Next Article in Journal
Impact of Oral Nutritional Supplementation and Dietary Counseling on Outcomes of Linear Catch-Up Growth in Indian Children Aged 3–6.9 Years: Findings from a 6-Month Randomized Controlled Trial
Previous Article in Journal
Acceptability Among Healthcare Providers of In Situ, Low-Dose, High-Frequency Neonatal Resuscitation Simulation Training Using Innovative Tools: Evidence from the Safer Births Bundle of Care
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Children
Volume 12
Issue 9
10.3390/children12091151
children-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Short-Term Maternal and Neonatal Outcomes in Preterm (<33 Weeks Gestation) Cesarean Deliveries Under General Anesthesia with Deferred Cord Clamping

by
Priya Jegatheesan
1,2,*,†,
Gloria Han
3,4,†,
Sudha Rani Narasimhan
1,2,
Matthew Nudelman
5,6,
Andrea Jelks
3,4 and
Dongli Song
1,2
1
Division of Neonatology, Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA 95128, USA
2
Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
3
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA
4
Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA 94305, USA
5
Department of Medicine and Clinical Informatics, School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI 53792, USA
6
Valley Health Foundation, San Jose, CA 95128, USA
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Children 2025, 12(9), 1151; https://doi.org/10.3390/children12091151
Submission received: 31 July 2025 / Revised: 26 August 2025 / Accepted: 27 August 2025 / Published: 29 August 2025
(This article belongs to the Section Pediatric Neonatology)
Review Reports Versions Notes

Abstract

Highlights

What are the main findings?
  • A majority (73%) of preterm infants delivered by Cesarean section under general anesthesia received at least 60 s of DCC.
  • General anesthesia and DCC were not associated with an increase in delivery room resuscitation or maternal hemorrhage.
What is the implication of the main finding?
  • DCC can be feasibly implemented in a majority of Cesarean deliveries performed at <33 weeks gestational age under general anesthesia with protocols to shorten DCC time where maternal or fetal safety is threatened.
  • DCC during Cesarean deliveries under general anesthesia does not increase maternal hemorrhage or need for neonatal resuscitation and may improve survival without morbidities in very preterm infants.

Abstract

Background: 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. Methods: This retrospective single-center observational study included CD at <33 weeks 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. Data was collected from reports from electronic medical records, neonatal intensive care unit database, and manually from the medical records of the patient. Multivariable regression analysis was used to assess the effect of anesthesia type and DCC on outcomes, adjusting for confounders. Results: This study included 170 mothers and 194 infants, and 84.9% of the infants received DCC ≥ 60 s. The GA group had a higher percentage of emergency CD and a lower median duration of DCC (105 s vs. 180 s, p ≤ 0.001) compared to RA. In multivariate regression analysis, GA was associated with lower odds (95% CI) of umbilical artery pH < 7 [0.1, (0.0, 0.6)], base deficit ≥ 16 [0.0, (0.0, 0.5)], and higher odds of necrotizing enterocolitis [28.2, (1.4, 560.0)]. GA was not associated with maternal hemorrhage, delivery room (DR) resuscitation, or other major neonatal morbidities or mortality. DCC ≥ 60 s 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)], and chronic lung disease [0.4, (0.2, 0.9)], and higher survival without major morbidities [2.8, (1.2, 6.8)]. Conclusions: DCC was performed in a majority of CD under GA by adhering to protocols to shorten DCC in cases where maternal or fetal safety was threatened. GA with DCC was not associated with increased neonatal resuscitation or major neonatal morbidities and was associated with lower maternal hemorrhage and transfusion.

1. Introduction

Deferred umbilical cord clamping (DCC), clamping the umbilical cord no sooner than 30–60 s after birth, promotes feto-neonatal transition and placental transfusion, which is critical for short and long-term neonatal outcomes. DCC of at least 30–60 s is recommended by the World Health Organization, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Pediatrics for vigorous term and preterm infants who do not require positive pressure ventilation [1,2].
In preterm infants, DCC is associated with improved hemodynamic stability after birth, higher hematocrit, lower risks of blood transfusion, intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC), and shorter length of neonatal intensive care unit (NICU) stay [3]. Long-term follow-up studies have demonstrated that DCC is associated with improved motor function at 1–2 years of age [4,5]. Remarkably, DCC is one of the most effective perinatal interventions in reducing mortality in preterm infants. Meta-analyses have shown that DCC reduces mortality by over 30% (odds ratio (OR) 0.68) compared to early cord clamping (ECC) at NICU discharge and at 2 years of age [6,7,8]. A recent network meta-analysis of preterm infants further showed that > 120 s of DCC reduced mortality by 70% (OR 0.31) compared to shorter duration of DCC [9]. We have previously reported that 60–75 s of DCC in very preterm infants, <33 weeks of gestation, reduced the risk of admission hypothermia, intubation, and red blood cell transfusion compared to 30–45 s DCC [10]. More recently, we showed that at least 120 s of DCC improved survival without major morbidities compared to 60 s DCC [11]. Regarding maternal safety, DCC has been shown not to worsen the risk of maternal hemorrhage in vaginal or cesarean delivery (CD) [6,12].
Approximately two-thirds of very preterm infants are born via CD, and 12–50% of these CDs are performed under general anesthesia (GA) [11,13,14]. While various studies have demonstrated the benefits of DCC in preterm infants, most prospective studies of DCC in premature infants have excluded CD under GA, and retrospective studies of DCC have described very few infants delivered under GA. Concerns have included high likelihood for infant resuscitation during emergent delivery and/or infant sedation from GA, as well as increased risk of maternal hemorrhage. A lack of data has led to ambiguity in professional society guidelines and may lead to uncertainty among obstetricians and neonatologists about the feasibility and safety of DCC in this group of high-risk infants.
At our institution, the duration of DCC was increased in a stepwise manner based on the updated literature and internal outcome evaluation. We initiated standardized delivery room (DR) resuscitation, including DCC of 30 s in 2007 [15]. In 2011, the Neonatal Resuscitation Program (NRP) 7th edition guidelines recommended DCC for 30–60 s, prompting us to increase DCC to 60 s. To maximize the benefits of DCC, we progressively increased the goal duration of DCC to 120 s in 2016 and 180 s in 2018. Our DCC protocol did not exclude infants born under GA as this group of high-risk infants may benefit the most from hemodynamic transition stability at birth. To ensure maternal and neonatal safety, we established standardized procedures, contraindications, and indications for early termination of DCC. We implemented an individualized approach to determine the duration of DCC based on open communication among providers who determine if there is a maternal or infant indication to abort DCC at each delivery.
This study aims to evaluate short-term maternal and neonatal outcomes after preterm CD under GA vs. regional anesthesia (RA) after implementing 180 s DCC in our institution.

2. Materials and Methods

We conducted a single-center, retrospective cohort study of all CD < 33 weeks gestation performed between January 2018 and December 2023 at Santa Clara Valley Medical Center in San Jose, California, USA. Institutional Review Board (IRB) approval was obtained (#24-007). During the study period, 198 preterm infants were born at <33 weeks gestation by CD and admitted to the NICU. Four cases of lethal fetal anomalies were excluded.
Data on maternal demographics, pregnancy characteristics, delivery data, and maternal and infant outcomes were obtained from standardized delivery reports in the electronic health record and NICU database. 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 prior to 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 < 34 weeks; and magnesium sulfate (4 g bolus with or without ongoing infusion 1–2 g/h) for neuroprotection was administered prior to delivery of all infants ≤ 32 0/7 weeks whenever feasible. All CDs were performed by in-house Obstetrics and Gynecology residents and their attending physicians. Anesthesia providers were available in house 24 h a day.
Throughout the study period, our standardized institutional protocol for DCC recommended waiting at least 180 s before cord clamping. In our center, waiting to clamp the cord for at least 60 s after birth was considered DCC and clamping before 60 s was considered ECC. 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 s of tactile stimulation and/or airway suctioning.
Our standardized DR resuscitation and management of preterm infants delivered by CD included the NICU provider being donned in sterile attire to assess and care for the infant immediately after delivery during DCC. Infants were placed on a thermal warming mattress on their mother’s thighs and gentle tactile stimulation, drying, and oral and nasal suctioning with a bulb syringe were provided. A team member verbalized the time in 1 min intervals after birth. Oxytocin infusion was initiated immediately after infant delivery (during DCC). Ring clamps were used as needed to clamp bleeding edges of the hysterotomy during this interval. In multiple gestations, the second-born multiple was delivered before clamping the cord of the first-born multiple whenever possible, thus minimizing the overall duration from uterine incision to closure. If DCC was aborted prior to 180 s, cord milking x4 was recommended, except for extremely preterm infants born at <29 weeks of gestation due to the increased risk of severe IVH [16]. After cord clamping, at the radiant warmer, continuous positive airway pressure (CPAP) was immediately initiated with a T piece and mask with 30% FiO2 for infants < 30 weeks or 21% for infants ≥ 30 weeks gestation. The infant’s temperature was assessed every 5 min, and plastic wrap and other appropriate interventions were utilized to prevent hypothermia during resuscitation [15].
Maternal and neonatal short-term outcomes were analyzed for this study. Outcomes assessed for this study included maternal quantitative blood loss (QBL), postpartum hemorrhage (PPH) defined as blood loss ≥ 1000 mL, and need for blood transfusion. Neonatal DR outcomes included umbilical artery (UA) and umbilical venous (UV) cord blood gas acidosis pH < 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 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 were analyzed using multivariable GEE models to evaluate the effect of anesthesia type and DCC ≥ 60 s. Models were adjusted for known confounders including gestational age, antenatal steroid (ANS), emergent CD, and DCC ≥ 60 s. We report effect estimates as odds ratios and regression coefficients. ANS was dropped from several multivariable analyses due to lack of heterogeneity, especially in rare events given the high ANS rate (88–99%) in the study cohort. Umbilical venous pH < 7 and base deficit ≥16 were analyzed using 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. Statistical analysis was performed using STATA 19.5 (Statacorp, College Station, TX, USA). A p-value < 0.05 was considered statistically significant.

3. Results

During the study period, 170 mothers underwent CD at <33 weeks gestation, delivering 194 infants. Of these, 30 mothers delivered under GA (33 infants) and 140 received RA (161 infants). The GA and RA groups were similar in maternal age, parity, race/ethnicity, payer, diabetes, severe preeclampsia/eclampsia and chorioamnionitis (Table 1). Emergent CD was significantly more common in the GA group (18/30 (60%) vs. 6/140 (4%), p ≤ 0.001). Indications for GA are shown in Table 1. The median (IQR) time from general anesthesia to delivery was 5 (4, 8) minutes. The groups were similar in infant gestational age, birth weight, sex, and ANS. More infants received DCC of at least 60 s (86% vs. 73%, p = 0.021) and ≥180 s (53% vs. 21%, p = 0.021) in the RA group compared to the GA group.
Table 2 shows the unadjusted analyses comparing maternal and neonatal outcomes in GA and RA groups. The odds of PPH ≥ 1000 mL, DR intubation, CLD, and severe ROP were higher in the GA compared to RA group.
Table 3 shows the adjusted multivariate analysis effects of DCC and GA on neonatal and maternal outcomes after adjusting for gestational age, ANS, and emergency CD. GA was associated with lower odds (95% CI) of UA pH < 7 [0.1, (0.0, 0.6)] and base deficit ≥16 [0.0, (0.0, 0.5)], and higher odds of NEC [28.2, (1.4, 560.0)]. After adjusting for anesthesia type, DCC ≥ 60 s was associated with lower QBL [Regression coefficient −698, 95% CI (−1193, −202)], lower odds of transfusion [0.4, (0.1, 1.0)], DR PPV [0.4, (0.2, 0.8)], CLD [0.4, (0.2, 0.9)], and higher odds of survival without major morbidities [2.8, (1.2, 6.8)].

4. Discussion

With a standardized DCC protocol and clear guidelines on when to abort DCC early due to maternal or neonatal safety concerns, more than 70% of very preterm infants born by Cesarean section under GA received ≥60 s DCC in our study. GA was not associated with higher risk of maternal blood loss or adverse outcomes like low APGARs, DR intubation, resuscitation, NICU neonatal morbidities, or mortality. DCC was associated with lower risk of maternal blood loss and transfusions, infant DR PPV, CLD, and higher preterm neonatal survival without major morbidities.
Previous studies have reported that CD under GA is associated with increased adverse maternal and neonatal outcomes compared to RA [13,17,18,19,20,21,22,23,24,25]. The poor outcomes might be attributed to the underlying reasons for performing emergent CD under GA, such as maternal bleeding disorder and/or unassured fetal conditions. In addition, GA itself decreases uterine contraction and may thus increase risk for PPH. Transfer of anesthetic agents across the placenta may cause infant sedation, which poses an additional risk for cardiopulmonary resuscitation. While numerous studies have shown that DCC reduces morbidities and mortality in premature infants, few of the studies included preterm deliveries under GA. Currently, obstetric and neonatal providers face a dilemma in performing DCC in these very high-risk deliveries: DCC facilitates feto-neonatal transition in these most vulnerable infants, yet, in some cases, DCC may worsen PPH and/or interfere with immediate neonatal cardiopulmonary resuscitation. Few recent clinical trials have shown the feasibility of performing neonatal resuscitation during DCC, and more RCTs are underway [26,27,28].

4.1. Feasibility of DCC in CD Under GA

Since 2018, our institution has incorporated 180 s of DCC as a part of standardized DR resuscitation of very premature infants with established criteria for contraindications and termination of DCC. In our center, 60–65% of <33 weeks preterm infants are delivered by CD. Notably, our DCC protocol does not exclude CD under GA. During each delivery, the obstetric providers assess for increased maternal bleeding that requires early termination of DCC, and pediatric providers evaluate the infant’s breathing and response to tactile stimulation in the first minute to determine if DCC needs to be terminated to initiate positive pressure ventilation. DCC duration and reasons for early termination of DCC are documented in the delivery notes. As an ongoing quality improvement effort, compliance with the DCC protocol in each very preterm delivery is reviewed at the weekly NICU meeting [29]. This individualized approach has allowed us to achieve a high rate of DCC completion at CD [10,11].
During this study period, almost three-fourths (73%) of infants born under GA received DCC of at least 60 s, with 133 s as the median duration of DCC. This data demonstrates that DCC is feasible in the majority of CD under GA and can be performed in the absence of an indication for earlier cord clamping. Notably, there were more infants in the RA group who received ≥60 and ≥180 s of DCC than in the GA group in this study. This observation is consistent with the literature that GA is associated with a higher likelihood of maternal PPH and the need for immediate neonatal cardiopulmonary resuscitation, which are standardized criteria for early termination of DCC in our center.

4.2. Maternal Outcomes

Multiple studies have observed a higher rate of PPH at CD under GA [17,18,19]. However, we could locate no studies reporting on the effect of DCC during preterm CD under GA. In the current study, we notably found that longer DCC duration was associated with lower blood loss and risk of transfusion when controlled for anesthesia type and other important confounders. Taken together with observational and randomized studies of DCC at the time of preterm CD, these studies and ours suggest that DCC itself does not alter maternal blood loss [6,30]. Rather, DCC is more likely to be completed when maternal bleeding is well controlled during CD, regardless of anesthesia type.

4.3. Neonatal DR Outcomes

One of the concerns about performing DCC during CD under GA is that the infant’s condition may be compromised while waiting for cord clamping. A recent randomized controlled trial and multiple retrospective studies have shown that APGAR scores are lower and neonatal asphyxia and risk of DR intubation are higher in infants who are delivered by CD under GA, although the cord management strategies were not described in these studies [13,20,21,22,23,24,25]. Another study demonstrated lower 1 min AGPAR and higher FiO2 need in preterm infants delivered under GA with cord clamped at 30 s after birth [31]. In our study, the APGAR scores were similar between the groups. The DR intubation rate was higher in the GA group; however, this was not significant when adjusted for gestational age and emergency CD. This suggests that the higher rate of DR intubation in GA group was likely due to lower gestational age and higher impaired fetal status as the indication for emergency CD.
In the literature, the effect of anesthesia type on cord pH has varied between no difference or lower pH in GA group compared to RA [32,33,34,35]. However, we observed a lower UA cord gas acidosis in GA group after adjusting for confounders. The difference in these DR outcome findings between our study and others may be related to the difference in cord management strategies. In our multivariate analysis, DCC ≥ 60 s was associated with lower risk of needing PPV in the delivery room. Our findings are reassuring that DCC at the time of CD under GA, in cases without maternal and neonatal complications, does not worsen the neonatal status at birth and may improve feto-neonatal transition.

4.4. Neonatal NICU and Long Term Outcomes

In previous studies, CD under GA was associated with a significant increase in severe neurological injury and adverse long term neurodevelopmental outcome in infants [13,36,37]. In this study, we found an increase in the risk of NEC but not in other morbidities in the GA group after adjusting for confounders. The incidence of NEC in this study cohort was low (2%). The wide range of 95% CI (1.4, 560.0) for NEC suggests that it is not a precise estimate which may be due to highly variable data and small sample size. This association needs to be evaluated in studies with larger sample size. The rates of CLD and severe ROP were higher in the GA group; however, this was not significant when adjusted for gestational age and emergency CD. This suggests that the higher rates of CLD and severe ROP in GA group were likely due to lower gestational age and impaired fetal status as the indication for emergency CD. In the multivariate analysis, regardless of anesthesia type, DCC was associated with a lower risk of CLD and improved survival without major morbidities. In these cases, DCC may be a surrogate to the overall infant’s state of well-being at the time of birth, or we can speculate that DCC may be playing a beneficial role in minimizing the adverse effects of GA in very high-risk preterm infants.

4.5. Strengths and Weakness

To our knowledge, this is the first study that addresses the feasibility and impact of DCC at the time of CD under GA. The strengths of our study include the use of a standardized institutional DCC protocol and high compliance across a 6-year time frame. Specific details pertaining to anesthesia, timing, and indications were able to be verified with manual chart review, ensuring accurate group assignment. Maternal blood loss was assessed quantitatively, rather than by surgeon estimate. Nevertheless, some important limitations must be acknowledged. Our study has a small sample size. Due to retrospective design, our study groups are not matched for important factors known to increase the risk of adverse infant outcomes and PPH. In particular, emergency delivery, non-reassuring fetal status, and maternal thrombocytopenia or bleeding disorder were much more prevalent in the GA group. Because we categorized patients by anesthesia type at the time of infant delivery, some patients in the RA group may have received general anesthesia later in their surgery for maternal indications, possibly affecting their overall hemorrhage risk. UA and UV cord gas values were missing in a third of our study population leading to a smaller sample size and limiting the interpretation of the cord gas data. Lastly, we do not have long-term infant follow-up data.

5. Conclusions

DCC of ≥60 s was achievable in a majority of preterm CDs under GA using protocols to shorten DCC in cases where maternal or fetal safety was threatened. In this study, GA with DCC was not associated with increased neonatal resuscitation or major NICU morbidities and had lower odds of maternal hemorrhage and transfusion. This study provides the baseline data for conducting multicenter large-scale studies of DCC in this high-risk delivery to evaluate short- and long-term maternal and neonatal outcomes.

Author Contributions

P.J., G.H., S.R.N., A.J., and D.S. contributed to the conception and design of the study; P.J., G.H., S.R.N., and A.J. contributed to the acquisition of the data; M.N. contributed to the analysis of the data; P.J., G.H., S.R.N., M.N., A.J., and D.S. contributed to the interpretation of the data; G.H. and P.J. prepared the original draft of the manuscript; and all authors contributed to the revision and finalization of the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was approved by the Institutional Review Board Office, Santa Clara Valley Medical Center, on 12 April 2024 (IRB reference #24-007) with annual renewal since.

Informed Consent Statement

This study was approved with waiver of both informed consent and HIPAA.

Data Availability Statement

De-identified data will be made available by the author upon request.

Acknowledgments

Gratitude is expressed to our patients and families and to the dedicated staff at Santa Clara Valley Medical Center neonatal intensive care unit and labor and delivery, and Santa Clara County First Five and Valley Medical Center Foundation. We are grateful to Balaji Govindaswami and James Byrne’s leadership in implementing delayed cord clamping. We are grateful for Lizeth Pulido, and Claudia Flores, for bibliography support.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. ACOG. Delayed Umbilical Cord Clamping After Birth: ACOG Committee Opinion, Number 814. Obstet. Gynecol. 2020, 136, e100–e106. [Google Scholar] [CrossRef]
  2. World Health Organization. Guideline: Delayed Umbilical Cord Clamping for Improved Maternal and Infant Health and Nutrition Outcomes; World Health Organization: Geneva, Switzerland, 2014. [Google Scholar]
  3. Rabe, H.; Gyte, G.M.; Díaz-Rossello, J.L.; Duley, L. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst. Rev. 2019, 9, CD003248. [Google Scholar] [CrossRef]
  4. Mercer, J.S.; Erickson-Owens, D.A.; Vohr, B.R.; Tucker, R.J.; Parker, A.B.; Oh, W.; Padbury, J.F. Effects of Placental Transfusion on Neonatal and 18 Month Outcomes in Preterm Infants: A Randomized Controlled Trial. J. Pediatr. 2016, 168, 50–55.e1. [Google Scholar] [CrossRef]
  5. Armstrong-Buisseret, L.; Powers, K.; Dorling, J.; Bradshaw, L.; Johnson, S.; Mitchell, E.; Duley, L. Randomised trial of cord clamping at very preterm birth: Outcomes at 2 years. Arch. Dis. childhood. Fetal Neonatal Ed. 2020, 105, 292–298. [Google Scholar] [CrossRef] [PubMed]
  6. Fogarty, M.; Osborn, D.A.; Askie, L.; Seidler, A.L.; Hunter, K.; Lui, K.; Simes, J.; Tarnow-Mordi, W. Delayed vs early umbilical cord clamping for preterm infants: A systematic review and meta-analysis. Am. J. Obstet. Gynecol. 2018, 218, 1–18. [Google Scholar] [CrossRef] [PubMed]
  7. Seidler, A.L.; Aberoumand, M.; Hunter, K.E.; Barba, A.; Libesman, S.; Williams, J.G.; Shrestha, N.; Aagerup, J.; Sotiropoulos, J.X.; Montgomery, A.A.; et al. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: A systematic review and individual participant data meta-analysis. Lancet 2023, 402, 2209–2222. [Google Scholar] [CrossRef]
  8. Robledo, K.P.; Tarnow-Mordi, W.O.; Rieger, I.; Suresh, P.; Martin, A.; Yeung, C.; Ghadge, A.; Liley, H.G.; Osborn, D.; Morris, J.; et al. Effects of delayed versus immediate umbilical cord clamping in reducing death or major disability at 2 years corrected age among very preterm infants (APTS): A multicentre, randomised clinical trial. Lancet Child Adolesc. Health 2022, 6, 150–157. [Google Scholar] [CrossRef] [PubMed]
  9. Seidler, A.L.; Libesman, S.; Hunter, K.E.; Barba, A.; Aberoumand, M.; Williams, J.G.; Shrestha, N.; Aagerup, J.; Sotiropoulos, J.X.; Montgomery, A.A.; et al. Short, medium, and long deferral of umbilical cord clamping compared with umbilical cord milking and immediate clamping at preterm birth: A systematic review and network meta-analysis with individual participant data. Lancet 2023, 402, 2223–2234. [Google Scholar] [CrossRef]
  10. Song, D.; Jegatheesan, P.; DeSandre, G.; Govindaswami, B. Duration of Cord Clamping and Neonatal Outcomes in Very Preterm Infants. PLoS ONE 2015, 10, e0138829. [Google Scholar] [CrossRef]
  11. Jegatheesan, P.; Belogolovsky, E.; Nudelman, M.; Narasimhan, S.R.; Huang, A.; Govindaswami, B.; Song, D. Longer Duration of Cord Clamping Improves Nicu Survival Without Major Morbidities in Very Preterm Infants. Children 2024, 11, 1546. [Google Scholar] [CrossRef]
  12. McDonald, S.J.; Middleton, P.; Dowswell, T.; Morris, P.S. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst. Rev. 2013, 7, CD004074. [Google Scholar] [CrossRef]
  13. Wang, L.; Liu, C.; Wang, X.; Zhu, S.; Zhang, L.; Wang, B.; Yu, Y. The impact of general anesthesia on the outcomes of preterm infants with gestational age less than 32 weeks delivered via cesarean section. Front. Pharmacol. 2024, 15, 1360691. [Google Scholar] [CrossRef]
  14. Laudenbach, V.; Mercier, F.J.; Roze, J.C.; Larroque, B.; Ancel, P.Y.; Kaminski, M.; Breart, G.; Diemunsch, P.; Subtil, D.; Lejus, C.; et al. Anaesthesia mode for caesarean section and mortality in very preterm infants: An epidemiologic study in the EPIPAGE cohort. Int. J. Obstet. Anesth. 2009, 18, 142–149. [Google Scholar] [CrossRef]
  15. Manani, M.; Jegatheesan, P.; DeSandre, G.; Song, D.; Showalter, L.; Govindaswami, B. Elimination of admission hypothermia in preterm very low-birth-weight infants by standardization of delivery room management. Perm. J. 2013, 17, 8–13. [Google Scholar] [CrossRef] [PubMed]
  16. Katheria, A.; Reister, F.; Essers, J.; Mendler, M.; Hummler, H.; Subramaniam, A.; Carlo, W.; Tita, A.; Truong, G.; Davis-Nelson, S.; et al. Association of Umbilical Cord Milking vs Delayed Umbilical Cord Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants. JAMA 2019, 322, 1877–1886. [Google Scholar] [CrossRef]
  17. Peclin, P.; Pavlica, M.; Druskovic, M.; Kavsek, G.; Verdenik, I.; Pintaric, T.S. Effect of Anesthetic Modality on Decision-to-Delivery Interval and Maternal-Neonatal Outcomes in Category 2 and 3 Cesarean Deliveries. J. Clin. Med. 2024, 13, 7528. [Google Scholar] [CrossRef]
  18. Iqbal, K.; Iqbal, A.; Rathore, S.S.; Ahmed, J.; Ali, S.A.; Farid, E.; Hasanain, M.; Azeem, Q.; Qadar, L.T.; Memon, F.R.; et al. Risk factors for blood transfusion in Cesarean section: A systematic review and meta-analysis. Transfus. Clin. Biol. 2022, 29, 3–10. [Google Scholar] [CrossRef]
  19. Rouse, D.J.; MacPherson, C.; Landon, M.; Varner, M.W.; Leveno, K.J.; Moawad, A.H.; Spong, C.Y.; Caritis, S.N.; Meis, P.J.; Wapner, R.J.; et al. Blood transfusion and cesarean delivery. Obstet. Gynecol. 2006, 108, 891–897. [Google Scholar] [CrossRef] [PubMed]
  20. Al-Sanjary, A. Maternal and Neonatal Outcome According to the Type of Anesthesia during Caesarean Section. Georgian Med. News 2025, 361, 185–189. [Google Scholar]
  21. Burguet, A.; Pez, O.; Debaene, B.; Untersteller, M.; Bettinger, G.; Kayemba-Kays, S.; Thiriez, G.; Bouthet, M.F.; Sanyas, P.; Menget, A.; et al. Very preterm birth: Is maternal anesthesia a risk factor for neonatal intubation in the delivery room? Arch. Pediatr. 2009, 16, 1547–1553. [Google Scholar] [CrossRef] [PubMed]
  22. Liu, T.; Wang, Y.; Xiao, X.; Chen, Z.; Li, X.; Liu, C. Comparison of maternal and neonatal outcomes between general anesthesia and combined spinal-epidural anesthesia in cesarean delivery for pregnancy complicated with placenta previa. BMC Anesth. 2025, 25, 294. [Google Scholar] [CrossRef] [PubMed]
  23. Munoz, J.L.; Hernandez, B.; Curbelo, J.; Ramsey, P.S.; Ireland, K.E. Effect of anesthesia selection on neonatal outcomes in cesarean hysterectomies for placenta accreta spectrum (PAS). J. Perinat. Med. 2022, 50, 1210–1214. [Google Scholar] [CrossRef]
  24. Chattopadhyay, S.; Das, A.; Pahari, S. Fetomaternal outcome in severe preeclamptic women undergoing emergency cesarean section under either general or spinal anesthesia. J. Pregnancy 2014, 2014, 325098. [Google Scholar] [CrossRef]
  25. Nwafor, M.I.; Aniebue, U.U.; Nwankwo, T.O.; Onyeka, T.C.; Okafor, V.U. Perinatal outcome of preterm cesarean section in a resource-limited centre: A comparison between general anaesthesia and subarachnoid block. Niger. J. Clin. Pract. 2014, 17, 613–618. [Google Scholar] [CrossRef]
  26. Duley, L.; Dorling, J.; Pushpa-Rajah, A.; Oddie, S.J.; Yoxall, C.W.; Schoonakker, B.; Bradshaw, L.; Mitchell, E.J.; Fawke, J.A.; Cord Pilot Trial Collaborative, G. Randomised trial of cord clamping and initial stabilisation at very preterm birth. Arch. Dis. childhood. Fetal Neonatal Ed. 2018, 103, F6–F14. [Google Scholar] [CrossRef] [PubMed]
  27. Raina, J.S.; Chawla, D.; Jain, S.; Khurana, S.; Sehgal, A.; Rani, S. Resuscitation with Intact Cord Versus Clamped Cord in Late Preterm and Term Neonates: A Randomized Controlled Trial. J. Pediatr. 2023, 254, 54–60.e4. [Google Scholar] [CrossRef] [PubMed]
  28. Pratesi, S.; Montano, S.; Ghirardello, S.; Mosca, F.; Boni, L.; Tofani, L.; Dani, C. Placental Circulation Intact Trial (PCI-T)-Resuscitation With the Placental Circulation Intact vs. Cord Milking for Very Preterm Infants: A Feasibility Study. Front. Pediatr. 2018, 6, 364. [Google Scholar] [CrossRef]
  29. Jegatheesan, P.; Lee, H.C.; Jelks, A.; Song, D. Quality improvement efforts directed at optimal umbilical cord management in delivery room. Semin. Perinatol. 2024, 48, 151905. [Google Scholar] [CrossRef]
  30. Salcido, C.; Shahidi, S.A.; Poeltler, D.M.; Gollin, Y.; Johnston, L.A.; Katheria, A.C. Maternal bleeding complications and neonatal outcomes following early versus delayed umbilical cord clamping in cesarean deliveries for very low birthweight infants. J. Perinatol. Off. J. Calif. Perinat. Assoc. 2023, 43, 39–43. [Google Scholar] [CrossRef]
  31. Willfurth, I.; Baik-Schneditz, N.; Schwaberger, B.; Mileder, L.; Schober, L.; Urlesberger, B.; Pichler, G. Cerebral Oxygenation in Neonates Immediately after Cesarean Section and Mode of Maternal Anesthesia. Neonatology 2019, 116, 132–139. [Google Scholar] [CrossRef]
  32. Harazim, H.; Stourac, P.; Blaha, J.; Grochova, M.; Klozova, R.; Noskova, P.; Seidlova, D.; Richterova, S.; Svoboda, M.; Jarkovsky, J.; et al. The influence of mode of anaesthesia for caesarean delivery on neonatal Apgar scores in the Czech Republic and Slovakia: Secondary analysis of the results of an international survey in 2015. Biomed. Pap. Med. Fac. Univ. Palacky Olomouc Czech Repub. 2019, 163, 147–154. [Google Scholar] [CrossRef] [PubMed]
  33. Chen, Y.; Liu, W.; Gong, X.; Cheng, Q. Comparison of Effects of General Anesthesia and Combined Spinal/Epidural Anesthesia for Cesarean Delivery on Umbilical Cord Blood Gas Values: A Double-Blind, Randomized, Controlled Study. Med. Sci. Monit. 2019, 25, 5272–5279. [Google Scholar] [CrossRef] [PubMed]
  34. Ozden, M.G.N.; Koruk, S.; Collak, Z.; Panik, N. Comparison of the effects of general and spinal anesthesia for cesarean delivery on maternal and fetal outcomes: A retrospective analysis of data. North. Clin. Istanb. 2023, 10, 575–582. [Google Scholar] [CrossRef] [PubMed]
  35. Tonni, G.; Ferrari, B.; De Felice, C.; Ventura, A. Fetal acid-base and neonatal status after general and neuraxial anesthesia for elective cesarean section. Int. J. Gynaecol. Obstet. 2007, 97, 143–146. [Google Scholar] [CrossRef]
  36. Chen, Y.C.; Liang, F.W.; Tan, P.H.; Ho, C.H.; Chang, Y.J.; Hung, K.C.; Chen, J.Y.; Yu, C.H. Association between general anesthesia for cesarean delivery and subsequent developmental disorders in children: A nationwide retrospective cohort study. BMC Med. 2025, 23, 119. [Google Scholar] [CrossRef]
  37. Robbins, L.S.; Blanchard, C.T.; Biasini, F.J.; Powell, M.F.; Casey, B.M.; Tita, A.T.; Harper, L.M. General anesthesia for cesarean delivery and childhood neurodevelopmental and perinatal outcomes: A secondary analysis of a randomized controlled trial. Int. J. Obstet. Anesthtet. 2021, 45, 34–40. [Google Scholar] [CrossRef]
Table 1. Demographics.
Table 1. Demographics.
GeneralRegionalAverage Marginal Effects (95% CI)p
Maternal CharacteristicsN = 30N = 140
Maternal age, years *31 ± 532 ± 61 (−1, 3)0.5
Gravity3 (2, 4)3 (2, 5)0 (−1, 1)1.0
Parity1 (0, 2)1 (0, 2)0 (−2, 2)1.0
Diabetes or gestational diabetes *5 (17%)40 (29%)13% (−3%, 28%)0.1
Eclampsia or pre-eclampsia with severe features12 (40%)55 (40%)0% (−19%, 20%)1.0
Chorioamnionitis *2 (7%)15 (11%)4% (−6%, 14%)0.4
Emergent cesarean delivery18 (60%)6 (4%)−56% (−74%, −38%)<0.001
Classical cesarean section *15 (50%)59 (42%)8% (−12%, 27%)0.5
General anesthesia indication
Abnormal placentation4 (13%)
NRFHT/need for emergent delivery18 (60%)
Maternal thrombocytopenia or bleeding disorder8 (27%)
English as preferred language *19 (63%)86 (62%)−1% (−20%, 18%)0.9
Medicaid or other government insurance *27 (90%)120 (87%)−3% (−15%, 9%)0.6
Race/ethnicity 0.8
White5 (17%)9 (6%)
Asian or Pacific Islander2 (7%)16 (11%)
Black2 (7%)7 (5%)
Hispanic21 (70%)104 (74%)
Multiracial0 (0%)2 (1%)
Unknown0 (0%)2 (1%)
Neonatal CharacteristicsN = 33N = 161
Gestational age, weeks28.4 (25.1, 31.6)30.1 (27.6, 32.0)1.7 (−0.6, 4.1)0.2
<29 weeks gestational age19 (58%)61 (38%)−19% (−40%, 1%)0.06
Birth weight, g1201 ± 5581324 ± 495119 (−91, 329)0.3
Birth weight < 1000 g17 (52%)54 (34%)−18% (−37%, 2%)0.07
Male sex14 (42%)88 (55%)13% (−7%, 32%)0.2
Multiples7 (21%)45 (28%)7% (−13%, 27%)0.5
Antenatal steroids29 (88%)160 (99%)11% (−2%, 25%)0.1
Delayed cord clamping (DCC) duration, s *105 (45, 153)180 (101, 180)75 (39, 111)<0.001
DCC duration categories 0.02
0–59 s9 (27%)22 (14%)
60–119 s8 (24%)22 (14%)
120–179 s9 (27%)32 (20%)
180+ s7 (21%)85 (53%)
Reason for DCC < 60 s 0.5
Maternal/placental6 (67%)18 (82%)
Neonatal3 (33%)3 (14%)
Both maternal and neonatal01 (5%)
1 min Apgar6 (4, 7)7 (5, 8)1 (−1, 3)0.4
5 min Apgar7 (5, 8)8 (7, 9)1 (−1, 3)0.3
Note: NRFHT—non reassuring fetal heart rate tracing; * Missing data from regional group: Maternal age, Chorioamnionitis, English as preferred language, Classical cesarean section, and Delayed cord clamping duration: n = 1; Medicaid or other government: n = 2; Diabetes or gestational diabetes, Eclampsia or pre-eclampsia with severe features: n = 3.
Table 2. Unadjusted Regression Analysis for Outcomes in General vs. Regional Anesthesia.
Table 2. Unadjusted Regression Analysis for Outcomes in General vs. Regional Anesthesia.
GeneralRegionalOdds Ratio or
Regression Coefficient (95% CI)		p
Maternal OutcomesN = 30N = 140
Blood loss, mL *1088 ± 662881 ± 762208 (−64, 479)0.134
Blood loss ≥ 1000 mL17 (57%)43 (31%)2.9 (1.3, 6.6)0.009
Transfusion9 (30%)21 (15%)2.4 (1.0, 6.0)0.056
Neonatal Delivery Room OutcomesN = 33N = 161
Delivery room (DR) intubation5 (15%)4 (3%)7.0 (1.8, 26.6)0.005
DR positive pressure ventilation (PPV)15 (46%)50 (31%)1.8 (0.8, 4.0)0.1
DR continuous positive airway pressure (CPAP)29 (88%)153 (95%)0.4 (0.1, 1.4)0.1
DR CPR †2 (6%)1 (1%)na0.08
DR epinephrine0 (0%)0 (0%)nana
Umbilical Artery Blood GasN = 20N = 96
UA pH < 72 (10%)5 (5%)2.0 (0.4, 11.3)0.4
UA base deficit ≥ 162 (11%)3 (3%)3.6 (0.6, 23.6)0.2
Umbilical Vein Blood GasN = 16N = 112
UV pH < 7 †0 (0%)4 (4%)na1.0
UV base deficit ≥ 16 †0 (0%)3 (3%)na1.0
Neonatal NICU OutcomesN = 33N = 161
Admission temperature, °C36.9 ± 0.436.8 ± 0.30.1 (0.0, 0.2)0.1
Length of stay, days *54 (33, 95)47 (27, 78)12 (−5, 30)0.2
Death1 (3%)5 (3%)1.0 (0.1, 8.6)1.0
Severe intraventricular hemorrhage1 (3%)4 (3%)1.2 (0.1, 10.7)0.9
Late onset sepsis5 (15%)9 (6%)3.0 (0.8, 11.4)0.1
Necrotizing enterocolitis2 (6%)2 (1%)5.1 (0.7, 36.8)0.1
Chronic lung disease13 (39%)30 (19%)2.8 (1.2, 6.5)0.02
Severe retinopathy of prematurity5 (15%)4 (3%)7.0 (1.6, 30.9)0.01
Severe neurologic injury (Severe IVH, cystic PVL)1 (3%)5 (3%)1.0 (0.1, 8.2)1.0
Survival without major morbidity/mortality20 (61%)116 (72%)0.6 (0.3, 1.4)0.2
Note: * Missing data: Blood loss: n = 2 (x1 regional and x1 general); Length of stay: n = 1 (regional); † Fisher’s exact test was performed due to lack of events.
Table 3. Adjusted Multivariable Regression Analysis for Outcomes.
Table 3. Adjusted Multivariable Regression Analysis for Outcomes.
Adjusted Regression Model *
General vs. Regional
Anesthesia		pDCC ≥60 s vs. DCC <60 sp
Odds Ratio or Regression Coefficient (95% CI)Odds Ratio or Regression Coefficient (95% CI)
Maternal Outcomes
Blood loss, mL179 (−194, 552)0.3−698 (−1193, −202)0.006
Blood loss ≥ 1000 mL2.5 (0.9, 7.0)0.080.5 (0.2, 1.2)0.1
Transfusion1.8 (0.5, 6.2)0.40.4 (0.1, 1.0)0.04
Neonatal Delivery Room Outcomes
Delivery room (DR) intubation1.0 (0.2, 5.4)1.00.7 (0.1, 4.1)0.7
DR positive pressure ventilation (PPV)2.1 (0.7, 6.7)0.20.4 (0.2, 0.8)0.02
DR continuous positive airway pressure (CPAP) †0.6 (0.1, 5.2)0.70.8 (0.1, 4.4)0.8
DR CPRnananana
DR epinephrinenananana
Umbilical Artery Blood Gas
UA pH < 7 †0.1 (0.0, 0.6)0.020.6 (0.0, 7.7)0.7
UA base deficit ≥ 16 †0.0 (0.0, 0.5)0.022.5 (0.3, 20.6)0.4
Umbilical Vein Blood Gas
UV base deficit ≥ 16 †nana0.1 (0.0, 1.1)0.06
UV pH < 7 †nana0.2 (0.0, 1.2)0.07
Neonatal NICU Outcomes
Admission temperature, °C0.0 (−0.2, 0.2)0.7−0.1 (−0.2, 0.0)0.2
Length of stay, days−6 (−14, 2)0.2−3 (−10, 4)0.4
Death ठ7.8 (0.8, 80.5)0.08nana
Severe intraventricular hemorrhage †1.1 (0.2, 6.9)0.90.9 (0.1, 12.0)1.0
Late onset sepsis †1.7 (0.3, 10.1)0.60.5 (0.1, 2.2)0.4
Necrotizing enterocolitis ‡†28.2 (1.4, 560.0)0.03nana
Chronic lung disease †1.2 (0.4, 3.7)0.80.4 (0.2, 0.9)0.04
Severe retinopathy of prematurity †1.7 (0.2, 12.4)0.60.8 (0.1, 5.2)0.8
Severe neurologic injury (Severe IVH, cystic PVL) †0.9 (0.2, 4.2)0.91.1 (0.1, 12.0)0.9
Survival without major morbidity/mortality †1.5 (0.4, 4.7)0.52.8 (1.2, 6.8)0.02
Note: * Regression model included anesthesia type, DCC ≥ 60 s, gestational age in weeks, antenatal steroids, and emergency cesarean deliveries (CD). † Antenatal steroids was not included in the multivariable regression model due to lack of heterogeneity in the events. ‡ DCC ≥ 60 s was not included in the multivariable regression model due to a lack of events. § Emergency CD was not included in the multivariable regression model due to a lack of events.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Jegatheesan, P.; Han, G.; Narasimhan, S.R.; Nudelman, M.; Jelks, A.; Song, D. Short-Term Maternal and Neonatal Outcomes in Preterm (<33 Weeks Gestation) Cesarean Deliveries Under General Anesthesia with Deferred Cord Clamping. Children 2025, 12, 1151. https://doi.org/10.3390/children12091151

AMA Style

Jegatheesan P, Han G, Narasimhan SR, Nudelman M, Jelks A, Song D. Short-Term Maternal and Neonatal Outcomes in Preterm (<33 Weeks Gestation) Cesarean Deliveries Under General Anesthesia with Deferred Cord Clamping. Children. 2025; 12(9):1151. https://doi.org/10.3390/children12091151

Chicago/Turabian Style

Jegatheesan, Priya, Gloria Han, Sudha Rani Narasimhan, Matthew Nudelman, Andrea Jelks, and Dongli Song. 2025. "Short-Term Maternal and Neonatal Outcomes in Preterm (<33 Weeks Gestation) Cesarean Deliveries Under General Anesthesia with Deferred Cord Clamping" Children 12, no. 9: 1151. https://doi.org/10.3390/children12091151

APA Style

Jegatheesan, P., Han, G., Narasimhan, S. R., Nudelman, M., Jelks, A., & Song, D. (2025). Short-Term Maternal and Neonatal Outcomes in Preterm (<33 Weeks Gestation) Cesarean Deliveries Under General Anesthesia with Deferred Cord Clamping. Children, 12(9), 1151. https://doi.org/10.3390/children12091151

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop