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Supplementary Materials

DELAYED VERSUS EARLY UMBILICAL CORD CLAMPING FOR PRETERM INFANTS:

A SYSTEMATIC REVIEW AND META-ANALYSIS

Contents

Item PageMeta-analysis combining RCTs of placental transfusion in Cochrane Review of 2012 with APTS 2Characteristics of excluded studies 3Characteristics of studies awaiting classification 5Characteristics of ongoing studies 6References 6Additional data sought by email contact with all authors 9Supplementary Table 1 11Protocol for Updated Systematic Review 21 July 2017 Appendix

1

Meta-analysis combining RCTs of the effects of placental transfusion on mortality to hospital

discharge in the Cochrane Review by Rabe et al, 2012 (11) with the Australian Placental

Transfusion Study (19)

The overall Risk Ratio (or Relative Risk -RR) is 0.71 (95% Confidence Interval 0.53 to 0.95, P= 0.02).

2

Characteristics of excluded studies

Al-Wassia2016[1]Reason for exclusion: Randomised trial of deferred umbilical cord clamping compared to umbilical cord milking in preterm infants. Excluded as cord milking comparison.Aladangady 2006[2]Reason for exclusion: Randomised trial in infants born 24+0 to 32+6 weeks gestation of delayed (30 to 90 seconds) versus immediate cord clamping. Excluded as no data able to be extracted. Part of larger trial unable to be identified. No response from author.APTS pilot study 2010[3]Reason for exclusion: Four arms of the pilot trial comprising (a) early cord clamping; vs three methods of placental transfusion: (b) milking OR (c) delayed cord clamping OR (d) delayed cord clamping with milking. Exclude trial arms with cord milking. Excluded as arms comparing early versus delayed cord clamping [without cord milking] included in APTS trial.Ashish 2017[4-6]Reason for exclusion: Enrolled women 34-41 weeks gestation to DCC versus ICC. Excluded as mean gestation 39 weeks (term) and preterm data not reported separately.Chen 2015[7]Reason for exclusion: Before and after study early versus delayed cord clamping in premature infants.El-Naggar 2016[8]Reason for exclusion: Cord milking compared with immediate cord clamping in infants born 24 to 31 weeks' gestation. Excluded as cord milking comparison.Elimian 2013[9, 10]Reason for exclusion: Randomised controlled trial of delayed versus early cord clamping in preterm infants. This was excluded as cord milking was allowed in delayed cord clamping group. Communication received that most infants had cord milking.Gomaa 2016[11]Reason for exclusion: A Randomized Controlled Trial of umbilical cord milking versus deferred cord clamping in premature neonates. Excluded as cord milking comparison.Guo 2014[12]Reason for exclusion: Trial of umbilical cord milking, delayed cord clamping or routine cord clamping. Excluded as did not report method of allocation or allocation to be random. No author response for clarification to date.Hosono 2008[13]Reason for exclusion: Infants born between 24 and 28 weeks' gestation randomly assigned to umbilical cord clamped either immediately or after umbilical cord milking. Excluded as cord milking comparison.Hosono 2009[14]Reason for exclusion: Randomised control study in infants born between 24 and 28 weeks' gestation of umbilical cord was clamped either immediately after birth or after umbilical cord milking. Excluded as cord milking comparison.Ibrahim 2000[15]Reason for exclusion: Randomised trial of early (immediate) versus early (20 seconds) cord clamping in 32 infants with birth weight of 501 to 1250 g and gestational ages of 24 and <29 weeks. Both arms meet criteria for early cord clamping.Josephsen 2014[16]Reason for exclusion: The experimental group consists of infants receiving an umbilical cord milking intervention and the control group consists of routine immediate cord clamping. Excluded as cord milking comparison.

3

Katheria 2014[17]Reason for exclusion: Infants born before 32 weeks gestation were randomized to receive UCM or ICC. Excluded as cord milking comparison.Katheria 2015[18]Reason for exclusion: Infants delivered before 32 weeks gestation by caesarean were randomly assigned to undergo UCM or DCC. Excluded as cord milking comparison.Katheria 2016[19]Reason for exclusion: Premature infants (23 0/7 to 31 6/7 weeks' gestational age) randomized to receive at least 60 seconds of ventilation with DCC or without assisted ventilation. Excluded as DCC in both arms.Katheria 2017[20]Reason for exclusion: Randomized Trial of Cerebral Oxygen Saturation in Infants Randomized to Umbilical Cord Milking or Delayed Cord Clamping. Excluded as cord milking comparison.Kilicdag 2016[21]Reason for exclusion: Fifty-eight pregnant women were randomly assigned to one of the umbilical cord milking and control groups. A total of 54 preterm infants (gestational age <=32 weeks) were enrolled into the study. Excluded as cord milking comparison.Krueger 2015[22]Reason for exclusion: Delayed cord clamping with and without cord stripping for singleton deliveries with estimated gestational ages between 22 and 31 6/7 weeks. Excluded as cord milking comparison.Kumar 2015Reason for exclusion: Late preterm neonates randomly allocated to early cord clamping or umbilical cord milking. Excluded as cord milking comparison.Lan 2017[23]Reason for exclusion: Randomised controlled trial premature infants 31-36 weeks gestation (n=70) to early cord clamping versus delayed cord clamping [2 minutes or pulsation ceased]. Excluded as no data able to be used in review. Awaiting author response.Malik 2013[24]Reason for exclusion: Single centre randomised controlled trial preterm babies (on clinical examination) with gestation age between 30 weeks and before 37 completed weeks of gestation (n=80) allocated to early cord clamping at 30 seconds versus delayed cord clamping at 120 seconds. Excluded as no data able to be used in review. Awaiting author response.March 2013[25]Reason for exclusion: Women admitted to a tertiary care centre and expected to deliver between 24 to 28 completed weeks of gestation were randomized to cord milking before clamping or immediate cord clamping. Excluded as cord milking comparison.Mercer 2016[26]Reason for exclusion: Randomised controlled trial of DCC versus ECC in preterm infants born 24-31.6 weeks gestation. At 30-45 seconds, the obstetrician was asked to milk the infant’s cord once, then clamp and cut the umbilical cord. If unable to carry out the DCC protocol as planned, the cord was milked quickly 2-3 times before clamping when possible. Excluded as cord milking comparison.Niu 2016[27]Reason for exclusion: Reported: 'They were randomly divided into immediate cord clamping( ICC) group umbilical cord milking (UCM) group and delayed cord clamping ( DCC) group." Method of allocation alternation by group 1, 2, 3. Excluded as quasi-randomisation trial.Rabe 2011[28]

4

Reason for exclusion: Infants delivered before 33 completed weeks of gestation randomized to clamping the cord 30 seconds after delivery or repeated (four times) milking of the cord. Excluded as cord milking comparison.Smith 2014[29]Reason for exclusion: Randomized controlled trial that will compare the effects of delayed umbilical cord clamping to umbilical cord milking in preterm infants (less than 34 weeks gestation). Excluded as cord milking comparison.Tiemersma 2013[30]Reason for exclusion: Women in labour with a presumed low birthweight baby (intrapartum symphysal-fundal height <34 cm) were randomized for early cord clamping (ECC, within 60 s) or DCC. Excluded as not preterm.Upadhyay 2013Reason for exclusion: Randomised controlled trial of early cord clamping versus early cord clamping and cord milking in infants born at 34 weeks and 0 days to 36 weeks and 6 days gestational age and delivered vaginally. Excluded as cord milking comparison.Varanattu 2017[31]Reason for exclusion: A Randomised Controlled Trial of intact Umbilical Cord Milking Versus Immediate Cord Clamping on Neonatal Outcomes and First Year Neurodevelopmental Outcomes in Very Preterm Infants. Excluded as cord milking comparison.Waycock 2011[32]Reason for exclusion: Milking the Umbilical Cord Versus Immediate Clamping in Pre-term Infants <33 Weeks: A Randomized Controlled Trial. Excluded as cord milking comparison.Xue 2015[33]Reason for exclusion: Delayed versus immediate cord clamping in term infants. Case control study.

Characteristics of studies awaiting classification

Hemmati 2016[34]Methods: Randomized controlled double blind clinical trial.Participants: 148 neonates with gestational ages 26 to 34 weeks.Interventions: ICC (cord clamped in 10-15 sec) or DCC (cord clamped in 30-45 sec).Outcomes: Haemoglobin; blood transfusion; peak bilirubin; phototherapy; IVH; length of stay.Notes: Abstract only. Awaiting author response.Murphy 2007[35, 36]Methods : Randomised controlled trial in Canada.Participants: Inclusion criteria: 24 0/7 to 32 0/7 weeks gestation.Interventions: Delayed umbilical cord clamping (n=19): 30-45 seconds versus immediate umbilical cord clamping (n=19).Outcomes: Primary Composite outcome of Intraventricular Hemorrhage and/or Late Onset Sepsis.Secondary Outcome Measures: 1) lung function 2) cardiovascular function and 3) anemia.Notes: Trial registry and abstract only. Awaiting author response.

5

Characteristics of ongoing studies

Giannone 2014[37]Study name: Indomethacin and Delayed Umbilical Cord Clamp for Preterm Infant IVHMethods : Randomized Controlled TrialParticipants: 24 Weeks to 30 Weeks (n=400).Interventions: 1. Immediate cord clamp & placebo IV solution. 2. Delay cord clamp & placebo IV solution. 3. Immediate cord clamp & indomethacin IV. 4. Indomethacin iv & delayed cord clamp.Outcomes: Primary Outcome Measures: fraction of survivors with no severe IVH (grades 3 or 4) or PVL.Starting date: August 2014Notes: Estimated completion 2020. Eligible.Perlman 2015[38]Study name: The Effects of Delayed Cord Clamping on Postnatal Circulatory Status in Preterm NeonatesMethods: Randomized Controlled TrialParticipants: 28 Weeks to 35 Weeks (n=150).Interventions: 30 seconds of DCC versus 60 seconds DCC.Outcomes: Primary Outcome Measures: Measurement of Hematocrit at one hour of lifeStarting date: July 2015Notes: Estimated completion 2017. Eligible.

References1. Efficacy and Safety of Deferred Umbilical Cord Clamping Compared to Umbilical Cord Milking in Preterm Infants: A Randomized Clinical Trial. ClinicalTrialsgov Identifier: NCT02996799.2. Aladangady N, McHugh S, Aitchison TC, Wardrop CAJ, Holland BM. Infants' blood volume in a controlled trial of placental transfusion at preterm delivery. Pediatrics. 2006;117:93-8.3. Tarnow Mordi W. Australian Placental Transfusion Study Four Arm Pilot Study.4. Effect of Timing of Umbilical Cord Clamping on Anaemia at 8 and 12 Months and Later Neurodevelopment in Late Pre-term and Term Infants; a Facility-based Randomized-controlled Trial in Nepal. ClinicalTrialsgov Identifier: NCT02222805.5. Ashish KC, Malqvist M, Rana N, Ranneberg LJ, Andersson O. Effect of timing of umbilical cord clamping on anaemia at 8 and 12 months and later neurodevelopment in late pre-term and term infants; a facility-based, randomized-controlled trial in Nepal. BMC Pediatrics. 2016;16 (1) (no pagination).6. Ashish KC, Rana N, Malqvist M, Ranneberg LJ, Subedi K, Andersson O. Effects of delayed umbilical cord clamping vs early clamping on anemia in infants at 8 and 12 months a randomized clinical trial. JAMA Pediatrics. 2017;171:264-70.7. Chen H, Wu L, Gu H, Fu J. Effect of delayed umbilical cord clamping on outcomes of neonates and maternal. China Medical Herald. 2015;103:97-9.8. El-Naggar W, Simpson D, Hussain A, Armson A, Dodds L, Warren A, Robin W, McMillan D. The effect of umbilical cord milking on cerebral blood flow of preterm infants: A randomized controlled trial. European Journal of Pediatrics. 2016;175:1698-.9. Elimian A, Goodman J, Escobedo M, Nightingale L, Knudtson E, Williams M. A randomized controlled trial of immediate versus delayed cord clamping in the preterm neonate. American Journal of Obstetrics and Gynecology. 2013;208:S22-S.10. Elimian A, Goodman J, Escobedo M, Nightingale L, Knudtson E, Williams M. Immediate compared with delayed cord clamping in the preterm neonate. Obstetrics and Gynecology. 2014;124:1075-9.11. The Hematologic Impact of Umbilical Cord Milking Versus Deferred Cord Clamping in Premature Neonates. A Randomized Controlled Trial. ClinicalTrialsgov Identifier: NCT03147846.

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12. Guo F, Zhu J, Luo W, Tang H, Zhang X, Li J, Pu L, Zhang J. Contribution of different umbilical cord ligation methods to neonatal complications in preterm babies. The Journal of Neonatology. 2014;29:386-9.13. Hosono S, Mugishima H, Fujita H, Hosono A, Minato M, Okada T, Takahashi S, Harada K. Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks' gestation: A randomised controlled trial. Archives of Disease in Childhood: Fetal and Neonatal Edition. 2008;93:F14-FF9.14. Hosono S, Mugishima H, Fujita H, Hosono A, Okada T, Takahashi S, Masaoka N, Yamamoto T. Blood pressure and urine output during the first 120 h of life in infants born at less than 29 weeks' gestation related to umbilical cord milking. Arch Dis Child Fetal Neonatal Ed. 2009;94:F328-F31.15. Ibrahim HM, Krouskop RW, Lewis DF, Dhanireddy R. Placental transfusion: umbilical cord clamping and preterm infants. Journal of perinatology. 2000;20:351-4.16. Josephsen J, Vlastos E, Potter S, Al-Hosni M. Milking the umbilical cord in extreme preterm infants. American Journal of Obstetrics and Gynecology. 2014;1:S403-S4S4.17. Katheria A, Blank D, Rich W, Finer N. Umbilical cord milking improves transition in premature infants at birth. PLoS ONE. 2014;9 (4) (no pagination).18. Katheria AC, Truong G, Cousins L, Oshiro B, Finer NN. Umbilical cord milking versus delayed cord clamping in preterm infants. Pediatrics. 2015;136:61-9.19. Katheria A, Poeltler D, Durham J, Steen J, Rich W, Arnell K, Maldonado M, Cousins L, Finer N. Neonatal Resuscitation with an Intact Cord: A Randomized Clinical Trial. Journal of Pediatrics. 2016;178:75-80.20. PREMOD2 NIRS Substudy - A Randomized Trial of Cerebral Oxygen Saturation in Infants Randomized to Umbilical Cord Milking or Delayed Cord Clamping. ClinicalTrialsgov Identifier: NCT03145142.21. Kilicdag H, Gulcan H, Hanta D, Torer B, Gokmen Z, Ozdemir SI, Antmen BA. Is umbilical cord milking always an advantage? Journal of Maternal-Fetal and Neonatal Medicine. 2016;29:615-8.22. Krueger MS, Eyal FG, Peevy KJ, Hamm CR, Whitehurst RM, Lewis DF. Delayed cord clamping with and without cord stripping: A prospective randomized trial of preterm neonates. American Journal of Obstetrics and Gynecology. 2015;212:394-.23. Lan XH, Yan GZ, Wu J. Effects of different clamping time of umbilical cord on serum bilirubin and hemoglobin in premature infant. Applied Journal of General Practice. 2017;15:996-8.24. Malik AU, Shahnawaz K, Riaz A. Comparison between the efficacy of early and delayed umbilical cord clamping in preterm infants. Pakistan Journal of Medical and Health Sciences. 2013;7:992-5.25. March MI, Hacker MR, Parson AW, Modest AM, De Veciana M. The effects of umbilical cord milking in extremely preterm infants: A randomized controlled trial. Journal of Perinatology. 2013;33:763-7.26. Mercer JS, Erickson-Owens DA, Vohr BR, Tucker RJ, Parker AB, Oh W, Padbury JF. Effects of Placental Transfusion on Neonatal and 18 Month Outcomes in Preterm Infants: A Randomized Controlled Trial. Journal of Pediatrics. 2016;168:50-5.27. Niu FH, Wang Y, Ren XY. Effect of umbilical cord milking and delayed cord clamping on mean blood pressure,cerebral blood flow and neurological assessment score in preterm infants. Jilin Medical Journal. 2016:2900-2.28. Rabe H, Jewison A, Fernandez Alvarez R, Crook D, Stilton D, Bradley R, Holden D. Milking compared with delayed cord clamping to increase placental transfusion in preterm neonates: A randomized controlled trial. Obstetrics and Gynecology. 2011;117:205-11.29. Delayed Clamping and Milking the Umbilical Cord Prior to Clamping in Preterm Infants and the Effect of Neonatal Outcomes. ClinicalTrialsgov Identifier: NCT02092103.30. Tiemersma S, Heistein J, Ruijne R, Van Lobenstein J, Lopez G, Van Rheenen P. Delayed cord clamping in a cohort of South African infants with presumed suboptimal intra uterine growth. Tropical medicine & international health. 2013;18:83-4.

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31. Effect of Intact Umbilical Cord Milking Versus Immediate Cord Clamping on Neonatal Outcomes and First Year Neurodevelopmental Outcomes in Very Preterm Infants - A Randomised Controlled Trial. ClinicalTrialsgov Identifier: NCT03200301.32. Milking the Umbilical Cord Versus Immediate Clamping in Pre-term Infants < 33 Weeks. ClinicalTrialsgov Identifier: NCT018195322011.33. Xue HY, Zhang SM, Wu YK. Effects of delayed cord clamping on maternal and neonates. China Medical Engineering. 2015;23:19-20.34. Hemmati F, Salarian L, Namavar Jahromi B. Randomized controlled double blind clinical trial comparing the effect of delayed versus immediate cord clamping on the development of intraventricular hemorrhage in preterm neonates. Professor Amirhakimi International Pediatric Congress; 2016.35. Delayed Umbilical Cord Clamping in Infants Less Than 32 Weeks: A Randomized Controlled Trial. ClinicalTrialsgov Identifier: NCT00562536.36. Chu K, Whittle W, Windrim R, Shah P, Murphy K. The DUC trial: A pilot randomized controlled trial of immediate vsdelayed umbilical cord clamping in preterm infants born between 24 and 32 weeks gestation. American Journal of Obstetrics and Gynecology. 2011;204:S201-S.37. Indomethacin and Delayed Umbilical Cord Clamp for Preterm Infant IVH. ClinicalTrialsgov Identifier: NCT02221219.38. The Effects of Delayed Cord Clamping on Postnatal Circulatory Status in Preterm Neonates. ClinicalTrialsgov Identifier: NCT02478684.

8

Additional data sought by email contact with all authors

Delayed versus early cord clamping for preterm infants

Criteria ResponseHow were infants enrolled? (Document the sequence of consent, enrolment and randomisation procedure.)What was the method of randomisation (eg computer generated random numbers, random number table, shuffled cards, other)?Were participants and staff unaware of allocation (ie blinded)? If so, how?Were investigators / measurements blinded? If so, how?Was cord milking (or ‘stripping’) performed in either trial group at delivery?If so, how many infants had cord milking performed?

All infants [please confirm data or provide additional data if available]

Outcome Delayed cord clamping n/N

Early cord clamping n/N

Number randomisedMortality prior to hospital discharge (latest time reported 36 weeks' postmenstrual age or greater).Postpartum haemorrhage (>500 mL)Maternal Blood transfusionApgar score at 1 minute <4Apgar score at 5 minutes <8Cardiorespiratory support (mask, intermittent positive pressure (IPPV), cardiac compression or adrenaline) at resuscitationIntubation in delivery roomTemperature on admission (mean / SD)Severe intracranial haemorrhage (Grade 3 or 4) (Papile 1978)Intraventricular haemorrhage (all grades)Periventricular leukomalaciaCombined periventricular leukomalacia or porencephaly or echodense intraparenchymal lesions or ventriculomegaly (≥97 percentile plus 4mmMechanical ventilationChronic lung disease defined as receiving supplemental oxygen or any form of assisted ventilation at ≥36 weeks post menstrual agePatent ductus arteriosus (medical or surgically treated)Necrotising enterocolitis (Bell's grade ≥stage 2) (Bell 1978)Late onset sepsis (after first 48 hours)Severe retinopathy of prematurity (treatment of ROP or stage 4)Blood transfusionPeak haematocrit (%) (mean / SD / n)Polycythaemia (haematocrit >65%)Partial exchange transfusion [for polycythaemia]Peak bilirubin (μmol/L) (mean / SD / n)Exchange transfusion [for hyperbilirubinaemia]

9

Infants born ≤28 weeks gestation [please provide additional data if available]



Number randomisedMortality prior to hospital discharge (latest time reported 36 weeks' postmenstrual age or greater).Severe intracranial haemorrhage (Grade 3 or 4) (Papile 1978)Chronic lung disease defined as receiving supplemental oxygen or any form of assisted ventilation at ≥36 weeks post menstrual ageNecrotising enterocolitis (Bell's grade ≥stage 2) (Bell 1978)Late onset sepsis (after first 48 hours)Severe retinopathy of prematurity (treatment of ROP or stage 4)Blood transfusion

Infants born by vaginal delivery [please provide additional data if available]




Infants born by caesarean delivery [please provide additional data if available]




10

Supplementary Table 1: Subgroup analyses according to (i) duration of delayed cord clamping, (ii) vaginal versus caesarean delivery, (iii) whether held at or below introitus / incision, (iv) timing of oxytocics and (v) timing of resuscitation.

Outcome Subgroups Studies /

Participants

RR [95% CI] Test for

subgroup

effects

Duration of delayed cord clamping:

Hospital mortality: ≥30-45 seconds versus <30

seconds

≥45 to 60 seconds versus

<30 seconds

≥60-120 seconds versus <30

seconds

≥120 seconds versus <30

seconds

7 / 333

1 / 39

5 / 1834

4 / 487

0.34 [0.11, 1.06]

0.35 [0.02, 8.10]

0.76 [0.56, 1.05]

0.37 [0.17, 0.84]

P = 0.24

Severe intraventricular

haemorrhage


seconds


<30 seconds


seconds


seconds

5 / 206

1 / 39

3 / 1643

2 / 352

0.42 [0.13, 1.37]

Not estimable

0.96 [0.61, 1.48]

0.84 [0.29, 2.45]

P = 0.45

Chronic lung disease ≥36

weeks


seconds

5 / 174

1 / 90

0.74 [0.50, 1.10]

0.80 [0.26, 2.42]

P = 0.35

11


<30 seconds


seconds


seconds

1 / 1439

1 / 248

1.06 [0.96, 1.16]

0.95 [0.66, 1.36]

Necrotizing enterocolitis ≥30-45 seconds versus <30

seconds


<30 seconds


seconds


seconds

6 / 248

1 / 90

1 / 1552

3 / 446

0.70 [0.33, 1.50]

Not estimable

0.79 [0.55, 1.13]

1.92 [0.79, 4.68]

P = 0.16

Late onset sepsis ≥30-45 seconds versus <30

seconds


<30 seconds


seconds


seconds

5 / 249

1 / 90

2 / 1627

2 / 180

0.83 [0.53, 1.30]

0.68 [0.23, 1.99]

0.99 [0.82, 1.20]

0.87 [0.43, 1.79]

P = 0.82

Severe retinopathy of

prematurity

≥30-45 seconds versus <30 1 / 40 0.81 [0.15, 4.36] P = 0.91

12

seconds


<30 seconds


seconds


seconds

0 / 0

2 / 1519

2 / 334

Not estimable

0.71 [0.48, 1.06]

0.94 [0.28, 3.16]

Blood transfusion ≥30-45 seconds versus <30

seconds


<30 seconds


seconds


seconds

7 / 268

1 / 39

4 / 1784

4 / 494

0.56 [0.39, 0.81]

0.59 [0.35, 1.00]

0.82 [0.75, 0.89]

0.81 [0.64, 1.02]

P = 0.17

Mode of delivery

Hospital mortality Vaginal delivery

Caesarean

6 / 803

4 / 1226

0.73 [0.46, 1.16]

0.69 [0.47, 1.01]

P = 0.84


haemorrhage

Vaginal delivery

Caesarean

4 / 736

3 / 1197

1.12 [0.67, 1.89]

0.66 [0.34, 1.27]

P = 0.21


weeks

Vaginal delivery

Caesarean

5 / 728

3 / 1125

1.06 [0.90, 1.25]

1.01 [0.91, 1.13]

P = 0.66

Necrotizing enterocolitis Vaginal delivery 5 / 830 0.93 [0.57, 1.53] P = 0.77

13

Caesarean

3 / 1204 0.85 [0.55, 1.29]

Late onset sepsis Vaginal delivery

Caesarean

4 / 719

2 / 1046

1.12 [0.82, 1.53]

0.97 [0.76, 1.24]

P = 0.47


prematurity

Vaginal delivery

Caesarean

4 / 690

3 / 1125

0.57 [0.32, 1.01]

1.03 [0.62, 1.72]

P = 0.12

Blood transfusion Vaginal delivery

Caesarean

5 / 856

2 / 1181

0.88 [0.77, 1.01]

0.81 [0.73, 0.90]

P = 0.36

Whether held below introitus / incision

Hospital mortality Above (on mother)

At same level

>5 to 10 cm below

>10 cm to 20 cm below

>20 cm below

2 / 131

4 / 488

1 / 1566

5 / 211

3 / 217

0.10 [0.01, 1.81]

0.46 [0.21, 1.02]

0.73 [0.53, 1.01]

0.30 [0.05, 1.73]

0.38 [0.10, 1.46]

P = 0.38


haemorrhage

Above (on mother)

At same level

>5 to 10 cm below


>20 cm below

0 / 0

3 / 438

1 / 1521

3 / 136

2 / 109

Not estimable

0.79 [0.30, 2.07]

0.93 [0.59, 1.48]

0.58 [0.11, 2.9]

0.31 [0.05, 1.75]

P = 0.64


weeks

Above (on mother)

At same level

>5 to 10 cm below


>20 cm below

0 / 0

1 / 248

1 / 1439

3 / 158

2 / 106

Not estimable

0.95 [0.66, 1.36]

1.06 [0.96, 1.16]

0.56 [0.29, 1.09]

0.92 [0.59, 1.45]

P = 0.28,

14

Necrotizing enterocolitis Above (on mother)

At same level

>5 to 10 cm below


>20 cm below

1 / 94

2 / 352

2 / 1552

3 / 187

2 / 109

2.84 [0.58, 13.92]

1.58 [0.53, 4.69]

0.79 [0.55, 1.13]

0.35 [0.06, 2.08]

0.69 [0.25, 1.92]

P = 0.32

Late onset sepsis Above (on mother)

At same level

>5 to 10 cm below


>20 cm below

1 / 94

1 / 86

2 / 1582

2 / 155

3 / 187

0.87 [0.43, 1.79]

Not estimable

1.01 [0.83, 1.23]

0.78 [0.31, 1.98]

0.56 [0.33, 0.94]

P = 0.21,


prematurity

Above (on mother)

At same level

>5 to 10 cm below


>20 cm below

0 / 0

2 / 334

1 / 1441

0 / 0

2 / 118

Not estimable

0.94 [0.28, 3.16]

0.75 [0.50, 1.13]

Not estimable

0.43 [0.11, 1.63]

P = 0.67,

Blood transfusion Above (on mother)

At same level

>5 to 10 cm below


>20 cm below

1 / 94

4 / 494

1 / 1553

3 / 140

3 / 254

0.76 [0.23, 2.51]

0.75 [0.60, 0.94]

0.86 [0.79, 0.94]

0.50 [0.30, 0.84]

0.55 [0.37, 0.81]

P = 0.05,

Timing of oxytocics

Hospital mortality Before cord clamping

After cord clamping

5 / 218

4 / 160

0.18 [0.04, 0.79]

1.15 [0.07, 17.80]

P = 0.24,

Severe intraventricular Before cord clamping 1 / 39 Not estimable n/a

15

haemorrhage After cord clamping 3 / 118 0.57 [0.05, 6.11]


weeks

Before cord clamping

After cord clamping

0 / 0

1 / 32

Not estimable

0.56 [0.24, 1.29]

n/a

Necrotizing enterocolitis Before cord clamping

After cord clamping

1 / 94

2 / 74

2.84 [0.58, 13.92]

0.80 [0.23, 2.77]

P = 0.22,

Late onset sepsis Before cord clamping

After cord clamping

2 /146

2 / 95

0.66 [0.36, 1.21]

0.95 [0.50, 1.81]

P = 0.43,


prematurity

Before cord clamping

After cord clamping

1 / 52

1 / 53

0.22 [0.01, 4.28]

0.21 [0.01, 4.12]

P = 0.99,

Blood transfusion Before cord clamping

After cord clamping

4 / 231

1 / 53

0.49 [0.31, 0.78]

0.19 [0.05, 0.77]

P = 0.21,

Timing of cord clamping relative to onset of resuscitation

Hospital mortality Before onset of

resuscitation

After onset of resuscitation

11 / 2201

1 / 270

0.66 [0.48, 0.89]

0.47 [0.20, 1.11]

P=0.47,


haemorrhage

Before onset of

resuscitation


8 / 1873

1 / 266

0.84 [0.54, 1.29]

0.84 [0.29, 2.45]

P= 0.99,


weeks

Before onset of

resuscitation


5 / 1667

1 / 248

1.03 [0.94, 1.14]

0.95 [0.66, 1.36]

P= 0.64,

Necrotizing enterocolitis Before onset of

resuscitation


9 / 2005

1 / 266

0.83 [0.61, 1.14]

1.58 [0.53, 4.69]

P= 0.27

16

Late onset sepsis Before onset of

resuscitation


9 / 2081

0 / 0

0.95 [0.80, 1.13]

Not estimable

n/a


prematurity

Before onset of

resuscitation


4 / 1645

1 / 248

0.72 [0.48, 1.06]

0.94 [0.28, 3.16]

P= 0.68

Blood transfusion Before onset of

resuscitation


8 / 2072

1 / 266

0.83 [0.76, 0.90]

0.91 [0.71, 1.17]

P= 0.45

17

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