DOI: 10.5061/dryad.ffbg79d78
title: Data from: Short-term maternal and neonatal outcomes in preterm (&lt; 33 weeks gestation) Cesarean deliveries under general anesthesia with deferred cord clamping

description: Deferred cord clamping (DCC) is beneficial for preterm infants, but there
 are concerns about the safety of DCC during Cesarean deliveries (CD) under
 general anesthesia (GA). We evaluated maternal and neonatal outcomes in
 preterm CD under GA vs. regional anesthesia (RA) after implementing 180 s
 of DCC. This retrospective single-center observational study included CD
 at &lt; 33 weeks of gestation, delivered between January 2018 and
 December 2023. The cord was clamped before 180 s for concerns of maternal
 bleeding or infant apnea after 30-45 s stimulation. Multivariable
 regression analysis was used to assess the effect of anesthesia type and
 DCC on outcomes, adjusting for confounders. This study included 170
 mothers and 194 infants, 84.9 % of the infants received DCC ≥ 60
 s. The GA group had higher emergency CD and lower median duration
 of DCC (105 s vs 180 s, p = &lt;0.001) compared to RA. GA was
 associated with lower odds (95 % CI) of UA pH &lt; 7 [0.1, (0.0,
 0.6)], base deficit ≥ 16 [0.0, (0.0, 0.5)], and higher odds of NEC [28.2,
 (1.4, 560.0)]. DCC ≥ 60 seconds was associated with lower maternal blood
 loss [Regression coefficient -698, (-1193, -202)], lower odds of
 transfusion [0.4, (0.1, 1.0)], DR resuscitation [0.4, (0.2, 0.8)], chronic
 lung disease [0.4, (0.2, 0.9)], and higher survival without major
 morbidities [2.8, (1.2, 6.8)]. DCC can be safely accomplished in
 majority of CD under GA with protocols to shorten DCC in cases where
 maternal or fetal safety is threatened. GA with DCC was not associated
 with increased neonatal resuscitation or major NICU morbidities and was
 associated with lower maternal hemorrhage and transfusion.
description: <strong>Materials and Methods</strong>
 We conducted a single-center, retrospective study of all CD
 &lt; 33 weeks gestation performed between January 2018 and December
 2023. Institutional Review Board (IRB) approval was obtained (#24-007).
 Cases of lethal fetal anomalies were excluded. Data on
 maternal demographics, pregnancy characteristics, delivery data, and
 maternal and infant outcomes were obtained from standardized reports in
 the electronic health record. Details on anesthesia timing, indication for
 CD, and indication for GA were confirmed with manual chart review.
 Anesthesia type was categorized as GA (if GA administration occurred
 before delivery of the infant) or RA, including spinal, epidural, or
 combined spinal epidural anesthesia. CD urgency was recorded by the
 delivering obstetrician at the time of surgery; “Emergency/STAT” was
 defined as need for immediate delivery due to impending fetal or maternal
 death or injury (e.g. fetal bradycardia.). Maternal blood loss was
 determined quantitatively: amniotic fluid quantity was marked on the
 suction cannister prior to placental delivery; all surgical drapes, chux,
 cannisters and lap pads were weighed at the conclusion of surgery and the
 weight of dry items and amniotic fluid subtracted. Antenatal steroid (ANS)
 for accelerating fetal maturation was administered prior to delivery of
 all infants &lt; 34 weeks and Magnesium sulfate (4 gram bolus with or
 without ongoing infusion 1-2 gm/hr) for neuroprotection was administered
 prior to delivery of all infants ≤ 32 0/7 weeks whenever feasible. All CD
 were performed by in-house Obstetrics and Gynecology residents and their
 attending physicians. Anesthesia providers were available in house 24
 hours a day. Throughout the study period, our
 standardized institutional protocol for DCC recommended waiting at least 3
 minutes before cord clamping. Contraindications to DCC included hydrops
 and recipient twin in twin-to-twin transfusion syndrome. Additional
 decisions to abort DCC early were based on discussion between the
 obstetric and neonatal providers in cases of significant maternal
 bleeding, cord avulsion, placental disruption or infant apnea after 30-60
 seconds of tactile stimulation and/or airway suctioning.
 Outcomes assessed for this study included maternal quantitative
 blood loss (QBL), PPH defined as blood loss &gt; 1000 ml, and need for
 blood transfusion. Neonatal DR outcomes included umbilical artery (UA) and
 venous (UV) cord blood gas acidosis pH &lt; 7 and base deficit (BD) ≥
 16, intubation, positive pressure ventilation (PPV), CPAP, and
 cardiopulmonary resuscitation (CPR). Neonatal NICU outcomes included
 admission temperature, severe IVH, late-onset sepsis, NEC, chronic lung
 disease (CLD), severe retinopathy of prematurity (ROP), severe neurologic
 injury including severe IVH and periventricular leukomalacia (PVL), length
 of stay, NICU death, and survival without major morbidities (late-onset
 sepsis, CLD, NEC, severe ROP, severe IVH or PVL).
 Neonatal and maternal characteristics (Table 1 in associated
 manuscript) were compared between GA and RA groups using univariable
 generalized estimating equations (GEE), quantile regression, chi-squared
 tests, and Fisher’s exact tests, as appropriate. Average marginal effects
 were reported to quantify differences between groups. Neonatal and
 maternal outcomes (Table 2, 3) were analyzed using multivariable GEE
 models to evaluate the effect of anesthesia type and DCC ≥ 60 s. Models
 were adjusted for known or suspected confounders, including gestational
 age, antenatal steroid (ANS), and emergent CD. We report effect estimates
 as odds ratios and regression coefficients. ANS was dropped from several
 multivariable analyses due to lack of events. Umbilical venous pH &lt;
 7 and base deficit ≥ 16 were instead analyzed using a Fisher’s exact test
 due to sparsity of events.  All infant-based regression
 models were clustered around pregnancy to account for multiple births.
 Robust standard errors were applied to all regression models. Linear,
 logistic, negative binomial, and Poisson models were selected based on the
 outcome and residual distributions. Descriptive statistics are presented
 as mean ± SD for normally distributed data, median (IQR) for non-normally
 distributed data, and n (%) for categorical variables. A p-value
 &lt;0.05 was considered statistically significant. 
description: # Data from: Short-term Maternal and neonatal outcomes in preterm (&lt; 33
 weeks gestation) Cesarean deliveries under general anesthesia with
 deferred cord clamping Dataset DOI:
 [10.5061/dryad.ffbg79d78](10.5061/dryad.ffbg79d78) ## Description of the
 data and file structure Data on maternal demographics, pregnancy
 characteristics, delivery data, and maternal and infant outcomes were
 obtained from standardized reports in the electronic health record.
 Details on anesthesia timing, indication for CD, and indication for GA
 were confirmed with manual chart review. ### Files and variables #### Data
 is available as a single csv file: “datadryad_de-identified_data.csv”
 Missing values are indicated by blank cells Variables, definitions, units,
 and legends are provided in the table belolw:   | Variable | variable
 label | vallab | legend | | :----------------- |
 :------------------------------------------------------------ |
 :--------------- | :----------------------------------------------- | |
 gravida | Gravity | 
 
 | 
 
 | | para | Parity | 
 
 | 
 
 | | bw cat | Birth weight, g, categories | 
 
 | 
 
 | | gaweeks | Gestational age (GA), weeks | 
 
 | 
 
 | | apgar1 | 1-minute Apgar | 
 
 | 
 
 | | apgar5 | 5-minute Apgar | 
 
 | 
 
 | | bloodloss | Blood loss, ml | 
 
 | 
 
 | | maternalage | Maternal age, years | 
 
 | 
 
 | | transfusion | Transfusion | lab\_yes\_no | 0 = no 1 = yes | | chorio
 | Chorioamnionitis | lab\_yes\_no | 0 = no 1 = yes | | cs\_type |
 C-section type | lab\_cs\_type | 0 = Classic/Vertical 1 = LTCS | | mult |
 Multiples | lab\_yes\_no | 0 = no 1 = yes | | diabetesorgdm | Diabetes or
 GDM | lab\_yes\_no | 0 = no 1 = yes | | eclampsia | Eclampsia or
 preeclampsia with severe features | lab\_yes\_no | 0 = no 1 = yes | | male
 | Male sex | lab\_yes\_no | 0 = no 1 = yes | | dcc\_group4 | DCC group 0 =
 0-59 s, 1 = 60-119 s, 2 = 120-179 s, 3 = 180+ s | lab\_dcc\_group4 | 0 =
 0-59 s 1 = 60-119 s 2 = 120-179 s 3 = 180+ s | | duration | Delayed Cord
 Clamping (DCC) duration, s | 
 
 | 
 
 | | dr\_cpap | DR continuous positive airway pressure (CPAP) |
 lab\_yes\_no | 0 = no 1 = yes | | aph | Umbilical artery (UA) pH | 
 
 | 
 
 | | aph\_lt7 | Umbilical artery pH &lt; 7 | lab\_yes\_no | 0 = no 1 = yes
 | | abicarb | Umbilical artery bicarbonate | 
 
 | 
 
 | | aco2 | Umbilical artery pCO2 | 
 
 | 
 
 | | abd | Umbilical artery Base deficit | 
 
 | 
 
 | | abd\_gte16 | Umbilical aretery base deficit &gt;= 16 | lab\_yes\_no |
 0 = no 1 = yes | | vph | Umbilical vein (UV) pH | 
 
 | 
 
 | | vph\_lt7 | Umbilical vein pH &lt; 7 | lab\_yes\_no | 0 = no 1 = yes |
 | vbicarb | Umbilical vein bicarbonate | 
 
 | 
 
 | | vco2 | Umbilical vein pCO2 | 
 
 | 
 
 | | vbd | Umbilical vein base deficit | 
 
 | 
 
 | | vbd\_gte16 | Umbilical vein base deficit &gt;= 16 | lab\_yes\_no | 0
 = no 1 = yes | | dr\_ppv | DR positive pressure ventilation (PPV) |
 lab\_yes\_no | 0 = no 1= yes | | dr\_intubation | Delivery room (DR)
 intubation | lab\_yes\_no | 0 = no 1 = yes | | dr\_cpr | Delivery room CPR
 | lab\_yes\_no | 0 = no 1 = yes | | los\_nicu | NICU Length of Stay, d | 
 
 | 
 
 | | ans | Antenatal steroids | lab\_yes\_no | 0 = no 1 = yes | | dr\_epi
 | Delivery room epinephrine | lab\_yes\_no | 0 = no 1 = yes | | admittemp
 | Admission temperature | 
 
 | 
 
 | | cld | Chronic lung disease | lab\_yes\_no | 0 = no 1 = yes | | los |
 Late onset sepsis | lab\_yes\_no | 0 = no 1 = yes | | sevrop | Severe
 retinopathy of prematurity | lab\_yes\_no | 0 = no 1 = yes | | anynec |
 Necrotizing enterocolitis | lab\_yes\_no | 0 = no 1 = yes | | sevivh |
 Severe intraventricular hemorrhage | lab\_yes\_no | 0 = no 1 = yes | |
 sevneuroinj | Severe neurologic injury | lab\_yes\_no | 0 = no 1 = yes | |
 death\_nicu | NICU death | lab\_yes\_no | 0 = no 1 = yes | | regional |
 Regional anesthesia | lab\_regional | 0 = General anesthesia 1 = Regional
 anesthesia | | cs\_emergent | Emergent cesarean delivery | lab\_yes\_no |
 0 = no 1 = yes | | bloodloss\_gte1000 | Blood loss &gt;= 1000 ml |
 lab\_yes\_no | 0 = no 1 = yes | | surv\_wo\_morb | Survival without major
 morbidity/mortality | lab\_yes\_no | 0 = no 1 = yes | ## Code/software
 Data can be viewed by any program that can read a CSV file, such as Excel,
 Stata, R, SAS, etc. ## Human subjects data This was a retrospective study
 that was approved by the institutional review board with waiver of
 consent. The data does not contain any direct identifiers. The two
 indirect identifiers were birth weight and gestational age. The birth
 weight was converted to weight categories in 100 g intervals, and
 gestational age was converted to categories in completed weeks of
 gestation.