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Effect of delayed umbilical cord clamping on blood gas analysis

Javier Valero, Domingo Desantes, Alfredo Perales-Puchalt, Juan Rubio, Vicente J. Diago Almela,Alfredo Perales *

Obstetrics Department, University Hospital La Fe, Valencia, Spain

1. Introduction

Blood gas analysis (BGA) from umbilical cord vessels is the most

objective determination of the fetal metabolic condition at the

moment of birth. It provides insight into intrapartum fetal

physiology and, if normal, excludes perinatal asphyxia or hypoxia

secondary to the birth process. Arterial umbilical cord BGA is an

essential criterion to define neonatal encephalopathy and cerebral

palsy due to an intrapartum cause [1], and for that reason,

immediate cord clamping (ICC) was advised as a component of

the active management of the third stage of labor [2]. There is,

however, no current evidence for ICC to be considered a component

in the management of the third stage of labor [3], and delayed cord

clamping (DCC) after thecessation ofcordpulsations hasemergedas

a standard of care in normal labor and delivery.

There are many studies on delayed BGA after ICC because

immediateanalysis isnotalways possible when theobstetrician andmidwife have to attend to the mother and her baby or there are

limited hospital facilities [4,5]. In contrast, to the best of our

knowledge, there are only two published studies about BGA after

DCC [6,7]. In DCC, since the cord remains in continuity with the

placenta, due to ongoing placental metabolism i.e. changes in the

cord

milieu

(gaseous

diffusion),

placental-maternal

gas exchange

(decrease in uteroplacental blood flow secondary to uterine

contraction after delivery) and newborn breathing a change in

acidbase status may happen. If a change in the parameter values

occurs with DCC, new standards should be defined. The objective of

this study was toascertain variation inumbilical cordBGAafter DCC

compared to ICC, and whether these changes are time-dependent.

2.

Materials

and

methods

This study was done in the University Hospital La Fe, Valencia,

Spain, and approved by its Ethical Committee. We obtained paired

blood samples from the umbilical artery and vein of 60 term

newborns. All neonates were full-term singletons born vaginally in

a vertex presentation. Only neonates expected not to need

immediate resuscitation procedures were included. All fetuses

were monitored with continuous cardiotocography (CTG) duringthe first and second stages of labor.

The classic cord clamping used in our center was the ICC, which

is done immediately after delivery of the neonate (within the first

30 s after birth). At that time we double clamp a segment of

umbilical cord and the midwife immediately takes a blood sample

from the umbilical artery and vein with a plastic syringe for BGA in

a blood gas analyzer that is in every delivery room. This is done

systematically after every delivery.

The DCC practice used in our center is to leave the neonate on

the mothers abdomen for early motherneonate contact and to

clamp the umbilical cord after its pulsation spontaneously ceases.

European Journal of Obstetrics & Gynecology and Reproductive Biology 162 (2012) 2123

A R T I C L E I N F O

Article history:

Received 9 October 2011

Received in revised form 24 December 2011Accepted 31 January 2012

Keywords:

Fetal monitoring

Blood gas analysis

Acidbase equilibrium

Umbilical cord

Lactic acid

Fetal blood

A B S T R A C T

Objective: To ascertain if there are differences in umbilical cord blood gas analysis between immediate

and delayed cord clamping.

Study design: In a prospective observational study on 60 vaginally delivered healthy term newborns, wesampled umbilical cord blood immediately after delivery and at the time umbilical cord pulsation

spontaneously ceased.

Results: Thereweresignificant decreasesin pH,oxygen saturation(sO2), glycemia,oxygencontent (ctO2),

bicarbonate (HCO3) and base excess (BE). Lactate and PCO2 increased. Delayed cord clamping pH

correlatedwith immediate cord clampingpH,PO2 , ctHb, sO2 and time (r2 = 0.77,p < 0.000). Delayed cord

clamping lactate was associated with immediate cord clamping lactate and time (r2 = 0.83, p < 0.000).

Delayed BE was associated with previous pH, lactate, glycemia, ctHb and time (r2 = 0.83, p < 0.000).

Conclusions: Delayed cord clamping alters acidbase parameters and lactate values compared to

immediate cord clamping. Those variations depend mainly on time, prior pH and lactate.

2012 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author at: Obstetrics Department, University Hospital La Fe,

Bulevar Sur s/n, Valencia 46026, Spain. Tel.: +34 600628569.

E-mail address: perales_alf@gva.es (A. Perales).

Contents

lists

available

at

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European Journal of Obstetrics & Gynecology andReproductive Biology

jour nal homepage: www.elsev ier .co m/ locate /e jogrb

0301-2115/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.ejogrb.2012.01.020

http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020mailto:perales_alf@gva.esmailto:perales_alf@gva.eshttp://www.sciencedirect.com/science/journal/03012115http://www.sciencedirect.com/science/journal/03012115http://www.sciencedirect.com/science/journal/03012115http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://dx.doi.org/10.1016/j.ejogrb.2012.01.020http://www.sciencedirect.com/science/journal/03012115mailto:perales_alf@gva.eshttp://dx.doi.org/10.1016/j.ejogrb.2012.01.020

8/10/2019 Effect of Delayed Umbilical Cord Clamping

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In this study, immediately after delivery we placed the neonate

on the mothers abdomen and took a blood sample from the

umbilical artery and vein. Weplaced a finger over the punctures to

avoid blood loss and detect umbilical cord pulsation. After

umbilical cord pulsation ceased we double clamped the umbilical

cord (1020 cm). We measured the time from birth to cord

clamping in each delivery. After DCC we obtained a new blood

sample from the umbilical artery and vein. From each umbilical

cord paired artery and vein samples were obtained, immediately

after birth and once pulsation ceased.

Each sample was collected in a 2 ml plastic syringe prepared in

advance. The BGA was performed in a Radiometer ABL 800 flex

analyzer (Radiometer A/S, Copenhagen, Denmark), immediately

after the sample collection. Daily quality control procedures using

the QualicheckTM quality control system from RadiometerTM was

done. After each procedure, the analyzer underwent an automatic

self-cleaning process and autocalibration took place every 30 min.

For each blood sample analyzed we obtained pH, PCO2 , PO2 , total

hemoglobin content (ctHb), oxygen saturation (sO2), base excess

(cBE), bicarbonate (HCO3), oxygen content (ctO2), glucose

concentration in plasma (cGlu), and lactate concentration in

plasma (cLac). The analyzer works by measuring pH and PCO2 by

potentiometry, PO2 , plasma glucose and lactate by amperometry

and total Hb, sO2 by spectrophotometry. The concentrations ofctO2, cBE and HCO3

are calculated parameters.

2.1.

Statistical

analysis

Comparisons wereperformed with the Wilcoxon matchedpairs

test. Association between pairs was done by the Spearman test. To

analyze the factors associated with the DCC pH, lactate and base

deficit, we performed a multiple regression analysis.

All statistical analyses were done with SPSS Statistics 15 (SPSS,

Chicago, IL). The level of significance used was p 0.05.

3. Results

All

newborns

were

vigorous,

according

the

Apgar

sore.

The

DCC

time range was between 45 and 180 s, and arterial pH ranged

between 7.08 and 7.38, while in venous blood it was from 7.18 to

7.45. When we took artery and vein together, there were

significant

decreases

in

pH,

sO2, glycemia, ctO2, HCO3,

and

BE,

while PCO2 and lactate increased (Table 1). Both artery and vein

showed similar changes when analyzed separately. Paired values

of blood gas analysis strongly and significantly correlated; the

Spearman

Rho

ranged

from

0.80

to

0.96,

and

for

all

cases

with

p < 0.001.

The time elapsed between ICC and DCC correlated with

differences

in

pH

(Rho

=

0.32

p