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DOI: 10.1111/j.1471-0528.2010.02781.x
www.bjog.org
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
transfusion.
Results Twenty-six babies were weighed. Start weights were
difficult to determine because of artefacts in the data as the baby
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
2010 The Authors Journal compilation RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
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.
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)
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
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
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
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.
74
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
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.
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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