice, Madeline Murguia

doi:10.1016/j.ajog.2022.08.015

Cited by 28 publications

(20 citation statements)

References 44 publications

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“…When compared to ECC, there was no evidence that UCM caused any harm. These findings may represent the first randomized controlled trial proof that UCM is possible, safe, and preferable to ECC in nonvigorous newborns (62). An ongoing trial in India aimed to reduce HIE may help determine whether UCM can be efficacious in non-vigorous newborns (NCT03657394).…”

Section: Cord Milking For Non-vigorous Babiesmentioning

confidence: 84%

Umbilical cord milking-benefits and risks

2023

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The most common methods for providing additional placental blood to a newborn are delayed cord clamping (DCC) and umbilical cord milking (UCM). However, DCC carries the potential risk of hypothermia due to extended exposure to the cold environment in the operating room or delivery room, as well as a delay in performing resuscitation. As an alternative, umbilical cord milking (UCM) and delayed cord clamping with resuscitation (DCC-R) have been studied, as they allow for immediate resuscitation after birth. Given the relative ease of performing UCM compared to DCC-R, UCM is being strongly considered as a practical option in non-vigorous term and near-term neonates, as well as preterm neonates requiring immediate respiratory support. However, the safety profile of UCM, particularly in premature newborns, remains a concern. This review will highlight the currently known benefits and risks of umbilical cord milking and explore ongoing studies.

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Section: Cord Milking For Non-vigorous Babiesmentioning

confidence: 84%

Umbilical cord milking-benefits and risks

2023

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“…The current recommendation in non-vigorous infants is to perform CC immediately after birth, prioritizing the initiation of resuscitation maneuvers 9 . However, a recently published RCT suggests that this practice may not, in fact, be beneficial 44 . It would be reasonable to assume that similar or more pronounced changes in cardiac performance occur with immediate CC compared to those described herein with DCC.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Cord Clamping on Haemodynamic Transition in Term Newborn Infants

Chioma

Finn

Healy

et al. 2023

Preprint

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Background: The transition from fetal to neonatal circulation is a complex physiological phenomenon, influenced by umbilical cord clamping and lung aeration, which triggers an increase in pulmonary blood flow and left ventricular preload. Although clinical evidence suggests that delayed cord clamping (DCC) prevents complications of haemodynamic instability, such as cerebrovascular injury, the cardiovascular consequences of DCC have not been investigated yet in humans. Methods: Echocardiography was performed in 46 term vigorous infants before DCC, immediately after DCC, and at 5 minutes of life. Pulsed-wave Doppler-derived cardiac output and the pulmonary artery acceleration time indexed to the right ventricle ejection time, as a proxy of right ventricular afterload, were obtained. As markers of pre- and afterload fluctuations, the myocardial performance indexes and the velocities of the tricuspid and mitral valve annuli were determined with tissue Doppler imaging. Heart rate was derived from Doppler imaging and obtained throughout the assessments. Echocardiographic parameters were compared across the three timepoints using repeated measures ANOVA or Friedman's test. Results: DCC occurred at a median of 65 seconds (interquartile range 60-70). Left ventricular output increased throughout the first minutes of life (mean(SD): 222.4(32.5) mL/Kg/min before CC vs. 239.7(33.6) mL/Kg/min at 5 minutes, P=0.01), while right ventricular output dropped after CC (306.5(48.2) mL/Kg/min before CC vs. 272.8(55.5) mL/Kg/min immediately after CC, P=0.001). Right ventricular afterload rose after CC, decreasing in the following minutes. The tissue Doppler measurements showed that the loading conditions of both ventricles were transiently impaired by CC, recovering at 5 minutes. The heart rate progressively decreased after birth, following a linear trend temporarily disrupted by CC. Forward stepwise regression indicated that the variation in left ventricular output across the CC was directly correlated to the fluctuation of left ventricular preload over the same period (P=0.03). Conclusion: This study unveils the cardiovascular consequences of DCC in term vigorous infants and offers insight into the haemodynamic transition from fetal to neonatal circulation in humans. Strategies that aim to enhance left ventricular preload before CC, such as initiating ventilation with an intact umbilical cord in apneic infants, may prevent complications of perinatal cardiovascular imbalance.

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“…Katheria et al [ 39 ]. compared umbilical cord milking (stripping the umbilical cord four times towards the neonate) prior to cord clamping to early cord clamping in non-vigorous near-term and term infants in a multicenter, cluster-randomization trial that was recently concluded and published Infants in the milking group needed less respiratory support and had lower incidence of moderate-to-severe hypoxic–ischemic encephalopathy and need for therapeutic hypothermia.…”

Section: Discussionmentioning

confidence: 99%

Role of Volume Replacement during Neonatal Resuscitation in the Delivery Room

et al. 2022

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Volume expanders are indicated in the delivery room when an asphyxiated neonate is not responding to the steps of neonatal resuscitation and has signs of shock or a history of acute blood loss. Fetal blood loss (e.g., feto-maternal hemorrhage) may contribute to perinatal asphyxia. Cord compression or a tight nuchal cord can selectively occlude a thin-walled umbilical vein, resulting in feto-placental transfusion and neonatal hypovolemia. For severe bradycardia or cardiac arrest secondary to fetal blood loss, Neonatal Resuscitation Program (NRP) recommends intravenous volume expanders (crystalloids such as normal saline or packed red blood cells) infused over 5 to 10 min. Failure to recognize hypovolemia and subsequent delay in volume replacement may result in unsuccessful resuscitation due to lack of adequate cardiac preload. However, excess volume load in the presence of myocardial dysfunction from hypoxic–ischemic injury may precipitate pulmonary edema and intraventricular hemorrhage (especially in preterm infants). Emergent circumstances and ethical concerns preclude the performance of prospective clinical studies evaluating volume replacement during neonatal resuscitation. Translational studies, observational data from registries and clinical trials are needed to investigate and understand the role of volume replacement in the delivery room in term and preterm neonates. This article is a narrative review of the causes and consequences of acute fetal blood loss and available evidence on volume replacement during neonatal resuscitation of asphyxiated neonates.

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Umbilical cord milking in nonvigorous infants: a cluster-randomized crossover trial

Cited by 28 publications

References 44 publications

Umbilical cord milking-benefits and risks

Umbilical cord milking-benefits and risks

The Impact of Cord Clamping on Haemodynamic Transition in Term Newborn Infants

Role of Volume Replacement during Neonatal Resuscitation in the Delivery Room

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