From the Editor

OB and neonatal medicine practices are evolving— in ways that might surprise you

Move away from, first, suctioning during normal term birth and, second, any immediate clamping of the cord. There’s more.


 

References

Obstetricians are trained to manage key aspects of the birth process, including protecting the maternal perineum and fetus from trauma and providing initial support to the newborn. Historically, our initial support for the newborn has included:

  • suctioning the oronasopharynx
  • immediate clamping of the cord
  • providing 100% oxygen if resuscitation is necessary.

The American Academy of Pediatrics recently modified its recommendations on initial support to emphasize several alternative practices.1 Here is a roundup of what the Academy recommends now.

For normal term birth

Reduce, or eliminate, the practice of suctioning the fetal oronasopharynx

During the past half century, the first action an OB took after delivering the fetal head was to perform oronasopharyngeal suctioning, using a bulb or DeLee device. The aim has been to remove secretions that might interfere with initial breathing by the newborn.

Recent expert guidance, however, recommends that OBs cease this practice1: For a healthy newborn, suctioning appears to do more harm than good because it can cause cardiorespiratory complications.

Study results were clear. In a randomized clinical trial, 140 newborns born by cesarean delivery were randomized to oronasopharyngeal suctioning or no suctioning. At 2 minutes and at 6 minutes after birth, infants who were treated with oronasopharyngeal suctioning had a lower mean O2 saturation and a higher mean heart rate than those who were not suctioned. In addition, the Apgar score was, on average, one point lower at 5 minutes in infants who were suctioned.2

Given a lack of evidence of benefit, and evidence of potential harm, reserve suctioning for newborns who have obvious respiratory difficulty caused by secretions. If you determine that suctioning is required, perform gentle bulb suctioning of the mouth and nares with minimal stimulation of the posterior pharynx, which can cause a vagal response and bradycardia.

For term and preterm births

Stop immediate clamping of the cord

At birth, when a newborn is placed on the maternal abdomen or held below the vaginal introitus and the cord is not clamped, approximately 25 mL of blood for every kilogram of birth weight is transfused from the placenta-cord into the newborn. Most of that transfusion occurs in the first 2 minutes after birth; in some infants, transfusion continues for as long as 5 minutes.3

Autotransfusion significantly increases hemoglobin concentration in a newborn. It’s notable that the newborn obtains benefit from delayed clamping whether it has been placed on its mother’s abdomen or held below the vaginal introitus4—suggesting that gravity alone isn’t responsible for cord-to-newborn transfusion. Although delayed cord clamping has been studied for 70 years,5 only 1% of OBs who participated in a recent survey in the United Kingdom reported that they delay cord clamping for at least 1 minute.6

Pluses & minuses. Evidence from many clinical trials indicates that delaying cord clamping carries benefits and risks4,7—but that the benefits outweigh risks, in most cases (TABLE).

Delayed cord clamping presents both benefits and risks to the baby

Benefits4,7
  • An increase in red blood cell volume, with an improvement in hemoglobin concentration of approximately 2 to 5 g/L
  • An increase in the serum ferritin level at 6 months of age
  • A diminished likelihood of being diagnosed with anemia in the first year of life
Risks7
  • An increase in the risk of neonatal jaundice
  • An increase in the need for phototherapy
  • An increase in blood viscosity immediately after birth

In addition, delayed cord clamping is associated with delayed administration of a postpartum uterine tocolytic. This delay does not, however, appear to increase the risk of postpartum hemorrhage.

Note: If you are concerned about waiting 1 to 5 minutes to clamp the cord because it might delay resuscitation of an infant, milking the cord four times appears to provide significant cord-to-fetus transfusion.8

Who benefits the most? Delayed clamping of the cord is likely to provide the greatest benefit to preterm newborns. In some studies, delayed clamping in very preterm infants (<32 weeks’ gestation) reduced the incidence of intraventricular hemorrhage and late-onset sepsis. For example, in a study in which 72 mother-infant pairs were randomized to delayed cord clamping or immediate cord clamping, intraventricular hemorrhage occurred in 14% of infants in the delayed group and in 36% of the immediate-clamping group.9

In a healthy term infant who has access to good postnatal nutrition, the benefits of delayed cord clamping are likely limited to a modest increase in hemoglobin concentration. The problem with delayed cord clamping in a healthy term infant is an increased risk of jaundice and need for phototherapy.7

In some centers, umbilical cord blood is collected and stored in a public cord blood bank for use in a bone marrow transplantation program. Autotransfusion of blood from the cord to the newborn reduces the success rate of cord blood collection for public banking because fewer stem cells are obtained from a depleted cord.

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