Original article

Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2018-316649 on 9 May 2019. Downloaded from http://fn.bmj.com/ on February 3, 2020 at Swets Subscription
Postpartum use of oxytocin and volume of placental
transfusion: a randomised controlled trial
Nestor E Vain,1,2 Daniela S Satragno,2,3 Juan Esteban Gordillo,4 Ariel L Fernandez,2
Guillermo Carrolli,5 Norma P Romero,4 Luis M Prudent2

1
Pediatrics, Hospital Trinidad, Abstract
University of Buenos Aires, Objective  To assess whether oxytocin administered What is already known on this topic?
Buenos Aires, Argentina
2
Fundasamin, Buenos Aires, before clamping the umbilical cord modifies the volume
►► Delaying umbilical cord clamping (DCC) for
Argentina of placental transfusion.
at least 1 min results in the passage of blood
3
Neonatology, Hospital de Ninos Design  Randomised controlled trial.
Ricardo Gutierrez, Buenos Aires, from the placenta to the infant (placental
Methods  Mothers of term infants born vigorous by
Argentina transfusion).
4 vaginal delivery with informed consent provided in early
Neonatology, Instituto de ►► DCC is currently recommended in term infants
Maternidad y Ginecología labour were randomly assigned to oxytocin (10 IU) given
to decrease iron deficiency, and in preterm
Nuestra Señora de Las intravenously within 15 s of birth (group 1) or after
Mercedes, Tucumán, Argentina births to improve cardiorespiratory transition
clamping the umbilical cord 3 min after delivery (group
5
Centro Rosarino de Estudios and increase blood volume.
2). Soon after birth, all infants were weighed using a 1 g
Perinatales, Rosario, Argentina ►► Oxytocin is routinely administered to mothers
precision scale and subsequently placed on the mother’s
soon after birth to prevent postpartum
Correspondence to
abdomen or chest. At 3 min, in both groups, the cord was
haemorrhage, but its influence on the volume of

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Dr Nestor E Vain, Pediatrics, clamped and cut, and the weight was again obtained.
placental transfusion is unknown.
Hospital Trinidad, University The primary outcome (volume of placental transfusion)
of Buenos Aires, Buenos Aires was estimated by the difference in weights.
1426, Argentina;
Results  144 patients were included. There were no
​nestorvain@​gmail.c​ om
differences in the primary outcome: infants in group
Received 4 December 2018 1 (n=70) gained a mean weight of 85.9 g (SD 48.3), What this study adds?
Revised 21 March 2019 and in group 2 (n=74) 86.7 g (SD 49.6) (p=0.92). No
Accepted 25 March 2019 differences were found in secondary outcomes, including ►► Routine administration of oxytocin to mothers
Published Online First immediately after birth, before delayed
9 May 2019 newborns’ haematocrit and bilirubin concentrations
and severe maternal postpartum haemorrhage. On the clamping of the umbilical cord, does not
advice of the Data and Safety Monitoring Committee, the influence the volume of placental transfusion.
trial was stopped due to futility at 25% of the planned ►► To administer oxytocin after clamping, the
sample size. umbilical cord would not modify the positive
Conclusions  When umbilical cord clamping is delayed effects of delaying umbilical cord clamping on
for 3 min, term newborn infants born vigorous receive term infants.
a clinically significant placental transfusion which is not
modified by the administration of intravenous oxytocin
immediately after birth.
Because of the increase in haemoglobin levels,
Trial registration number  NCT02618499.
iron stores and other potential benefits, delayed
UCC is currently recommended by the Interna-
tional Liaison Committee on Resuscitation and
The optimal timing for umbilical cord clamping other professional associations.6–8
(UCC) has been controversial. After delivery of the To decrease the risk of maternal postpartum
infant and before the cord is clamped, passage of haemorrhage, administration of oxytocin to
blood from the placenta to the infant takes place;
the mother soon after birth is currently recom-
this is known as placental transfusion (PT). Blood
mended.9 10 A study from 1968 suggested that
returning from the placenta towards the infant
administration of another uterotonic, methylergo-
through the umbilical veins, and from the infant
metrine, increases the passage of blood to the infant
to the placenta through the umbilical arteries,
continues for several minutes.1 A number of factors during the first minute of life.11 It is important to
influence the volume of PT, including timing of know whether postpartum oxytocin administered
UCC, onset of breathing, crying, uterine contrac- before the umbilical cord is clamped, a sequence of
© Author(s) (or their events occurring in a large number of deliveries all
employer(s)) 2020. No
tions and other less investigated factors.1–3 Gravity
has been considered another factor.4 However, over the world, influences the volume of PT. To our
commercial re-­use. See rights
and permissions. Published we demonstrated in a randomised controlled trial knowledge no clinical studies evaluating its effects
by BMJ. (RCT) that gravity has no influence: in infants have been previously published. We aimed to assess
To cite: Vain NE, Satragno with UCC at 2 min, there was no difference in the whether administration of intravenous oxytocin
DS, Gordillo JE, et al. Arch Dis volume of PT comparing a group held on the moth- immediately after birth modifies the volume of PT
Child Fetal Neonatal Ed er’s abdomen or chest with others held at the level in infants whose umbilical cord was clamped at
2020;105:F14–F17. of the vagina.5 3 min.
F14   Vain NE, et al. Arch Dis Child Fetal Neonatal Ed 2020;105:F14–F17. doi:10.1136/archdischild-2018-316649
 Original article

Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2018-316649 on 9 May 2019. Downloaded from http://fn.bmj.com/ on February 3, 2020 at Swets Subscription
Methods
Study design and participants
This is a single-­ centre RCT conducted at a large maternity
hospital in Argentina (Instituto de Maternidad y Ginecología
Nuestra Señora de Las Mercedes, Tucumán) to test the hypoth-
esis that oxytocin given to mothers at birth increases the volume
of PT. Mothers were approached and gave written consent on
admittance to hospital for labour (mothers in advanced labour
were not approached because of insufficient time to obtain
an ethically valid informed consent). Women with a term
normal pregnancy in whom a vaginal uncomplicated delivery
was expected were eligible. Exclusion criteria were history of
placenta previa or postpartum haemorrhage, multiple gesta-
tion, intrauterine growth restriction, congenital malforma-
tions, maternal diseases and request by parents for cord blood
banking. Vigorous newborn babies born by vaginal delivery in
cephalic presentation were included in the analysis. According
to pre-­ established elimination criteria, infants delivered by
caesarean section or forceps, born with a short umbilical cord or
a tight nuchal cord, or needing resuscitation, although initially
randomised, were not considered in the analysis. Figure 1  Flow chart.

Randomisation and masking

Statistical analysis

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Eligible newborns were randomly assigned in a 1:1 ratio to
Based on our previous study using a similar model, for sample
group 1 (immediate oxytocin) or group 2 (oxytocin at 3 min)
size calculation, we assumed a weight difference of 55±46 g
using computer-­generated allocation sequence in block sizes
(SD).5 A sample size of 275 infants per group was estimated to
of four to eight. Allocation was concealed by sequentially
detect a 20% difference in the increment in birth weight (two
numbered, sealed, opaque envelopes.
tails), with 80% power and significance level of 5%.
We used t-­test, Mann-­Whitney U test and χ² test for group
Procedures comparison, and multivariable linear regression analysis to
After obtaining informed parental consent, we randomly adjust for confounding factors (Stata IC V.11).
assigned newborns to the immediate or 3 min oxytocin group, An external Data and Safety Monitoring Committee (DSMC)
and the obstetric team was notified. All infants were weighed composed of three experienced investigators (a paediatrician,
immediately after birth at the level of the vagina using an elec- a neonatologist and an obstetrician) who had no relationship
tronic 1 g precision scale (STW-6 BB Electronic, Balanzas CAM, with the participating hospital was notified of any adverse event
Argentina; coefficient of variation of 0.0006 g). A reliable weight throughout the study. A previously planned interim analysis was
is usually obtained within the first 15 s. A towel with a known performed after inclusion of the first 144 patients (25% of the
dry weight was kept in advance on the weight scale. The infant estimated population of the study) to ensure safety and to assess
was wrapped with the towel during the process to prevent even- the need for a re-­estimation of the sample size.
tual loss of urine outside the weight scale. Time 0 was delivery of
the shoulders. Using a stopwatch (SH-688 STAR, Fuego, China),
a nurse notified the team at 15 s and 180 s. Ten international Results
units of oxytocin were administered intravenously to mothers Between May and November 2016, 171 newborns fulfilled
assigned to group 1 within the first 15 s after birth, and after the inclusion criteria and 5 mothers refused consent. After
clamping the umbilical cord at 3 min to those assigned to group informed consent was obtained, some infants could not be
2. All infants were placed after birth on the mother’s abdomen; studied: 14 were delivered by caesarean section or forceps, 9
care was taken to avoid compression of the umbilical vessels. had a short umbilical cord or a tight nuchal cord, 3 needed resus-
At 3 min, the cord was clamped and cut in the babies of both citation, and in 1 case the investigator was not available. One
groups, and they were weighed again on the same scale. hundred and forty-­ four infants were analysed: 70 assigned
Apgar scores and time to initial weight were recorded. Venous to immediate oxytocin and 74 to the 3 min oxytocin group
haematocrit and bilirubin values were obtained at 36–48 hours (figure 1). We recorded no serious adverse events. Following the
simultaneously with routine neonatal screening. predetermined analysis of these 144 infants, the DSMC recom-
mended to stop recruitment due to futility after a predetermined
Outcomes recalculation of the sample size based on the available data
We used the increment in birth weight as a proxy for volume of resulted in an excessively large trial.
PT as it has been previously reported.5 12–14 The primary outcome Table 1 presents the characteristics of the mothers and
was the difference between the infant’s weight obtained immedi- newborn babies. Both groups were comparable with regard to
ately after birth and the one registered at 3 min. demographics and other clinical characteristics. We found a
The secondary outcomes were haematocrit and bilirubin difference in gender and time to first breath between the groups,
concentrations, incidence of polycythaemia, need for photo- as shown in table 1. The linear regression model that considered
therapy and severe maternal postpartum haemorrhage, defined these covariates as possible confounding factors of the associa-
by the need for blood transfusion or the use of any treatment for tion between the difference in PT and the  group was −1.95 g
haemodynamic instability. (95% CI −19.13 to 15.22) (p=0.822).
Vain NE, et al. Arch Dis Child Fetal Neonatal Ed 2020;105:F14–F17. doi:10.1136/archdischild-2018-316649 F15
 Original article

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Table 1  Characteristics of mothers and newborn babies
Group 1 Group 2
Oxytocin 15 s (n=70) 3 min (n=74)
Maternal age, years, mean±SD 25±6.8 24.2±6.2
First pregnancy, n (%) 27 (38) 26 (35)
Apgar score, median (IQR)
1 min* 8 (8–8) 8 (8–8)
5 min 9 (9–9) 9 (9–9)
Gestational age (weeks), mean±SD 39.1±0.9 39.1±0.9
Birth weight (g), mean±SD 3309±424 3218±377
Gender, female, n (%)‡ 26 (37) 44 (59)
Time to first breath (s), mean (SD)§ 9.5 (10) 6.2 (5.6)
Admitted to the NICU, n (%) 3 (4.2) 2 (2.7)
*P=0.2480.
†P=0.2497.
‡P=0.007.
Figure 2  Initial and 3 min weight in group 1 and group 2.
§P=0.016.
NICU, neonatal intensive care unit.
found that in infants whose mothers received oxytocin during
the first 15 s after birth, the volume of PT estimated by the
Table 2 and figure 2 show the data on the primary outcome. The weight gain was 85.9±48.3 g, almost identical to the weight
average weight gain for newborn babies in the immediate oxytocin gain in the group receiving oxytocin at 3 min after clamping the
group was 85.9 g (SD 48.3), and 86.7 g (SD 49.6) in the 3 min

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umbilical cord (86.7±49.6 g).
oxytocin group (after clamping the umbilical cord). This could also The difference in PT between the two groups adjusted for
be expressed as 26.2 g/kg (SD 15.4 g/kg) in group 1 and 27 g/kg (SD gender and time to first breath was on average −1.95 g. Based
15.4 g/kg) in group 2. The weight increase represents 2.62% of on the 95% CI, the difference can vary between an increase of
the body weight in group 1 and 2.7% in group 2. 15.2 g or a decrease of 19 g. This difference was considered of no
There were no differences in venous bilirubin and haematocrit clinical relevance. The DSMC recommended stopping the trial
concentrations obtained at 36–48 hours (table 3). Four infants in due to futility. They considered that the study demonstrated no
group 1 and five in group 2 had haematocrit ≥65%. In none of effect of oxytocin on the volume of PT.
the groups we observed cases of symptomatic polycythaemia or In 1968, a study by Yao et al11 suggested that administration
severe maternal postpartum haemorrhage. of methylergometrine, a different uterotonic in use at that time,
increased the speed but not the final volume of PT in infants
Discussion whose umbilical cords were clamped at 3 min. The authors
Delayed cord clamping is recommended by leading professional postulated that after birth the contraction of the uterus gener-
organisations.6 15 Its use in term births contributes to decreased ated by methylergometrine squeezes the placenta, creating a
iron deficiency in infants and children, a frequent public health pressure gradient between the placenta and the baby, affecting
problem in low-­income countries,16 17 but also common in devel- the initial phase of PT. Our study was not designed to evaluate
oped regions such as North America and Western Europe.18 Up this sequence of events; we did not routinely record uterine
to 20% of preschool children in the USA have depleted iron contractions after the delivery of the infant and before clamping
stores and up to 8% have iron deficiency anaemia.19 of the umbilical cord. Our results confirm that the administra-
Oxytocin is routinely administered to mothers soon after birth tion of a uterotonic does not influence the total volume of PT.
to decrease the risk of postpartum haemorrhage.10 However, A recent study performed in sheep by Polglase et al20 evalu-
optimal timing for its administration (before or after clamping ated the effects of intravenous oxytocin given to the ewe at birth
the umbilical cord) is unknown since the potential impact of on fetuses instrumented in utero and delivered by caesarean
oxytocin on the volume of PT had not previously been investi- section. They found that the contractions produce a significant
gated in clinical studies. decrease in placental blood flow by reducing flow through the
Our RCT demonstrated that 10 IU of intravenous oxytocin umbilical arteries and subsequently blood return through the
administered to mothers immediately after birth does not umbilical veins. As a consequence, there was a decrease in fetal
modify the volume of PT in term infants born vigorous by
vaginal delivery and in whom clamping of the cord was delayed
for 3 min. Table 3  Secondary outcomes
The predetermined evaluation by the DSMC performed on Secondary outcomes Group 1 (n=70) Group 2 (n=74) P value
recruitment of 144 infants (25% of the estimated sample size)
Total bilirubin (mg/dL), 10.7±4.3 10.3±4.15 0.59
mean±SD*
95% CI 9.6 to 11.8 9.3 to 11.4
Table 2  Primary outcome Mean difference −0.4 (−1.1 to 1.9)
Group 1 Group 2 Haematocrit (%), mean±SD* 56.8± 5.9 57.3±4.5 0.64
Weight change (g) 15 s (n=70) 3 min (n=74) P value
95% CI 55.4 to 58.3 56.2 to 58.4
Mean±SD 85.9±48.3 86.7±49.6 0.92 Mean difference −0.4 (−2.3 to 1.4)
95% CI 74.3 to 97.4 75.2 to 98.2 Phototherapy, n (%) 2 (2.8) 2 (2.7) 0.95
Mean difference 0.8g; 95% CI −16.9 to 15.4 (g).
*Values obtained at 36–48 hours.

F16 Vain NE, et al. Arch Dis Child Fetal Neonatal Ed 2020;105:F14–F17. doi:10.1136/archdischild-2018-316649
 Original article

Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2018-316649 on 9 May 2019. Downloaded from http://fn.bmj.com/ on February 3, 2020 at Swets Subscription
oxygenation and an increase in cerebral blood flow and heart design, data collection, data analysis, data interpretation and writing of the report.
rate. They did not quantify the impact of oxytocin on the total The corresponding author had full access to all the data in the study and had final
responsibility for the decision to submit for publication.
volume of PT. The authors recommended postponing the admin-
istration of oxytocin until the umbilical cord has been clamped. Competing interests  None declared.
Although it is unknown if these findings in the sheep model can Patient consent for publication  Not required.
be extrapolated to humans born by vaginal delivery or even by Ethics approval  Protocol and consent were approved by the hospital’s
caesarean section, it may be justified to administer oxytocin after institutional review board.
the umbilical cord is clamped. There are no studies demonstrating Provenance and peer review  Not commissioned; externally peer reviewed.
any differences in maternal blood loss comparing oxytocin given
intravenously immediately after birth with the administration a
few minutes later. In many cases of natural birth with no intra- References
venous in place during labour, oxytocin is given intramuscularly 1 Boere I, Roest AA, Wallace E, et al. Umbilical blood flow patterns directly after birth
before delayed cord clamping. Arch Dis Child Fetal Neonatal Ed 2015;100:F12
after the delivery. It is unlikely that oxytocin provided intrave-
1–F125.
nously at 3 min would be less rapid and/or effective than intra- 2 Bhatt S, Alison BJ, Wallace EM, et al. Delaying cord clamping until ventilation
muscular administration given at birth.10 21 22 onset improves cardiovascular function at birth in preterm lambs. J Physiol
Another interesting aspect of our findings is the total volume 2013;591:2113–26.
of transfusion received by the infants. In the current trial, with 3 Hooper SB, Te Pas AB, Lang J, et al. Cardiovascular transition at birth: a physiological
sequence. Pediatr Res 2015;77:608–14.
cord clamping at 3 min in both groups, the weight increments 4 Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet 1969;2:505–8.
were approximately 86 g, equivalent to 82 cc of blood.23 In a 5 Vain NE, Satragno DS, Gorenstein AN, et al. Effect of gravity on volume of placental
previous study using a similar model, we showed no difference transfusion: a multicentre, randomised, non-­inferiority trial. Lancet 2014;384:235–40.
in the volume of PT of infants held on the mother’s abdomen 6 Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal resuscitation: 2015
or chest compared with those held at the level of the vagina.5 In american heart association guidelines update for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2015;132(18 Suppl 2):S543–S560.
that study, the cord was clamped in all infants at 2 min, and the 7 McDonald SJ, Middleton P, Dowswell T, et al. Effect of timing of umbilical cord
weight increments tested with the same methodology and using

Service REF: 44147171. Protected by copyright.

clamping of term infants on maternal and neonatal outcomes. Cochrane Database
the same weight scale were only approximately 55 g. We may Syst Rev 2013;7:CD004074.
assume that in vigorous infants born by vaginal delivery, PT is 8 WHO. Guideline: Delayed umbilical cord clamping for improved maternal and infant
incomplete when the cord is clamped at 2 min. Furthermore, the health and nutrition outcomes. Geneva: World Health Organization, 2014.
9 Begley CM, Gyte GM, Devane D, et al. Active versus expectant management for
increments of weight in the present study are similar to those women in the third stage of labour. Cochrane Database Syst Rev 2015;3:CD007412.
reported by Farrar et al and with the results from the most recent 10 Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third stage of labour to
Cochrane review of clinical trials comparing early versus delayed prevent postpartum haemorrhage. Cochrane Database Syst Rev 2013;10:CD001808.
cord clamping.7 14 Of note, by protocol, all infants in our study 11 Yao AC, Hirvensalo M, Lind J. Placental transfusion-­rate and uterine contraction.
Lancet 1968;1:380–3.
were born by vaginal delivery, and therefore our results may not
12 Gunther M. The transfer of blood between baby and placenta in the minutes after
apply to infants born by caesarean section. birth. Lancet 1957;272:1277–80.
We did not find any difference in the occurrence of severe 13 Fonseca D. Importancia del aporte de sangre placentaria al niño recién nacido.
maternal haemorrhage, but the study is underpowered to confirm Su medida por medio del registro ponderal continuo. Arch Pediatr Uruguay
this finding. Similarly, we found differences between groups in 1962;7:444–56.
14 Farrar D, Airey R, Law GR, et al. Measuring placental transfusion for term births:
gender, most likely related to chance because of the small sample size weighing babies with cord intact. BJOG 2011;118:70–5.
due to early stopping of recruitment than to an effect of oxytocin. 15 Delayed umbilical cord clamping after birth. Committee Opinion No. 684. American
The advantages of avoiding early clamping of the umbilical cord College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e5–10.
have been clearly demonstrated. Delayed UCC in term newborns 16 Durán P, Mangialavori G, Biglieri A, et al. [Nutrition status in Argentinean children 6 to
increases haemoglobin levels and iron stores.7 In premature 72 months old: results from the National Nutrition and Health Survey (ENNyS)]. Arch
Argent Pediatr 2009;107:397–404.
infants it appears to facilitate cardiovascular stabilisation at birth, 17 Nojilana B, Norman R, Dhansay MA, et al. Estimating the burden of disease
and decrease the need for blood transfusions and the risk of necro- attributable to iron deficiency anaemia in South Africa in 2000. S Afr Med J
tising enterocolitis.6 In both preterm and term infants, there is a 2007;97:741–6.
slight increase in the development of jaundice.6 7 24 Based on these 18 Andersson O, Hellström-­Westas L, Andersson D, et al. Effect of delayed versus early
findings, delayed UCC is currently recommended for infants born umbilical cord clamping on neonatal outcomes and iron status at 4 months: a
randomised controlled trial. BMJ 2011;343:d7157.
vigorous.6 8 25 26 In all preterm and term deliveries, oxytocin is indi- 19 Eden AN, Sandoval C. Iron deficiency in infants and toddlers in the United States.
cated soon after birth to decrease the risk of maternal postpartum Pediatr Hematol Oncol 2012;29:704–9.
haemorrhage. Our study demonstrates that there is no difference 20 Polglase G, Stenning F, Kluckow M, et al. Effects of Oxytocin Administration During
in the volume of PT by giving oxytocin immediately after birth or Physiological-­Based Clamping at Preterm Birth. PAS Meeting 2017. abstract.#3135.1.
21 Dagdeviren H, Cengiz H, Heydarova U, et al. Intramuscular versus intravenous
after clamping the umbilical cord at 3 min.
prophylactic oxytocin for postpartum hemorrhage after vaginal delivery: a randomized
controlled study. Arch Gynecol Obstet 2016;294:911–6.
Contributors  NV was responsible for the idea of the study, developed the protocol, 22 Neri-­Mejía M, Pedraza-­Avilés AG. [Active management of the third stage of
organised the study methods, managed and coordinated the study, participated labor: Three schemes of oxytocin: randomised clinical trial]. Ginecol Obstet Mex
in data analysis, and wrote the report. DSS developed the protocol, managed and 2016;84:306–13.
coordinated the study, trained the staff, participated in data analysis, reviewed the 23 Trudnowski RJ, Rico RC. Specific gravity of blood and plasma at 4 and 37 degrees C.
study methods and data collection procedures, and wrote the report. GC developed Clin Chem 1974;20:615–6.
the protocol and reviewed the report. LMP developed the protocol and wrote the 24 Rabe H, Diaz-­Rossello JL, Duley L, et al. Effect of timing of umbilical cord clamping
report. ALF participated in the development of the protocol, designed the statistical and other strategies to influence placental transfusion at preterm birth on maternal
methodology, and performed the data analysis and statistical evaluation. JEG and and infant outcomes. Cochrane Database Syst Rev 2012;8:CD003248.
NPR participated in data management and analysis of the results, and reviewed 25 Clamping of the Umbilical Cord and Placental Transfusion. Royal college of
the report. All authors approved the final manuscript as submitted and agree to be obstetricians and gynaecologists. 2015;14. Scientific Impact Paper No. https://www.​
accountable for all aspects of the work. rcog.​org.​uk/​globalassets/​documents/g​ uidelines/​scientific-i​ mpact-​paper/​sip-​14.​pdf.
Funding  Perez Companc Foundation and Foundation for Maternal-­Infant Health 26 Intrapartum care for healthy women and babies. NICE Guidance. 2014. https://www.​
(Fundasamin) funded the study. The sponsor of the study had no role in study nice.​org.​uk/​guidance/​cg190 (Updated Feb 2017).

Vain NE, et al. Arch Dis Child Fetal Neonatal Ed 2020;105:F14–F17. doi:10.1136/archdischild-2018-316649 F17