Resuscitation with an intact umbilical cord improves neonatal transition

1. In a randomized trial including late preterm and term infants resuscitated with positive pressure ventilation (PPV) at birth, expanded Apgar score at 5 minutes was significantly higher in infants resuscitated with an intact cord than those who had immediate cord clamping.

2. Delayed cord clamping was also associated with increased oxygen saturation within the first 10 minutes of life and decreased rates of oxygen requirement at 12 hours.

Evidence Rating Level: 1 (Excellent)

Study Rundown: The benefits of delayed umbilical cord clamping are well established in uncomplicated births. Currently, however, cords are often clamped immediately for neonates needing resuscitation at birth due to logistical challenges initiating positive pressure ventilation (PPV) with an intact cord. This non-blinded randomized trial sought to examine whether intact cord resuscitation was beneficial based on 5-minute expanded Apgar scores. A total of 496 infants born at or after 34 weeks gestation were randomized before birth to receive delayed or immediate cord clamping if they were born not breathing. A custom resuscitation cart was used for neonates in the intact cord group. Among 71 infants in the intact cord group and 91 in the immediate clamping group who required PPV, median expanded Apgar scores were one point higher at 5 minutes in the intact cord group. Oxygen saturation was significantly higher in the intact cord group at 1, 5, and 10 minutes as well as at 12 hours, and the rate of oxygen requirement was lower at 12 hours. However, rates of intubation, NICU admission for birth asphyxia, and all-cause mortality did not significantly differ between groups. There is an intuitive argument for easing neonatal transition and maximizing blood flow from the placenta for infants requiring resuscitation just as for those born breathing. This small randomized study tallies with past studies in more limited populations in showing a benefit for delayed clamping. However, larger, multicenter studies would give further insight into both the physical feasibility of this resuscitation approach at scale and the clinical significance of this benefit.

Click to read the study in the Journal of Pediatrics

Relevant Reading: Neonatal resuscitation: Updated guidelines from the American Heart Association

In-Depth [randomized controlled trial]: Infants born at a single tertiary hospital in India between 2020 and 2021 were included. Mothers were approached based on a broad set of maternal and fetal risk factors. Infants born by both vaginal and cesarean delivery were included. Infants were randomized 1:1 prenatally in stratified blocks. In the intact cord group, clamping was to be performed between 3 and 5 minutes; in the early clamping group, within 30 seconds. About 24% of infants randomized to delayed cord clamping who received PPV had clamping before 3 minutes for maternal indications, including early placental separation. For the intact cord group, 28.7% required PPV compared to 36.5% in the early clamping group. In addition to the Apgar score, the expanded Apgar score gives one point each if an infant does not receive oxygen, continuous positive airway pressure, PPV, intubation, surfactant, chest compressions, and medication, for a maximum score of 17. The 95% confidence interval (CI) for the median difference in 5-minute expanded Apgar score between groups was 0 to 1 (p<0.001). Median oxygen saturations at 5 minutes were 89.2% and 85.4% in the intact and clamped groups, respectively (p=0.001).

Image: PD

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