DCC-ET-Caesar: Feasibility and safety of delayed cord clamping with ex-utero transfusion in elective caesarean deliveries - A pilot study.

Abstract

BackgroundDelayed cord clamping (DCC) and placental transfusion techniques have been associated with improved neonatal outcomes, including enhanced haemodynamic stability and increased haemoglobin levels. Physiological cord clamping (PCC) also ensures a smoother cardiovascular transition at birth by maintaining placental circulation until the neonate establishes independent respiration. However, the optimal timing for clamping in cases of delayed cord clamping remains unclear. This pilot study aims to evaluate the feasibility and safety of delayed cord clamping with ex-utero transfusion (DCC-ET), after Doppler-confirmed cessation of umbilical blood flow in elective caesarean deliveries.MethodsA prospective, single-arm pilot feasibility study was conducted on women undergoing elective caesarean sections at term. The DCC technique used in this study, delayed cord clamping with ex-utero transfusion (DCC-ET), is a modification of the methods previously described in literature. Following delivery, the uterine incision was inspected, and bleeding points were secured without urgency to clamp the cord. The placenta was allowed to separate spontaneously and was removed with controlled cord traction. The newborn remained attached to the placenta, which was elevated approximately 30 cm above the baby to facilitate ex-utero transfusion. Cord clamping was performed only after complete cessation of umbilical blood flow, confirmed by Doppler assessment at a fixed point 10 cm from the cord insertion. Maternal-neonatal outcomes, including Apgar scores, haemoglobin levels, neonatal intensive care unit admissions, maternal blood loss, and any adverse events, were recorded.ResultsA total of 40 women were included. The DCC-ET procedure was successfully completed in all cases. The mean time to umbilical cord blood flow cessation, and umbilical cord clamping was 6.60 ± 1.91 minutes post-delivery. Compared to the 1-minute DCC group, maternal blood loss was significantly lower, and postoperative haemoglobin drop was less in the DCC-ET group. Residual placental blood volume was markedly reduced (11.40 ± 2.56 mL vs 45.91 ± 13.01 mL; p = 0.001). Neonatal haematocrit at 48-72 hours was significantly higher in the DCC-ET group (61.25 ± 2.39% vs 55.81 ± 5.41%; p = 0.001), with no increase in neonatal hypothermia or adverse outcomes. Cord separation occurred earlier in the DCC-ET group. Apgar scores and phototherapy requirements were comparable between groups. No significant postpartum haemorrhage or maternal complications were observed.ConclusionThe present pilot study demonstrates that DCC-ET is a feasible and safe procedure during elective caesarean deliveries. The protocol was successfully implemented in the majority of cases, with no increase in maternal or neonatal complications and acceptable integration into routine clinical practice. Doppler assessment of umbilical blood flow provided a practical method to individualize cord clamping timing, although variability in time to flow cessation between participants highlighted the need for a physiology-guided, rather than time-based, approach. Further randomized controlled trials are required to compare this combined method with standard delayed cord clamping and isolated ex-utero transfusion to better understand potential additional benefits and to refine best practices for neonatal transition.