Effect of Timing of Umbilical Cord Clamping and Other Strategies to Influence Placental Transfusion at Preterm Birth on Maternal and Infant Outcomes

Effect of Timing of Umbilical Cord Clamping and Other Strategies to Influence Placental Transfusion at Preterm Birth on Maternal and Infant Outcomes T review update analyzes what regimens of cord clamping improve outcomes for preterm neonates (less than 37 weeks of gestation). Delayed cord clamping is thought to be associated with improved outcomes owing to improved blood circulation during the immediate transition to life outside of the uterus. The authors reviewed four different strategies for management, but only one had enough data to draw reliable conclusions: delayed cord clamping compared with early cord clamping, both with immediate neonatal care after clamping. Data were available from 40 studies reporting on 4,884 neonates. Delayed cord clamping in the trials typically ranged from 30 to 180 seconds. The authors found that, compared with early cord clamping, delayed cord clamping probably reduces the number of preterm neonates who die before discharge (average risk ratio [aRR] 0.73, 95% CI 0.54–0.98, moderate-certainty evidence) and may slightly reduce the number of neonates with any grade of intraventricular hemorrhage (aRR 0.83, 95% CI 0.7–0.99). Delayed cord clamping had little or no effect on chronic lung disease, and there was insufficient evidence for other outcomes. Comparisons of umbilical cord milking with delayed cord clamping or early cord clamping demonstrated either little or no differences in outcomes or had insufficient evidence to draw conclusions. In line with this review, the American College of Obstetricians and Gynecologists currently recommends delayed cord clamping for 30–60 seconds for preterm neonates owing to significant neonatal benefits, including lower risks of necrotizing enterocolitis and intraventricular hemorrhage as well as a decreased need for blood transfusions. Furthermore, it was not noted to increase risk of postpartum hemorrhage or blood transfusion in the mother.1 Bottom Line: Delayed cord clamping likely reduces mortality risk for preterm neonates, but there is insufficient evidence to conclude what duration is optimal, whether neonatal care should be administered before or after cord clamping, or whether umbilical cord milking is beneficial. Box 1. Abstracts Discussed in This Summary

T his review update analyzes what regimens of cord clamping improve outcomes for preterm neonates (less than 37 weeks of gestation). Delayed cord clamping is thought to be associated with improved outcomes owing to improved blood circulation during the immediate transition to life outside of the uterus. The authors reviewed four different strategies for management, but only one had enough data to draw reliable conclusions: delayed cord clamping compared with early cord clamping, both with immediate neonatal care after clamping. Data were available from 40 studies reporting on 4,884 neonates. Delayed cord clamping in the trials typically ranged from 30 to 180 seconds. The authors found that, compared with early cord clamping, delayed cord clamping probably reduces the number of preterm neonates who die before discharge (average risk ratio [aRR] 0.73, 95% CI 0.54-0.98, moderate-certainty evidence) and may slightly reduce the number of neonates with any grade of intraventricular hemorrhage (aRR 0.83, 95% CI 0.7-0.99). Delayed cord clamping had little or no effect on chronic lung disease, and there was insufficient evidence for other outcomes. Comparisons of umbilical cord milking with delayed cord clamping or early cord clamping demonstrated either little or no differences in outcomes or had insufficient evidence to draw conclusions.
In line with this review, the American College of Obstetricians and Gynecologists currently recommends delayed cord clamping for 30-60 seconds for preterm neonates owing to significant neonatal benefits, including lower risks of necrotizing enterocolitis and intraventricular hemorrhage as well as a decreased need for blood transfusions. Furthermore, it was not noted to increase risk of postpartum hemorrhage or blood transfusion in the mother. 1 Bottom Line: Delayed cord clamping likely reduces mortality risk for preterm neonates, but there is insufficient evidence to conclude what duration is optimal, whether neonatal care should be administered before or after cord clamping, or whether umbilical cord milking is beneficial.

Mechanical Methods for Induction of Labour
This large review update compared safety and efficacy of various mechanical methods for labor induction with pharmacologic methods across 113 trials of 22,373 women. Comparisons included: 1) specific mechanical methods (balloon catheter, laminaria tents, and extra-amniotic space injection) compared with prostaglandins (varied types and routes) or oxytocin; 2) single compared with double balloon; and 3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone. There were 21 total comparisons made in the review. The authors found that mechanical induction with a balloon is likely as effective as vaginal prostaglandin E 2 in achieving vaginal delivery within 24 hours (primary outcome, low-certainty evidence) and also has a more favorable safety profile, with reduced risk of hyperstimulation with fetal heart rate changes (risk ratio 0.35, 95% CI 0.18-0.67), serious neonatal morbidity or mortality (risk ratio 0.48, 95% CI 0.25-0.93), and neonatal intensive care unit admission (risk ratio 0.82, 95% CI 0.65-1.04). Compared with misoprostol, balloon catheter was found to probably increase the risk of vaginal delivery not occurring within 24 hours when compared with oral misoprostol (risk ratio 1.28, 95% CI 1.13-1.46), but it was uncertain whether there was a difference in this outcome compared with vaginal misoprostol. However, the balloon catheter slightly increased the risk of cesarean delivery compared with vaginal and oral misoprostol (risk ratio 1.28 and 1.17, respectively). A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate changes compared with vaginal misoprostol, but it was uncertain whether there was a difference compared with oral misoprostol. Other comparisons did not have sufficient evidence to make conclusions or were uncertain as to whether there was a difference.
Bottom Line: Balloon catheters are safer and just as effective as vaginal prostaglandin E 2 and may be slightly less effective than oral misoprostol, but it remains unclear whether there is a difference in safety outcomes for the neonate. When compared with vaginal misoprostol, evidence shows a balloon may be as effective and may have a better safety profile.
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