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Am J Perinatol
DOI: 10.1055/a-2725-9711
Letter to the Editor

Expanding the “Physiological Sequence” after Birth

Autoren

  • Lukas P. Mileder

    1   Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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With their seminal work, Stuart Hooper and colleagues[1] beautifully illustrated that if spontaneous breathing—or non-invasive ventilation in case of absent breathing efforts—occurs before clamping of the umbilical cord, cardiac preload is maintained, resulting in a more stable cardio-circulatory adaptation after birth. The logical consequence of this physiological process has been the development of the concept of physiological-based cord clamping, where the umbilical cord is only clamped and cut after successful lung aeration and subsequent cardio-pulmonary stabilization.

In a multi-center randomized controlled superiority trial involving 669 preterm neonates below 30 weeks of gestation, Knol et al[2] compared physiological-based cord clamping, with variable time before cord clamping based on the achievement of stable heart rate and oxygenation, to so-called “time-based” delayed cord clamping 30 to 60 seconds after birth. Although there was no difference between the groups in the primary study outcome of survival without major cerebral injury and/or necrotizing enterocolitis, neonates required significantly fewer blood transfusions and had lower incidences of late-onset sepsis and post-hemorrhagic ventricular dilatation after physiological-based cord clamping.[2] Almost as important, parents were more content, felt less anxious, and had an improved feeling of safety with the physiological-based cord clamping approach.[2]

Early skin-to-skin contact with the mother after birth not only facilitates natural maternal–infant “togetherness” but also has significant impact on breastfeeding success as well as on maternal self-efficacy, anxiety, and mental health. Accordingly, kangaroo care, with its main focus on skin-to-skin contact between infants and caregivers, is associated with improved infant growth, neurodevelopment, breastfeeding outcomes, and reduced infant stress levels.[3]

In their randomized controlled trial in very preterm neonates, Kristoffersen et al[4] showed that 2 hours of early skin-to-skin contact with the mother was feasible in the majority of infants after initial assessment and delivery room stabilization. Of 149 infants, only 22 could not be randomized due to medical reasons, including a birth weight below the pre-defined minimum of 1,000 g, high oxygen demand, and the need for invasive ventilation. In the randomized preterm neonates, there were no differences during the first 24 hours in mean body temperature, heart rate, respiratory rate, oxygen saturation, and the amount of supplemental oxygen between the skin-to-skin contact group and the control group receiving standard postnatal care including transfer to the neonatal intensive care unit in an incubator.[4] However, hyperthermia above 37.5°C was significantly more common within 2 hours after birth among neonates receiving standard care (47 vs. 26%).[4]

Combining both of these interventions aiming at stabilizing and supporting immature infants after birth, i.e., physiological-based cord clamping and skin-to-skin contact with the mother as soon as possible in the delivery room, seems logical and complementary to each other. Te Pas et al[5] already suggested mobile resuscitation tables for the purpose of physiological-based cord clamping as being “an in-between station” before the neonate is actually placed on the mother's chest. In situations where the mother is not available due to medical reasons, as illustrated by the 14 cases in the previously mentioned study by Kristoffersen et al,[4] which had to be excluded because mothers themselves were intubated, fathers should be considered for initial skin-to-skin contact.

In my opinion, combining physiological-based cord clamping with early postnatal skin-to-skin contact would complete the physiological sequence[1] by neonatal care providers again taking advantage of biological resources and natural processes immediately after birth. However, this suggestion must be considered with caution, as thorough clinical research is needed to prove both feasibility and safety especially in very and extremely preterm neonates. Among numerous aspects that need to be considered and investigated, the primary method and mode of non-invasive respiratory support, temperature management strategies, and convenient, yet also relevant monitoring concepts during the immediate postnatal transition period seem to be of utmost importance.



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Eingereicht: 03. Juli 2025

Angenommen: 17. Oktober 2025

Artikel online veröffentlicht:
31. Oktober 2025

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