Neonatal Resuscitation with an Intact Cord: A Randomized Clinical Trial

Abstract

Objective To assess whether providing ventilation during delayed cord clamping (V-DCC) increases placental transfusion compared with delayed cord clamping alone (DCC only). Study design Inborn premature infants (230-316 week gestational age) were randomized to receive at least 60 seconds of delayed cord clamping with ventilation (V-DCC: initial continuous positive airway pressure [CPAP]) with addition of positive pressure ventilation if needed) or without assisted ventilation (DCC only). For the DCC only group, infants were dried and stimulated by gently rubbing the back if apneic. The primary outcome was the peak hematocrit in the first 24 hours of life. Delivery room outcomes were analyzed from video recordings and a data acquisition system. Hemodynamic measurements were performed using functional echocardiography (fECHO), near infrared spectroscopy (NIRS), and electrical cardiometry (EC). Results There was no difference in the primary outcome of peak hematocrit in the first 24 hours of life. The onset of breathing was similar between both groups (25±20 and 27±28 seconds, p=0.627). However, infants receiving DCC received a greater duration of stimulation than VDCC (41±19 and 20±21 seconds p=0.002). There were no differences in delivery room interventions, early hemodynamics (cerebral oxygenation by NIRS, cardiac output and stroke volume by EC, or superior vena cava flow by fECHO) or neonatal outcomes. Conclusions Ventilation during delayed cord clamping was feasible but did not lead to any measurable clinical improvements immediately after delivery or reduce subsequent neonatal morbidity. Caretakers should consider providing adequate stimulation prior to cord clamping. Trial registration ClinicalTrials.gov: NCT02231411

The Changing Landscape in Supporting Preterm Infants at Birth

“…As such, lung aeration before cord clamping will lead to a large increase in type E prostaglandin metabolism, thereby reducing its inhibitory affect. Indeed, Katheria et al [43] observed that infants not receiving respiratory support during DCC needed significantly more and longer stimulation to initiate regular breathing. Further studies in preterm infants using objective measures are needed to determine the influence of PBCC on respiratory effort.…”

Providing a Placental Transfusion in Newborns Who Need Resuscitation

“…The Lifestart™ bed (Inditherm Medical, Rotherham, UK) has been used by ourselves and others and is designed to provide a safe, adjustable, platform for the infant with space provided for the mounting of equipment (64, 65). We outfitted our Lifestart™ beds with a T-piece resuscitator, an air–oxygen blender, an oxygen flowmeter, and 50 psi air and oxygen hoses to connect to gas supply in any environment (Figure 1).…”

“…Sterile ventilation masks and circuits are not yet available commercially but some vendors are willing to provide sterile equipment for clinical trials at this time. The Lifestart™ bed is lowered to at least the level of the uterine incision and the neonatal provider in sterile attire will provide support as needed (64) (Figure 2A). An additional resuscitation team member should be in the operating room to provide assistance as needed.…”

“…Delaying clamping of the cord in preterm infants is well tolerated, and the majority will establish respirations within at least 30 s (35, 64). It appears that for non-breathing infants, a delay in cord clamping may have adverse outcomes of CLD or severe IVH but not death; however, larger trials are needed to confirm this.…”

Mask Continuous Positive Airway Pressure Therapy with Simultaneous Extrauterine Placental Transfusion for Resuscitation of Preterm Infants – A Preliminary Study

“…PSG testing is considered the gold standard for diagnosing OSA [9]. Although OSA could be diagnosed using PSG with the patient at home, this examination usually requires admission to a hospital or a specialized sleep testing center.…”