A Randomized Controlled Trial of Intact Cord Milking versus Immediate Cord Clamping in Term Infants Born by Elective Cesarean Section.

OBJECTIVE: We evaluated whether intact umbilical cord milking (UCM) is more effective than immediate cord clamping (ICC) in enhancing placental transfusion after elective cesarean delivery. STUDY DESIGN: In a randomized trial, volume of placental transfusion was assessed by Δ hematocrit (Hct) between neonatal cord blood and capillary heel blood at 48 hours of age, corrected for the change in body weight. RESULTS: There were no significant differences in cord blood mean Hct values at birth (UCM, 44.5 ± 4.8 vs. ICC, 44.9 ± 4.2%, p = 0.74). Conversely, at 48 hours of age, the UCM group had significantly higher capillary heel Hct values (UCM, 53.7 ± 5.9 vs. ICC, 49.8 ± 4.6%, p < 0.001), supporting a higher placental transfusion volume (Δ Hct, UCM 9.2 ± 5.2 vs. ICC 4.8 ± 4.7, p < 0.001), despite comparable neonatal body weight decrease (UCM, -7.3 vs. ICC, -6.8%, p = 0.77). CONCLUSION: Higher Δ Hct between cord blood at birth and capillary heel blood at 48 hours of age, corrected for the change in body weight, suggests that intact UCM is an efficacious and safe procedure to enhance placental transfusion among neonates born via elective cesarean delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT03668782.

Determinants and effects of fluid status changes in caesarean delivered neonates.

AIM: Evidence suggests that caesarean section is associated with a reduced placental transfusion and poor iron-related haematological indices, both in cord and peripheral blood, compared with vaginal delivery. We assessed determinants and effects of fluid status changes on placental transfusion in neonates delivered by elective (ElCD) and emergency (EmCD) caesarean section. METHODS: Placental transfusion was estimated by ∆ haematocrit (Hct) increase from birth to 48 hours of life, accounting for contemporaneous ∆ body weight decrease, in 143 women/infant pairs, 62 who underwent ElCD and 81 EmCD, respectively. RESULTS: Cord blood Hct levels at birth of ElCS neonates were significantly lower than those of EmCD neonates (44.58 + 4.87vs 49.93 + 4.29, P = .01). At 48 hours of life, capillary heel Hct levels of ElCD and of EmCD neonates were comparable. ElCD had a higher ∆ body weight decrease (ElCD -7.25 ± 1.74% vs EmCD -6.31 ± 2.34% [P: .011]) and ∆ Hct increase ([ElCD + 5.93 ± 4.92 vs EmCD + 3.59 ± 5.29, [P: .011]). In a linear regression model analysis, gestational age in ElCD neonates had a significant effect on the differences in arterial cord blood Hct, body weight at birth and body weight decrease at 48 hours after birth. CONCLUSION: Early-term surgical delivery is a determinant of transient dilutional anaemia in ElCD neonates, lacking neuroendocrine response of labour and delivery.

'Two-step' head-to-body delivery activates foetal gluconeogenesis.

AIM: The 'two-step' head-to-body delivery method, which involves waiting for the next contraction to deliver the shoulders, causes a decrease in umbilical artery pH. The aim of this study was to assess whether foetal acidemia activates gluconeogenesis. METHODS: We tested umbilical artery cord blood glucose concentration and pH after 341 spontaneous and 25 vacuum extractor 'two-step' vaginal deliveries (VD) and after 85 elective and 49 emergency caesarean sections (CS). RESULTS: Cord blood glucose concentration was significantly higher (95.5 ± 21.4 mg/dL vs 75.6 ± 16.4, p < 0.001), and pH values significantly lower (7.31 ± 0.09 vs 7.33 ± 0.06, p = 0.003) in 'two-step' VD neonates than in CS delivered neonates. In addition, cord blood glucose concentration was significantly higher (101.4 ± 30.6 mg/dL, p = 0.004), and pH values were significantly lower (7.26 ± 0.10, p < 0.001) in VD by vacuum extractor than in all other groups. The cord blood glucose concentration is significantly and negatively correlated with pH in the study population (r = -0.094, p = 0.036) and strongly significantly and negatively correlated in VD by vacuum extractor (r = -0.594, p = 0.007). CONCLUSION: Cord blood glucose concentrations are significantly higher and pH values significantly lower in 'two-step' VD neonates, indicating activated foetal gluconeogenesis.

Calcium and lactate in the fetal-to-neonatal transition.

OBJECTIVE: To explore the relationship between calcium and lactate in arterial cord blood of healthy term neonates in response to the stress of labor. METHODS: This was a prospective cohort study of consecutive, vaginal, term births in a community medical center (April 2029 to February 2020). Calcium and lactate were measured in cord blood gas analysis immediately after delivery. RESULTS: In the arterial cord blood of 480 neonates, calcium levels were 1.5 (1.4; 1.5) mmol/L and lactate levels were 3.8 (2.9; 4.9) mmol/L. Calcium and lactate showed a statistically significant positive correlation (Pearson's correlation, r = 0.15, p = .001). Calcium levels had a significant positive correlation with PaCO2 and a significant negative correlation with pH, PaO2, HCO3-, and ABE levels. Multivariable analysis models confirmed that calcium levels were associated with HCO3-, gestational age, and birth weight, all accounting for 7% of the variability. CONCLUSION: In healthy term vaginally delivered neonates, it was found that calcium and lactate were strongly correlated, together pointing to a neonatal response to the stress of labor and delivery. Cord blood calcium regulation may have an ancillary role in defining neonatal adaptation to extrauterine life.

Umbilical cord bilirubin level and pre-discharge hyperbilirubinemia risk.

OBJECTIVES: To assess whether arterial umbilical cord bilirubin (aUCB) level at delivery predicts predischarge neonatal hyperbilirubinemia, facilitating a safe discharge from the hospital. METHODS: Prospective analysis of hospital biochemistry records identified near term and term infants with recorded aUCB and predischarge, at 36 h of life, capillary heal bilirubin (cHB), to identify those with a cutoff of bilirubin levels >9 mg/ml, >75th percentile on the nomogram of Bhutani et al. RESULTS: Of 616 study neonates, median (IQR) aUCB and cHB levels were 1.5 mg % (IQR 0.7-2.2) and 7.7 mg % (IQR 6.6-8.9), respectively. The values resulted statistically correlated (Pearson correlation coefficient 0.26, p < .0001) and an increment of 1 mg/dl in aUCB was associated with an increment (Regression coefficient, 95% confidence interval) of mean cHB 0.49 (0.33-0.65, p < .0001). Among these, 143 (23.2%) neonates developed bilirubin levels >9 mg/ml at 36 h of life and multivariable analysis confirmed that cHB levels (OR 1.49, 95% CI 1.22-1.82; p < .0001) and vaginal delivery (OR 2.34, 95% CI 1.33-4.36; p = .005) were significantly associated with bilirubin levels >9 mg/ml. CONCLUSIONS: These data suggest that aUCB should be added to the list of major risk factors for neonatal hyperbilirubinemia.

Laryngeal Mask Airway for neonatal resuscitation in a developing country: evaluation of an educational intervention. Neonatal LMA: an educational intervention in DRC.

BACKGROUND: Studies carried out in developing countries have indicated that training courses in newborn resuscitation are efficacious in teaching local birth attendants how to properly utilize simple resuscitation devices. The aim of this study was to assess the knowledge and expertise gained by physicians and midwifes who participated in a Neonatal Resuscitation Course and workshop organized in a Third World Country on the use of Laryngeal Mask Airway (LMA). METHODS: A 28-item questionnaire, derived from the standard test contained in the American Heart Association and the American Academy of Pediatrics Neonatal Resuscitation Manual, was administered to 21 physicians and 7 midwifes before and after a course, which included a practical, hands-on workshop focusing on LMA positioning and bag-ventilation in a neonatal manikin. RESULTS: The knowledge gained by the physicians was superior to that demonstrated by the midwifes. The physicians, in fact, demonstrated a significant improvement with respect to their pre-course knowledge. Both the physicians and the midwives showed a good level of expertise in manipulating the manipulating the manikin during the practical trial session. The midwifes and physicians almost unanimously manifested a high degree of approval of neonatal resuscitation by LMA, as they defined it a sustainable and cost-effective method requiring minimal expertise. CONCLUSIONS: Further studies are warranted to test the advantages and limits of the neonatal LMA training courses in developing countries.

Correction to: Morphine-induced supraventricular tachycardia in near-term fetus.

The original article [1] contained an error whereby all authors' names were mistakenly inverted.

Maternal areola pH: A chemical basis for mother-infant recognition.

BACKGROUND: The human female's areolar region is the point of arrival of a natural progression from birth to breastfeeding continuum, supported by numerous functional features. AIMS: The aim of this study was to look more closely into the areola' skin chemical signals that are uniquely important for mother-infant chemoemission, chemoreception, and breastfeeding continuum. STUDY DESIGN: A dermatological study of the areolae and corresponding breast quadrants was undertaken on 71 healthy, at-term women. Areolar and corresponding breast quadrant pH were assessed pre-partum and 1 and 2 days post-partum using a corneometer (Soft Plus 5.5; Callegari S.P.A., Parma, Italy). RESULTS: Pre-partum, the pH of the areola was significantly higher than the pH of the breast quadrant (4.25 ±â€¯0.26 vs. 4.06 ±â€¯0.44, p < 0.015). Post-partum, the pH of the areola was significantly higher that the pH of the breast quadrant both on day one (4.28 ±â€¯0.31 vs 4.01 ±â€¯0.25, p < 0.001) and on day two (4.39 ±â€¯0.19 vs 4.01 ±â€¯0.16, p < 0.001), respectively. In addition, pre-labor pH of the areola increased on day one post-partum and significantly on day two postpartum (4.25 ±â€¯0.26 vs 4.39 ±â€¯0.19, p 0.004). Moreover, the pH of the areola increased significantly from day one to day two post-partum (4.28 ±â€¯0.31 v s 4.39 ±â€¯0.19, p < 0.041). CONCLUSIONS: Our findings show, for the first time, that the areola has a higher pH than the surrounding breast skin, and this increases from day one to day two postpartum. We believe that the pH changes of the areolar region may act as a unique chemical signal to guide the infant directly to the nipple.

Morphine-induced supraventricular tachycardia in near-term fetus.

BACKGROUND: Fetal supraventricular tachycardia (SVT), characterized by fetal heart rate between 220 and 260 bpm, is a rare but most commonly encountered fetal cardiac arrhythmia in pregnancy that may be associated with adverse perinatal outcome. CASE PRESENTATION: We describe a 36/6 week near term fetus who presented morphine-induced SVT after maternal treatment of a renal colic. Following emergency cesarean section, the neonate had resolution of symptoms. CONCLUSIONS: The pathophysiology of morphine-related SVT, previously documented in experimental animal models, and for the first time reported in the human fetus, is presented.

Short hospitalization after caesarean delivery: effects on maternal pain and stress at discharge.

PURPOSE: To characterize predischarge maternal pain and stress after caesarean delivery and short hospitalization. MATERIALS AND METHODS: This is a descriptive study with 60 women in the postoperative period of caesarean section and 60 control women after vaginal delivery. Pain and stress were measured by McGill Pain Questionnaire (MGPQ) and by the Stress Measure (Psychological Stress Measure (PSM)), respectively, at mother-infant dyad discharge, scheduled at 36 hours after delivery. RESULTS: Caesarean section was the delivery modality with the highest MGPQ pain and sensorial, evaluative and mixed pain descriptive categories scores. The pain location involved lower abdomen, with associated localizations at back, breast and shoulders. Conversely, vaginal delivery was the delivery modality with the highest stress scores. CONCLUSION: This study provides important information on the quality of care implications of early discharge practices in puerperae after caesarean delivery, a critical time characterized by qualitatively and quantitatively high pain and stress.

Umbilical cord blood acid-base analysis and the development of significant hyperbilirubinemia in near-term and term newborns: a cohort study.

BACKGROUND: The recognition, follow-up, and early treatment of neonatal jaundice has become more difficult, since the earlier discharge of newborns from hospitals has become common practice. Since intrapartum hypoxic stress has been pointed as predisposing factor for the occurrence of hyperbilirubinemia risk, we tested the association with the cord blood acid-base index tests. METHODS: A cohort of healthy term and near-term newborns underwent umbilical cord hemogasanalysis at birth and capillary heel total serum bilirubin (TSB) pre-discharge, scheduled at 36 h of life, to define the risk of significant hyperbilirubinemia, defined as >9 mg/dL TSB level, ≥ 75th percentile on nomogram of Bhutani et al. RESULTS: It was found that among 537 studied neonates, 133 (24.8%) had pre-discharge TSB levels of >9 mg/dL. When the cord blood gas analysis index tests were compared, their acidemia levels were significantly higher than those of neonates with normal TSB levels: HCO3- (20.71 ± 2.37 vs. 21.29 ± 2.25 mEq/L, p < 0.010), base deficit (-3.52 ± 3.188 vs. -2.68 ± 3.266 mEq/L, p < 0.010), and lactacidemia (3.84 ± 1.864 vs. 3.39 ± 1.737 mEq/L, p < 0.012), respectively. However, logistic regression analysis showed that base deficit was the strongest index of the pre-discharge hyperbilirubinemia risk (OR, 95% CI 0.593; 0.411-0.856), and the hyperbilirubinemia risk increased by 40% with the decrease of 1 mEq/L of base deficit. CONCLUSIONS: Umbilical cord blood acidemia and lactacidemia are significant indexes of adaptive mechanisms at birth. The base deficit provides the strongest association with future development of high bilirubin on an hour specific bilirubin nomogram generating risk stratification score in term and near-term neonates.

Neonatal resuscitation by laryngeal mask airway after elective cesarean section.

The aim of this case-control study was to determine whether unplanned resuscitation using a laryngeal mask airway (LMA) is suitable for neonates delivered by elective cesarean section, a procedure known to carry a risk of inadequate physiological response to birth with a consequent adverse respiratory outcome. During a 3-year period, from January 1998 to December 2000, all newborns delivered by elective cesarean section at term were compared with the next infant born vaginally in the same maternity unit (level III center). The two groups were matched for gestational age >37 weeks. The requirement for resuscitation with positive-pressure ventilation (PPV) using either the LMA or an endotracheal tube (ETT), together with the occurrence of an adverse neonatal outcome, was recorded and analyzed in the cesarean section and vaginal delivery groups. During this time 1,284 at-term elective cesarean sections were performed. 3% (n = 43) of the cesarean section deliveries and 1.4% (n = 18) of the vaginal controls required PPV resuscitation by LMA or ETT, a significant difference (OR 1.26; 95% CI 2.38-5.1; p < 0.01). Of the cesarean section group requiring resuscitation, 30 neonates were managed with the LMA and 13 with the ETT, while in the control vaginal delivery group the numbers were 13 and 5, respectively. LMA use accounted of about 70% of the overall PPV resuscitations and was associated with a successful outcome in 42 of 43 cases. One case was unsuccessfully managed with the LMA, and the ETT subsequently used was effective. Moreover, the probability for the LMA-resuscitated newborns of both cesarean and vaginal groups to have a <5 Apgar score at 1 and 5 min, neonatal intensive care unit admission, and respiratory insufficiency requiring oxygen and intermittent mandatory ventilation was statistically lower than for the ETT group (p < 0.01). In conclusion, infants born by elective cesarean section at term are at increased risk of requiring PPV resuscitation as compared with those born by vaginal delivery. We have shown that about 70% of the neonates who required PPV resuscitation after elective cesarean section and vaginal delivery were arbitrarily treated with LMA by the attending anesthesiologist, without adverse negative respiratory outcome.