Just wait a minute, and you save thousands of preterm babies a year

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November 17 is celebrated as World Prematurity Day and theme for this year is ‘let them thrive.’

According to WHO An estimated 15 million babies are born preterm every year – more than 1 in 10 babies around the world and this number is rising. Preterm birth complications are the leading cause of death for children under 5.

Well, the obstetricians and health care personal assisting in child birth could save thousands of lives by waiting 60 seconds before clamping the umbilical cord after birth instead of clamping it immediately reports the results of a systematic review and meta-analysis led by the University of Sydney's National Health and Medical Research Council Clinical Trials Centre.

The review will be published in forthcoming issue of American Journal of Obstetrics and Gynecology.

The researchers  looked into data from 18 randomized controlled trials that compared delayed vs early clamping amounting to total of 2834 infants born before 37 weeks' gestation. The cord was clamped after 60 seconds in infants allocated to delayed cord clamping group.

Infants who had their cord clamped after 1 minute faced a 32% reduced risk of mortality and 33 infants need to have delayed cord clamping to save one infant (number need to treat = 33).

Out of 18 trials, 3 trials consisted of about 1000 infants born before ≤28 weeks’ gestation. They had a 30% reduction in mortality and the number need to treat was 20.

The two groups were comparable for Apgar scores, intubation for resuscitation, admission temperature, mechanical ventilation, intraventricular hemorrhage, brain injury, chronic lung disease, patent ductus arteriosus, necrotizing enterocolitis, late-onset sepsis, or retinopathy of prematurity.

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Delay in cord clamping improved the hematocrit by 3% and 10% fewer babies required blood transfusion.

The side effects of delayed clamping were polycythemia and hyperbilirubinemia.

"The review shows for the first time that simply clamping the cord 60 seconds after birth improves survival," said the University of Sydney's Professor William Tarnow-Mordi, senior author.

"It confirms international guidelines recommending delayed clamping in all preterm babies who do not need immediate resuscitation."

"We estimate that for every thousand very preterm babies born more than ten weeks early, delayed clamping will save up to 100 additional lives compared with immediate clamping," said the University of Sydney's Associate Professor David Osborn, the review's lead author and a neonatal specialist at Royal Prince Alfred Hospital.

"This means that, worldwide, using delayed clamping instead of immediate clamping can be expected to save between 11,000 and 100,000 additional lives every year."

The study findings are in accordance with a second Australian study published in The New England Journal of Medicine. The Australian study enrolled about 1500 babies, from25 centers in 7 countries. The babies were born on an average 10 weeks early. Delayed cord clamping saved 3% more babies, as compared to immediate cord clamping (mortality was  6% vs 9%)(p=0.03).

Currently, WHO recommends waiting at least 60 seconds before cord clamping in premature and term babies.

ACOG also recommends, “a delay in umbilical cord clamping for all healthy infants for at least 30-60 seconds after birth given the numerous benefits to most newborns.” 

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ACOGrecommendations for delayed cord clamping

WHO recommendations for delayed cord clamping

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ACOG recommends against vaginal seeding in Cesarean births

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ACOG today issued a policy statement against the practice of vaginal seeding in cesarean deliveries, in absence of sufficient data on potential benefits associated with the procedure.

The new policy statement published in the November issue of Journal Obstetrics and Gynecology. Earlier Danish Society of Obstetrics and Gynecology has already issued a similar statement at the national meeting on 19 January 2017.

Vaginal seeding is practiced at cesarean birth and consists of transferring maternal vaginal fluid with a gauze or swab to mouth, nose, or skin of a newborn infant to inoculate him with maternal bacteria. 

This practice came into vogue following a dramatic rise in prevalence of childhood asthma, atopic disease, and other immune disorders that paralleled a steep increase in cesarean sections rate worldwide, which prevented the fetal natural colonization with maternal vaginal flora.

At present ACOG only endorse it as a part of research project in institutions under an approved protocol.

If a patient or her attended insist for the procedure, they should be fully informed about the lack of scientific data in favor of any potential benefits. They should be explained the risks associated with the procedure and the mother should be tested for infectious diseases and potentially pathogenic bacteria. Lab testing should be ordered for herpes simplex virus and cultures for group B streptococci, Chlamydia trachomatis, and Neisseria gonorrhea.

The discussion with the patient should always be documented in her medical records and take in presence of other gynecologist, family physician or pediatrician. In the event of neonatal infection or sepsis, they are at least aware of the procedure.

The relationship between breast feeding and childhood asthma and allergies remains uncertain, ACOG recommends exclusive breast feeding for the first six months of life as it has ‘multiple known benefits.’

More research is needed on the subject before the potential benefits of this procedure is documented. Till date, the only available research on vaginal seeding is the result of a small pilot study published in Nature Medicine that was able to document similarities between bacterial communities of infants delivered by cesarean section and undergone vaginal seeding and babies delivered vaginally.

Related posts:

Danish Society of Obstetrics and Gynecology recommends against vaginal seeding in Cesarean births

Microbirthing: The " Vaginal Seeding" is growing fad, but thin evidence concerns physicians!

Full Text of the committee opinion

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Danish Society of Obstetrics and Gynecology recommends against vaginal seeding in Cesarean births

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The potential risks associated with practice of vaginal seeding (VS) in Cesarean Delivery outweighs the hypothetical benefits and consequently we do not recommend it at present says the national recommendations released by Danish Society of Obstetrics and Gynaecology at the national meeting on 19 January 2017.

The recommendation along with a commentary was published online 22 AUG 2017 in British Journal of Obstetrics and Gynecology.

“We could not identify any other national or international society that had systematically investigated the clinical approach to VS,” write Thor Haahr, MD, PhD, from the Department of Obstetrics and Gynaecology at the Institute for Clinical Medicine, Aarhus University Hospital, Skejby, Denmark.

The recommendations are aimed at providing fellow obstetricians and midwives with the basic information about VS so that it can be discussed with couples and families opting for it.

The recommendations state that:

Maternity wards should not take part in screening, guiding or encouraging women for Vaginal Seeding.

Vaginal seeding is contraindicated in infants born before 37 weeks, born to mothers who meet national criteria for group B streptococci(GBS) prophylaxis during delivery, situations in which the cesarean section is done to prevent vertical transmission of infection such as—primary vaginal herpes infection, HIV infection with HIV-RNA >50 copies/ml and any other situations in which the VS will cause potential harm to the fetus.

Parents who still wish to perform VS, can do so provided “it does not interfere with or delay other procedures.” They should be informed about insufficient evidence in favor of any potential benefit and should be provided with patient information booklet. They should also be educated about signs of infection in neonates should any infection occurs after the procedure.

Interest in VS sparked after Dominguez-Bello and colleagues published the results of their pilot study in 2016 stating that Neonatal colonization can be partially restored in cesarean born babies by VS.  Several other studies have since followed involving VS which stress the importance of more research and publications on this topic.

Microbirthing:The " Vaginal Seeding" is growing fad, but thin evidence concerns physicians!

Although, the risk associated with VS is very low, the immediate concern after VS is early onset neonatal sepsis (EOS) with Escherichia coli or GBS.

David A. Eschenbach, MD, from the Department of Obstetrics and Gynecology, University of Washington, Seattle raised several questions in his accompanying commentary that need to be addressed before VS becomes a routine practice.

His major concern was our current inability to identify that which vaginal bacteria/gut bacteria will produce potential benefit while minimizing the harm. Choosing between ‘harmful’ and ‘helpful’ bacteria is expensive procedure and it is here the cost -benefit analysis comes in.

"We simply are too far behind in knowledge to start this practice without heeding the Society's recommendations," he concluded.

The authors suggest that clinicians whose patients want to adopt the practice should be told about the risk involved and other ways of that have an effect on neonatal colonization, including early skin-to-skin contact, breast-feeding, and diet during pregnancy.

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