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Intrapartum care

DOI: 10.1111/j.1471-0528.2010.02781.x
www.bjog.org

Measuring placental transfusion for term births:


weighing babies with cord intact
D Farrar,a,b R Airey,c GR Law,b D Tuffnell,c B Cattle,b L Duleyb
a
Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK b Centre for Epidemiology and Biostatistics,
University of Leeds, Leeds, UK c Womens and Newborn Unit, Bradford Royal Infirmary, Bradford, UK
Correspondence: Dr D Farrar, Bradford Institute for Health Research, Duckworth Lane, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK.
Email diane.farrar@bradfordhospitals.nhs.uk

Accepted 5 October 2010. Published Online 18 November 2010.

Objective To estimate the volume and duration of placental

transfusion at term.
Design Prospective observational study.
Setting Maternity unit in Bradford, UK.
Population Twenty-six term births.
Methods Babies were weighed with umbilical cord intact using

digital scales that record an average weight every 2 seconds.


Placental transfusion was calculated from the change in weight
between birth and either cord clamping or when weighing
stopped. Start and end weights were estimated using both a
B-spline and inspection of graphs. Weight was converted to
volume, 1 ml of blood weighing 1.05 g.
Main outcome measures Volume and duration of placental

transfusion.
Results Twenty-six babies were weighed. Start weights were
difficult to determine because of artefacts in the data as the baby

was placed on the scales and wrapped. The mean difference in


weight was 116 g [95% confidence interval (CI), 72160 g] using
the B-spline and 87 g (95% CI, 64110 g) using inspection.
Converting this to the mean volume of placental transfusion gave
110 ml (95% CI, 69152 ml) and 83 ml (95% CI, 61106 ml),
respectively. Placental transfusion was usually complete by
2 minutes, but sometimes continued for up to 5 minutes. Based
on the B-spline, placental transfusion contributed 32 ml (95% CI,
3033 ml) per kilogram of birth weight to blood volume, but
24 ml (95% CI, 1932 ml) based on inspection. This equates to
40% (95% CI, 3742%) and 30% (2440%), respectively, of total
potential blood volume.
Conclusion Inspection of the graphs probably underestimates

placental transfusion. For term infants, placental transfusion


contributes between one-third and one-quarter of total potential
blood volume at birth.
Keywords Observational study, placental transfusion, weighing

term babies.

Please cite this paper as: Farrar D, Airey R, Law G, Tuffnell D, Cattle B, Duley L. Measuring placental transfusion for term births: weighing babies with cord
intact. BJOG 2011;118:7075.

Introduction
At birth, blood flow in the umbilical arteries and veins usually continues for a few minutes. The additional blood volume transferred to the infant during this time is known as
placental transfusion. Immediate clamping of the umbilical
cord has traditionally been recommended as part of active
management of the third stage of labour, together with a
prophylactic uterotonic drug and controlled cord traction,1
to reduce postpartum haemorrhage. Use of a prophylactic
uterotonic drug clearly reduces the risk of major haemorrhage.2 The timing of cord clamping does not appear to
have a major impact on the risk of haemorrhage, although
a modest effect remains possible. Deferring cord clamping

70

will allow a larger placental transfusion. Having been a


neglected topic for decades, there is now growing interest
in assessing the effects of placental transfusion for both
term and preterm infants.3,4
Estimates of the volume and duration of placental transfusion are largely derived from studies conducted 50 years
ago, most of which used indirect methods.58 For term
infants having a normal vaginal birth, estimates range from
60 to 240 ml, with an average of 100 ml often quoted.9
This is equivalent to 2030% of blood volume and red cell
mass at birth. The speed and duration of placental transfusion may also be influenced by gravity and the uterotonic
drug. Raising or lowering the baby 20 cm or more from
the level of the placenta will affect placental transfusion.10

2010 The Authors Journal compilation RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

Measuring placental transfusion for term births

Methods
Women planning to give birth at the Bradford Royal Infirmary, West Yorkshire, UK, with a singleton pregnancy and
live baby at term were eligible for inclusion. Information
about the study was given to women at 2628 weeks of
gestation when they came for oral glucose tolerance test,
which is offered to all women at this unit. They were
invited to participate either during the first stage of labour
or during preparation for caesarean section. Women who
agreed to participate provided written consent. They were
free to withdraw at any time.

Procedure for weighing


Babies were weighed using digital scales (Mettler Toledo
excellence XS precision balance Model: XS8001L, Im Langacher, CH-8606 Greifensee, Switzerland), which automatically calculate an average weight every 2 seconds, with data
stored in a linked computer. The scales were zeroed to
allow for the weight of a plastic sheet and two towels, used
to wrap the baby during weighing.
At birth, babies were placed on the scales as quickly
as possible, with the cord intact. The attending clinician
was asked not to touch the baby, the cord or the scales
until weighing was complete. If the scales were knocked
or the baby or cord touched, this was recorded by the
research midwife. For vaginal births, the scale pan was
either at the level of the bed or the womans abdomen.
For caesarean births, it was either at the level of the bed
or the womans thighs. Weighing continued for up to
5 minutes. The cord was clamped earlier and weighing
stopped if requested either by the woman or the clinician. Delivery of the placenta was according to normal
clinical practice. Once delivered, the placenta was placed
in a funnel to drain any residual placental blood. All
other aspects of care were at the discretion of the
attending clinician.

Data collection
Parity and gestation at birth were recorded. For women
having a vaginal birth, data were collected on whether
labour was induced or augmented, the use of analgesia, the
mode of delivery and the maternal position during the second and third stage. For women having a caesarean birth,
data were collected on the indication for caesarean section
and the type of anaesthesia. For all women, data were
collected on the timing of the uterotonic drug, time of
cord clamping, maternal blood loss during the third stage,
length of the third stage and use of controlled cord traction. For the baby, information was collected on the time
of birth (recorded as delivery of the buttocks for cephalic
births, and head for breech births), temperature after cord
clamping, need for resuscitation at birth and whether
admitted to the neonatal unit. In addition, a log was kept
for each weighing, which included events such as the scales
being knocked or the cord touched. All data were anonymous, and were checked for completeness and accuracy.

Statistical analysis
The characteristics of the women and events during labour
were described for women who had a vaginal birth and
those who had a caesarean birth. As 1 ml of blood weighs
1.05 g,20 placental transfusion was calculated by the conversion of weight to volume.
The scales were switched on as the baby was born; the
start time for weighing was when the baby was placed on
the scales. In our protocol, we planned to calculate the
change in weight, between the start time and either cord
clamping or when weighing stopped, by manual inspection
of a graph of weight over time (an example of which is
shown in Figure 1). This proved to be more difficult than
anticipated, however, because of artefacts (sharp spikes in
the graphs, see example in Figure 1) as the baby was placed
on the scales and wrapped in the towels. It was often several seconds before the graph became interpretable. To help
overcome this problem of determining the start weight, we
used a B-spline to smooth the data.21

Artefact as baby
placed on scales

Weight (g)

If an intravenous ergot alkaloid is given, placental transfusion is quicker.11,12 Ergot alkaloids are no longer recommended as a prophylactic uterotonic,1 however, because of
adverse effects.2,13 In the UK, intramuscular oxytocin is
now recommended.1 It has been suggested that placental
transfusion may not occur at caesarean births,14 although
others disagree.15
Immediate cord clamping remains common practice.1618
Large randomised trials to assess the effects of deferring
cord clamping to allow placental transfusion for term
births have been called for.4,19 In order to plan the interventions to evaluate in such a trial, and to guide clinical
practice, we conducted this study to measure the volume
and duration of placental transfusion for vaginal and caesarean births at term.

Cord clamped

3740
3720
3700
3680
3660
3640
3620
3600
3580
3560
3540
3520
3500
3480
3460
3440
3420
3400
1

2
Time (minutes)

Figure 1. Weight change from birth to cord clamping.

2010 The Authors Journal compilation RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

71

Farrar et al.

For the B-spline, first the raw weight data were manually
cleaned, with clear artefacts removed. These artefacts
occurred in the first few seconds after the baby was placed
on the scales, and when the scales were knocked or the
baby touched. The weight measurements remained open to
considerable noise and a smoothing process was used to
remove this. In order to examine the dynamics of the
change in weight, a Loess smoothed regression was fitted to
the first derivative against time. Each measurement is not
independent, but will depend smoothly (in a mathematical
sense) on the preceding weights: step changes in weight are
not anticipated. We therefore modelled the weights as a
trajectory, which is a continuous function of weight, collected every 2 seconds in time. A B-spline was fitted to the
weight against time plots individually for each baby.
A spline allows a number of smooth functions to be fitted
to the data, starting at different points, known as knots.
The number of knots was allowed to be determined in an
automated way, and then manually checked for consistency.
The start and end weights were estimated from the
B-spline at the first time a measurement was made and at
the last measurement time. The exact weight at birth was
not extrapolated. The mean weight, across all babies, was
calculated and t-tests were used to determine the significance of the difference in start and end weights.
For the inspection of graphs, two authors (DF and LD)
independently assessed the start and end weights. Differences were then compared and resolved by discussion. The
mean weight, across all babies, was calculated and t-tests

were used to determine the significance of the difference in


start and end weights.
Pre-specified subgroups were based on the mode of birth
(vaginal or caesarean), position of the baby (at the level of
the introitus or on the mothers abdomen for vaginal
births; at the level of the bed or on the mothers anterior
thighs for caesarean births) and, for vaginal births, on the
timing of oxytocin administration (with anterior shoulder
or after cord clamping). All statistical analyses were conducted in SPSS,22 R23 or Stata.24

Results
From July to December 2008, 78 eligible women were
approached, 52 of whom gave consent. Of these, 26 women
did not have their baby weighed. The reasons were: software problem (n = 2), short cord (n = 5), birth out of
working hours (n = 14) and clinician felt not appropriate
(n = 5). For 26 women, the baby was weighed, 13 at vaginal birth and 13 at caesarean. The baseline characteristics
and information about labour and birth are given in
Table 1. For women having a vaginal birth, the median
length of the first stage of labour was 6 hours 50 minutes
(range, 2 hours 45 minutes to 14 hours 0 minutes) and, for
the second stage of labour, was 40 minutes (range, 7 minutes to 2 hours 24 minutes). Indications for caesarean section were previous caesarean (n = 7), unstable lie (n = 2),
breech (n = 2) and failed induction (n = 2). Intramuscular
oxytocin was the prophylactic uterotonic drug for all

Table 1. Characteristics of the women and events during labour and at birth
Vaginal birth
(n = 13)
Primigravid
Gestation at birth (weeks and days; mean, SD)
Use of analgesia or anaesthesia
Entonox
Pethidine
Epidural
Spinal
General anaesthetic
Induction of labour
Third stage of labour
Oxytocin before cord clamping
Oxytocin after cord clamping
Estimated blood loss (ml; mean, SD)
Manual removal of placenta
Residual placental volume (ml; mean, SD)
Baby at birth
Temperature after cord clamping (oC; mean, SD)
Need for resuscitation
Admitted to special care baby unit

72

Caesarean birth
(n = 13)

Total
(n = 26)

5 (38%)
393 (11)

5 (38%)
393 (13)

10 (38%)
393 (12)

7
2
2

2 (15%)

11
2
2 (15%)

7
2
2
11
2
4

13 (100%)

531 (205)

21 (19)

21
5
367

21

36.7 (0.4)

36.7 (0.4)

8
5
204

23

(62%)
(38%)
(69)
(11)

36.8 (0.4)

(81%)
(19%)
(224)
(11)

2010 The Authors Journal compilation RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

Measuring placental transfusion for term births

Table 2. Weight and weight change at birth using a B-spline and inspection of the graphs

B-spline
Total
Mode of birth
caesarean section
Vaginal
Position of baby
Above bed
On bed
Uterotonic drug**
Yes
No
Inspection
Total
Mode of birth
caesarean section
Vaginal
Position of baby
Above bed
On bed
Uterotonic drug**
Yes
No

Start mean
weight (g)

End mean
weight (g)

Mean difference in
weight (g) (95% CI)

t (df)*

26

3295

3411

116 (72160)

5.44 (25)

<0.001

13
13

3466
3124

3597
3225

131 (64198)
101 (36167)

0.69 (24)

0.5

14
12

3235
3364

3332
3504

96 (38154)
139 (64214)

)0.99 (22)

0.3

21
5

3408
2820

3530
2913

122 (69174)
93 (-17204)

)0.60 (8)

0.6

26

3339

3426

87 (64111)

7.7 (25)

13
13

3534
3144

3613
3240

79 (57100)
96 (51141)

0.8 (24)

0.5

14
12

3265
3425

3344
3521

80 (52108)
97 (53140)

0.7 (24)

0.5

21
5

3457
2844

3548
2913

91 (66118)
69 (6145)

0.8 (24)

0.4

<0.0001

*t-test and degrees of freedom.


**Intramuscular oxytocin.

vaginal births and intravenous oxytocin for all caesarean


births. All women had controlled cord traction.
From birth to the baby being on the scales took a mean
of 16 seconds (standard deviation [SD], 15 seconds) for
vaginal births and 38 seconds (SD, 67 seconds) for caesarean births. An example of weight change over time is
shown in Figure 1. Using the B-spline, the mean difference
in weight for all births was 116 g (95% CI, 72160 g)
(Table 2). Converting this to the volume of placental transfusion (1 ml of blood weighs 1.05 g) gives 110 ml (95%
CI, 69152 ml). There was no statistically significant difference between vaginal and caesarean births. Based on this
approach, placental transfusion contributed 32 ml (95% CI,
3033 ml) per kilogram of birth weight to the neonatal
blood volume. Assuming that the blood volume at birth
following immediate cord clamping is 80 ml per kilogram
birth weight,25 this equates to 40% (3742%) of the total
potential blood volume at birth.
Using inspection of the graphs, the mean difference in
weight for all births was 87 g (95% CI, 64111 g)
(Table 2). Converting this to the volume of placental transfusion gives 83 ml (95% CI, 61106 ml). Based on this
approach, placental transfusion contributed 24 ml (95% CI,
1932 ml) per kilogram of birth weight to the neonatal

blood volume; this equates to 30% (2440%) of the total


potential blood volume at birth.
The time at which net placental flow appeared to cease
for most infants was at 2 minutes (data not shown).
Nevertheless, for some infants, flow continued for up to
5 minutes.
Although the numbers were small, the volume of placental transfusion did not appear to be influenced by whether
intramuscular oxytocin had been given before or after cord
clamping at vaginal births, or by whether the baby was
level with the bed or raised to the level of the mothers
abdomen (vaginal births) or anterior thigh (caesarean
births) (Table 2).

Discussion
The direct measurement of placental transfusion by weighing babies at birth with the cord intact suggests that the
mean volume is between 83 and 110 ml, equivalent to
2432 ml per kilogram of birth weight. Typically, placental
transfusion represents between one-third and one-quarter
of the potential blood volume at birth. There is considerable variation between individual babies, with a few infants
receiving relatively small volumes of placental transfusion,

2010 The Authors Journal compilation RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

73

Farrar et al.

whilst others received quite large volumes. For most


infants, placental transfusion appeared to be complete by
2 minutes, but, for some, it continued for up to 5 minutes.
A practical problem in our study was the difficulty in
determining the start weight because of the artefact associated with placing the baby on the scales and wrapping towels around to keep the baby warm. We had originally
planned to use direct inspection of the graphs to measure
the weight change, but this was more difficult than we had
anticipated because of these artefacts in the first few seconds that the baby was on the scales. We attempted to
overcome this problem by smoothing the data using a
B-spline. This approach has the advantage that it uses the
early weight measurements to estimate the probable start
weight, but these early weight measurements are ignored
on inspection of the graph, which takes the start weight as
the weight when the artefacts cease. We present results
from both methods to indicate the difficulty in interpreting
these data. Although there are differences, the data are consistent in demonstrating that placental transfusion potentially contributes a significant proportion of the blood
volume at birth.
Direct inspection of the graphs is likely to underestimate
the true placental transfusion as, when using this method,
the start weight is often 20 seconds or more after the time
of birth and, by the time weighing begins, some transfusion
would already have occurred. The B-spline may overestimate placental transfusion if the smoothing is incomplete.
It therefore seems plausible that the true value is somewhere between the two estimates. Similarly, we probably
underestimated the duration of placental transfusion by up
to 30 seconds, as the start time for weighing was when the
baby was placed on the scales.
Although placental weight and pathology at birth may
affect the volume and duration of placental transfusion,
they cannot be altered. Whatever are the placental effects,
they are fixed for an individual birth. Our study aimed to
measure net placental transfusion to assess the effect on the
blood transferred to the baby.
Previous studies have suggested that, although lifting or
lowering the baby by 40 cm will influence placental transfusion, raising or lowering the baby by 1020 cm from the
level of the placental bed does not substantially influence
the volume or duration of placental transfusion.10,26
Although our study was small, the data presented here support this: raising the baby to the level of the mothers
abdomen or anterior thighs (both of which are common
practice) whilst the cord is intact does not appear to have
a major impact on placental transfusion.
The use of intravenous ergot alkaloids shortens the duration of placental transfusion at vaginal births.12 These
drugs are no longer recommended for clinical practice, as
oxytocin has a similar effectiveness with fewer adverse

74

effects.1 Our study suggests that the use of intramuscular


oxytocin does not have the same impact on the duration of
placental transfusion. Our data for these subgroups should
be interpreted with caution, however, as the numbers are
small.
Some previous studies have suggested that placental
transfusion is reduced for caesarean births,14,15,27 possibly
as a result of uterine atony related to the uterine incision
or anaesthetic drugs, and/or timing of the uterotonic drug.
In our study, the volume and duration of placental transfusion were similar for caesarean and vaginal births. This
may be because the use of spinal anaesthesia (as in this
study) does not influence uterine tone, whereas many of
the early studies would have been conducted with general
anaesthesia.
The duration of placental transfusion may be as important as the volume for the newborn infant, as this is a
period of transition from the fetal to the neonatal circulation. Before birth, just 8% of blood volume goes to the
lungs. As the lungs expand, the infant needs to redirect
blood flow to fill the expanding respiratory circulation. If it
does not have access to placental transfusion, the infant
may need to redirect blood from other essential organs,
such as the skin, liver and kidneys. Access to placental
transfusion may be the optimal mechanism for establishing
the respiratory circulation. Once the neonatal circulation is
established, the additional blood volume is rapidly
absorbed, and the red cell mass is broken down and iron is
efficiently stored. This additional red cell mass seems to
lead to a marginal increase in jaundice and, possibly, an
associated increase in phototherapy. The long-term effects
of placental transfusion are unclear, as no trials have
reported long-term follow-up.19
Our study suggests that, for term birth, placental transfusion contributes between one-third and one-quarter of the
neonatal blood volume. Immediate cord clamping is recommended in the UK as part of the active management
of the third stage of labour.1 Clamping the cord before
23 minutes is likely to restrict placental transfusion. The
short-term and long-term effects of this simple intervention
remain unclear.19 Further evaluation of the effects of alternative policies for the timing of cord clamping at term
births has been identified as a priority for future randomised trials1,4 The data presented here would be helpful for
determining the appropriate interventions to compare in
such trials. As the physiology of placental transfusion for
preterm birth may be different from that for term birth,
further research is also required to explore how placental
transfusion varies with gestational age.

Disclosure of interest
All authors declare that they have no conflicts of interest
and therefore have nothing to declare.

2010 The Authors Journal compilation RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

Measuring placental transfusion for term births

Contribution to authorship
LD conceived the idea. The protocol was developed by DF
and LD, with comments from the other authors. DF and
RA weighed the babies and collected the data. GRL carried
out the B-spline analysis. DF and LD drafted the paper,
with comments from the other authors.

Details of ethics approval


The study was approved by the Bradford Ethics Committee, with approval being granted on 30 July 2008, REC reference 08/H1302/65.

Funding
The study was supported by the Bradford Teaching Hospitals NHS Foundation Trust.

Acknowledgements
Our thanks to the women who took part in this study and
to all the staff who contributed. Thanks also to Jim Thornton for comments on the protocol. j

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