Hematocrit levels in newborns: EPP vs. DCC study reveals surprising findings


A recent study in JAMA Network Open investigates the impact of extrauterine placental perfusion versus delayed cord clamping on hematocrit levels in newborns, shedding light on potential alternatives for optimizing infant outcomes during birth.

Hematocrit levels in newborns: EPP vs. DCC study reveals surprising findings | Image Credit: © Gary - © Gary - stock.adobe.com.

Hematocrit levels in newborns: EPP vs. DCC study reveals surprising findings | Image Credit: © Gary - © Gary - stock.adobe.com.

Hematocrit levels are similar among infants of mothers receiving extrauterine placental perfusion (EPP) vs delayed cord clamping (DCC), according to a study with evaluation from October to December 2021 and published in JAMA Network Open.


  1. The study found that hematocrit levels in infants of mothers who underwent extrauterine placental perfusion (EPP) were similar to those in infants subjected to delayed cord clamping (DCC).
  2. DCC for 30 seconds or more was associated with increased odds of survival and reduced risks of intraventricular hemorrhage, red blood cell transfusions, and death or disability in newborns.
  3. While there's a scarcity of data guiding DCC recommendations for very low birth weight (VLBW) infants, animal studies suggest physiological-based cord clamping (PBCC) could be beneficial.
  4. EPP presents a modified approach where infants are born via cesarean delivery while still connected to the placenta. This method could be a potential alternative to PBCC, as investigated in a randomized clinical trial.
  5. The study's findings indicate that EPP might be a viable procedure to explore as an alternative to optimize neonatal outcomes. Larger trials are recommended to further assess the impact of EPP on newborn health.

The timing of cord clamping during the transition from intrauterine to extrauterine life is directly associated with the transition process and infant outcomes. DCC by 30 seconds or more is associated with increased odds of survival and decreased intraventricular hemorrhage, red blood cell transfusion rate, and death or disability risk.

There is a lack of data on very low birth weight (VLBW) guiding DCC recommendations. However, animal studies have indicated physiological-based cord clamping (PBCC) may be vital for DCC benefits.

EPP is a modified approach where infants are born through cesarean delivery while the placenta is still connected through an intact umbilical cord and transferred to the resuscitation unit. Investigators have theorized this method may be used as an alternative for PBCC and conducted a randomized clinical trial to evaluate this hypothesis.

Participants included pregnant patients at 23 weeks and 6 days’ gestation or greater and an estimated fetal weight under 1500 g at risk of preterm delivery. All eligible infants were born by cesarean delivery.

Exclusion criteria included fetal or maternal risk, vaginal delivery, placenta accreta or increta, placental abruption or placenta previa, congenital anomalies, monochorionic multiples, and not providing consent. Opaque, sealed envelopes were used for randomization, with stratification based on pregnancy type and gestational age.

Patients receiving DCC were placed into the control group. Following cesarean delivery, infants in this group were placed in a sterile plastic suit and gently stimulated through rubbing of the back or feet if apenic until breathing. The minimal time until cord clamping was 30 seconds, with oxytocin given to mothers after cord clamping. Afterward, the placenta was manually detached.

In the EPP intervention group, infants were born by, “cesarean delivery with gentle detaching of the placenta from the uterus along with the infant and intact umbilical cord,” according to study authors. Following delivery, mothers were given oxytocin and infants were transferred to a resuscitation unit, receiving resuscitation using the same protocol as the control group.

Placental weight and oxygen saturation were measured following resuscitation. Hematocrit level was the primary outcome of the analysis, first measured at 15 to 60 minutes after birth then at 12 and 24 hours after birth and reported as the mean of these measurements.

There were 59 infants included in the final analysis, with a mean gestational age of 28 weeks. The average birth weights were 982.8 g in the EPP group and 970.2 in the DCC group.

The primary outcome did not significantly differ between the 2 groups, with mean hematocrit levels of 56% and 53.9% in the EPP and DCC groups respectively. These results did not significantly change when stratifying for mode of pregnancy, sex, and gestational age.

Significantly increased pulse oximetry levels were seen in the intervention group, indicating higher oxygen saturation. Significantly higher cerebral oxygenation was also observed during the first few minutes after birth.

These results indicated EPP may be used as an alternative procedure for PBCC in infants. Investigators recommended larger trials be conducted to assess the impact of EPP on neonatal outcomes.


Kuehne B, Grüttner B, Hellmich M, Hero B, Kribs A, Oberthuer A. Extrauterine placental perfusion and oxygenation in infants with very lowbirth weight: A randomized clinical trial. JAMA Netw Open. 2023;6(11):e2340597. doi:10.1001/jamanetworkopen.2023.40597

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