Ventilation of Preterm Infants during Delayed Cord Clamping (VentFirst): A Pilot Study of Feasibility and Safety

Abstract

Background Establishing lung inflation prior to umbilical cord clamping may improve the cardiovascular transition and reduce the risk of intraventricular hemorrhage in preterm infants. We developed a pilot feasibility and safety study in which infants < 33 weeks' gestation received assisted ventilation during delayed cord clamping (DCC).

Methods Infants born between 24 0/7 and 32 6/7 weeks' gestation whose mothers consented were enrolled. All infants received continuous positive airway pressure or positive pressure ventilation during 90 seconds of DCC. Outcomes included feasibility (ability to complete protocol and maintain a sterile field during cesarean deliveries) and safety variables (Apgar scores, umbilical cord pH and base deficit, admission temperature, and postcesarean infection).

Results A total of 29 infants were enrolled, including one set of twins (median gestation: 30 weeks; 72% cesarean births). In all cases, the protocol was completed. Heart rate at 60 seconds was more than 100 beats per minute in all infants. Apgar scores, cord blood gas values, and admission temperature were comparable to other preterm deliveries at our institution.

Conclusion Assisting ventilation of very preterm infants during 90 seconds of DCC is challenging but feasible and appears to be safe in this small pilot study. A randomized clinical trial is warranted to determine clinical benefit.

Keywords

delayed cord clamping - prematurity - intraventricular hemorrhage - resuscitation

• References

• 1 Behrman RE, Butler AS. Preterm Birth: Causes, Consequences and Prevention. Washington, DC: Institute of Medicine of the National Academies; 2007
• 2 Whitelaw A. Core concepts: Intraventricular hemorrhage. NeoReviews 2011; 12 (2) e94-e101
• 3 Sharp J, The Midwives Book: Or the Whole Art of Midwifry Discovered (Women Writers in English 1350–1850). Hobby E ed. 1st ed. New York, NY: Oxford University Press; 1999
• 4 Budin P. A quel moment doit-on pratiquer la ligature du cordon ombilical?. Prog Med (Paris) 1875; 3 (51) 765-767
• 5 Yao AC, Moinian M, Lind J. Distribution of blood between infant and placenta after birth. Lancet 1969; 2 (7626) 871-873
• 6 Aflaifel N, Weeks A. Push, pull, squeeze, clamp: 100 years of changes in the management of the third stage of labour as described by Ten Teachers. BMJ 2012; 345: e8270
• 7 Kattwinkel J Ed. Textbook of Neonatal Resuscitation. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics/American Heart Association; 2011
• 8 McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2013; 7: CD004074
• 9 Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. (Review) Cochrane Database Syst Rev 2012; 8: CD003248
• 10 Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Timing of umbilical cord clamping after birth. Committee Opinion No. 543. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; 120: 1522-1526
• 11 Kim AJH, Warren JB. Optimal timing of umbilical cord clamping: Is the debate settled? Part 2 of 2: Evidence in preterm and term infants, alternatives, and unanswered questions. NeoReviews 2015; 16 (5) e270-e277
• 12 Hooper SB, Te Pas AB, Lang J , et al. Cardiovascular transition at birth: a physiological sequence. Pediatr Res 2015; 77 (5) 608-614
• 13 Polglase GR, Dawson JA, Kluckow M , et al. Ventilation onset prior to umbilical cord clamping (physiological-based cord clamping) improves systemic and cerebral oxygenation in preterm lambs. PLoS ONE 2015; 10 (2) e0117504
• 14 Bhatt S, Alison BJ, Wallace EM , et al. Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol 2013; 591 (8) 2113-2126
• 15 Volpe JJ. Intraventricular hemorrhage in the premature infant—current concepts. Part II. Ann Neurol 1989; 25 (2) 109-116
• 16 Georgiadis L, Keski-Nisula L, Harju M , et al. Umbilical cord length in singleton gestations: a Finnish population-based retrospective register study. Placenta 2014; 35 (4) 275-280
• 17 Naeye RL. Umbilical cord length: clinical significance. J Pediatr 1985; 107 (2) 278-281
• 18 Andersson O, Lindquist B, Lindgren M, Stjernqvist K, Domellöf M, Hellström-Westas L. Effect of delayed cord clamping on neurodevelopment at 4 years of age: a randomized clinical trial. JAMA Pediatr 2015; 169 (7) 631-638
• 19 Hill AL, Fontenot HB. Beliefs and practices of obstetric care providers regarding umbilical cord clamping. Nurs Womens Health 2014; 18 (5) 413-419
• 20 Oddie S, Rhodes P ; Very Preterm Birth Qualitative Collaborative Group. Barriers to deferred cord clamping in preterm infants. Arch Dis Child Fetal Neonatal Ed 2014; 99 (5) F391-F394
• 21 Ersdal HL, Linde J, Mduma E, Auestad B, Perlman J. Neonatal outcome following cord clamping after onset of spontaneous respiration. Pediatrics 2014; 134 (2) 265-272
• 22 Nevill E, Meyer MP. Effect of delayed cord clamping (DCC) on breathing and transition at birth in very preterm infants. Early Hum Dev 2015; 91 (7) 407-411
• 23 Bradshaw LE, Pushpa-Rajah A, Dorling J, Mitchell EJ, Duley L ; Cord Pilot Trial Collaborative Group. Cord pilot trial: update to randomised trial protocol. Trials 2015; 16 (1) 407 . Available at http://www.trialsjournal.com/content/16/1/407
• 24 Katheria A, Rich W, Finer N. Optimizing care of the preterm infant starting in the delivery room. Am J Perinatol 2016; 33 (3) 297-304
• 25 Katheria A, Rich W, Finer N. Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation. Pediatrics 2012; 130 (5) e1177-e1181
• 26 van Vonderen JJ, Hooper SB, Kroese JK , et al. Pulse oximetry measures a lower heart rate at birth compared with electrocardiography. J Pediatr 2015; 166 (1) 49-53
• 27 Weeks AD, Watt P, Yoxall CW , et al. Innovation in immediate neonatal care: development of the Bedside Assessment, Stabilisation and Initial Cardiorespiratory Support (BASICS) trolley. BMJ Innov 2015; 1 (2) 53-58
• 28 Perlman JM, Wyllie J, Kattwinkel J , et al; Neonatal Resuscitation Chapter Collaborators. Part 11: neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010; 122 (16) (Suppl. 02) S516-S538
• 29 World Health Organization. Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants. Available at http://www.who.int/elena/titles/cord_clamping/en/ . Accessed September 23, 2015