Neonatal Resuscitation with Placental Circulation Intact

A special issue of Children (ISSN 2227-9067). This special issue belongs to the section "Pediatric Neonatology".

Deadline for manuscript submissions: closed (10 January 2022) | Viewed by 33030

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Special Issue Editors

Neonatal Intensive Care Unit, Università degli Studi di Firenze, 50121 Firenze, Italy
Interests: neonatal transition; neonatal resuscitation; neonatal jaundice; phototherapy for neonatal hyperbilirubinemia; near-infrared spectroscopy
Special Issues, Collections and Topics in MDPI journals
Materials and Engineering Research Institute, Hallam University, Sheffield, UK
Interests: equipment design; process and training to achieve motherside neonatal resuscitation with an intact cord
Special Issues, Collections and Topics in MDPI journals
Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA 92123, USA
Interests: neonatal transition; neonatal resuscitation; near-infrared spectroscopy

Special Issue Information

Dear Colleagues,

Neonatal transitional physiology should include a delay in cord clamping until after the newborn is breathing: this is easy to perform in a healthy term newborn but not in a sick or preterm newborn. A delayed cord clamping of 30 seconds reduces the hospital mortality of preterm newborns. Very limited data are available on delayed cord clamping in term newborns who require neonatal resuscitation at birth. Resuscitation with an intact cord has been feasible and safe, both in term and preterm newborns, and could be the best way to stabilize a newborn in the delivery room.

Immediate cord clamping still represents the standard care in preterm and sick newborns worldwide. To promote a different, more physiological approach to newborns in need of assistance at birth, neonatologists should move close to the delivering mother, so to evaluate the tone, heart rate, and efforts of the newborn to breathe, and start at least the initial steps of stabilization (above all breathing tactile stimulation) before the cord is clamped. Recent studies have demonstrated that it is safely feasible, using special equipped and a movable trolley. However, these devices still need technological improvements and are too expensive to permit a rapid spread of this approach in delivery room care protocols.

The goal of this research topic is to promote the spread of a new way of resuscitating newborns in the delivery room: to perform exactly the same neonatal resuscitation procedures but with a different landscape, that is at motherside with an intact cord. Contributors are invited to send original research articles, clinical trial articles, study protocol, brief research, or case report articles and technology and code articles, addressing themes such as the following:

  • Delayed cord clamping, longer than 1 minute after newborn’s breathing, in preterm babies
  • Neonatal resuscitation/assistance with an intact cord in preterm newborns
  • Neonatal resuscitation with an intact cord in asphyxiated term newborns
  • Neonatal resuscitation with an intact cord in congenital fetal anomalies (hydrops fetalis, diaphragmatic hernia, etc.)
  • Technological advances (trolley, heating system, ventilation system, etc.) to promote neonatal assistance with an intact cord
  • High fidelity simulation to promote multi-professional neonatal assistance with an intact cord
  • Physiological (hemodynamic and respiratory) neonatal adaptation during an intact cord transition (both animal or human studies)

Dr. Simone Pratesi
Dr. David Hutchon
Dr. Anup Katheria
Guest Editors

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Keywords

  • Delayed cord clamping;
  • Immediate cord clamping;
  • Neonatal resuscitation at motherside;
  • Neonatal assistance with an intact cord;
  • Physiologically based cord clamping

Published Papers (11 papers)

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Editorial

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6 pages, 471 KiB  
Editorial
How to Provide Motherside Neonatal Resuscitation with Intact Placental Circulation?
Children 2021, 8(4), 291; https://doi.org/10.3390/children8040291 - 08 Apr 2021
Cited by 9 | Viewed by 2802
Abstract
Immediate clamping and cutting of the umbilical cord have been associated with death and/or neurodisability [...] Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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Research

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14 pages, 2334 KiB  
Article
Maintaining Normothermia in Preterm Babies during Stabilisation with an Intact Umbilical Cord
Children 2022, 9(1), 75; https://doi.org/10.3390/children9010075 - 05 Jan 2022
Cited by 4 | Viewed by 2067
Abstract
Background: We had experienced an increase in admission hypothermia rates during implementation of deferred cord clamping (DCC) in our unit. Our objective was to reduce the number of babies with a gestation below 32 weeks who are hypothermic on admission, whilst practising DCC [...] Read more.
Background: We had experienced an increase in admission hypothermia rates during implementation of deferred cord clamping (DCC) in our unit. Our objective was to reduce the number of babies with a gestation below 32 weeks who are hypothermic on admission, whilst practising DCC and providing delivery room cuddles (DRC). Method: A 12 month quality improvement project set, in a large Neonatal Intensive Care Unit, from January 2020 to December 2020. Monthly rates of admission hypothermia (<36.5 °C) for all eligible babies, were tracked prospectively. Each hypothermic baby was reviewed as part of a series of Plan, Do, Study Act (PDSA) cycles, to understand potential reasons and to develop solutions. Implementation of these solutions included the dissemination of the learning through a variety of methods. The main outcome measure was the proportion of babies who were hypothermic (<36.5 °C) on admission compared to the previous 12 months. Results: 130 babies with a gestation below 32 weeks were admitted during the study period. 90 babies (69.2%) had DCC and 79 babies (60%) received DRC. Compared to the preceding 12 months, the rate of hypothermia decreased from 25/109 (22.3%) to 13/130 (10%) (p = 0.017). Only 1 baby (0.8%) was admitted with a temperature below 36 °C and 12 babies (9.2%) were admitted with a temperature between 36 °C and 36.4 °C. Continued monitoring during the 3 months after the end of the project showed that the improvements were sustained with 0 cases of hypothermia in 33 consecutive admissions. Conclusions: It is possible to achieve low rates of admission hypothermia in preterm babies whilst providing DCC and DRC. Using a quality improvement approach with PDSA cycles is an effective method of changing clinical practice to improve outcomes. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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23 pages, 5492 KiB  
Article
The BabySaver: Design of a New Device for Neonatal Resuscitation at Birth with Intact Placental Circulation
Children 2021, 8(6), 526; https://doi.org/10.3390/children8060526 - 21 Jun 2021
Cited by 4 | Viewed by 3542
Abstract
The initial bedside care of premature babies with an intact cord has been shown to reduce mortality; there is evidence that resuscitation of term babies with an intact cord may also improve outcomes. This process has been facilitated by the development of bedside [...] Read more.
The initial bedside care of premature babies with an intact cord has been shown to reduce mortality; there is evidence that resuscitation of term babies with an intact cord may also improve outcomes. This process has been facilitated by the development of bedside resuscitation surfaces. These new devices are unaffordable, however, in most of sub-Saharan Africa, where 42% of the world’s 2.4 million annual newborn deaths occur. This paper describes the rationale and design of BabySaver, an innovative low-cost mobile resuscitation unit, which was developed iteratively over five years in a collaboration between the Sanyu Africa Research Institute (SAfRI) in Uganda and the University of Liverpool in the UK. The final BabySaver design comprises two compartments; a tray to provide a firm resuscitation surface, and a base to store resuscitation equipment. The design was formed while considering contextual factors, using the views of individual women from the community served by the local hospitals, medical staff, and skilled birth attendants in both Uganda and the UK. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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11 pages, 1238 KiB  
Article
Sustained Inflation Reduces Pulmonary Blood Flow during Resuscitation with an Intact Cord
Children 2021, 8(5), 353; https://doi.org/10.3390/children8050353 - 29 Apr 2021
Cited by 4 | Viewed by 1791
Abstract
The optimal timing of cord clamping in asphyxia is not known. Our aims were to determine the effect of ventilation (sustained inflation–SI vs. positive pressure ventilation–V) with early (ECC) or delayed cord clamping (DCC) in asphyxiated near-term lambs. We hypothesized that SI with [...] Read more.
The optimal timing of cord clamping in asphyxia is not known. Our aims were to determine the effect of ventilation (sustained inflation–SI vs. positive pressure ventilation–V) with early (ECC) or delayed cord clamping (DCC) in asphyxiated near-term lambs. We hypothesized that SI with DCC improves gas exchange and hemodynamics in near-term lambs with asphyxial bradycardia. A total of 28 lambs were asphyxiated to a mean blood pressure of 22 mmHg. Lambs were randomized based on the timing of cord clamping (ECC—immediate, DCC—60 s) and mode of initial ventilation into five groups: ECC + V, ECC + SI, DCC, DCC + V and DCC + SI. The magnitude of placental transfusion was assessed using biotinylated RBC. Though an asphyxial bradycardia model, 2–3 lambs in each group were arrested. There was no difference in primary outcomes, the time to reach baseline carotid blood flow (CBF), HR ≥ 100 bpm or MBP ≥ 40 mmHg. SI reduced pulmonary (PBF) and umbilical venous (UV) blood flow without affecting CBF or umbilical arterial blood flow. A significant reduction in PBF with SI persisted for a few minutes after birth. In our model of perinatal asphyxia, an initial SI breath increased airway pressure, and reduced PBF and UV return with an intact cord. Further clinical studies evaluating the timing of cord clamping and ventilation strategy in asphyxiated infants are warranted. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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7 pages, 516 KiB  
Article
Changes in Umbilico–Placental Circulation during Prolonged Intact Cord Resuscitation in a Lamb Model
Children 2021, 8(5), 337; https://doi.org/10.3390/children8050337 - 26 Apr 2021
Cited by 4 | Viewed by 1462
Abstract
Some previous studies reported a benefit to cardiopulmonary transition at birth when starting resuscitation maneuvers while the cord was still intact for a short period of time. However, the best timing for umbilical cord clamping in this condition is unknown. The aim of [...] Read more.
Some previous studies reported a benefit to cardiopulmonary transition at birth when starting resuscitation maneuvers while the cord was still intact for a short period of time. However, the best timing for umbilical cord clamping in this condition is unknown. The aim of this study was to explore the duration of effective umbilico–placental circulation able to promote cardiorespiratory adaptation at birth during intact cord resuscitation. Umbilico–placental blood flow and vascular resistances were measured in an experimental neonatal lamb model. After a C-section delivery, the lambs were resuscitated ventilated for 1 h while the cord was intact. The maximum and mean umbilico–placental blood flow were respectively 230 ± 75 and 160 ± 12 mL·min−1 during the 1 h course of the experiment. However, umbilico–placental blood flow decreased and vascular resistance increased significantly 40 min after birth (p < 0.05). These results suggest that significant cardiorespiratory support can be provided by sustained placental circulation for at least 1 h during intact cord resuscitation. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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10 pages, 546 KiB  
Article
The Assisted Breathing before Cord Clamping (ABC) Study Protocol
Children 2021, 8(5), 336; https://doi.org/10.3390/children8050336 - 26 Apr 2021
Cited by 3 | Viewed by 1757
Abstract
Major physiologic changes occur during the transition after birth. For preterm infants, current understanding favours allowing the initial changes to occur prior to cord clamping. Amongst other improved outcomes, systematic reviews have indicated a significant reduction in neonatal blood transfusions following delayed cord [...] Read more.
Major physiologic changes occur during the transition after birth. For preterm infants, current understanding favours allowing the initial changes to occur prior to cord clamping. Amongst other improved outcomes, systematic reviews have indicated a significant reduction in neonatal blood transfusions following delayed cord clamping. This may be due to a placental transfusion, facilitated by the onset of respiration. If breathing is compromised, placental transfusion may be reduced, resulting in a greater red cell transfusion rate. We designed a randomised trial to investigate whether assisting respiration in this high-risk group of babies would decrease blood transfusion and improve outcomes. The Assisted Breathing before Cord Clamping (ABC) study is a single-centre randomised controlled trial. Preterm infants < 31 weeks that have not established regular breathing before 15 s are randomised to a standard or intervention group. The intervention is intermittent positive pressure ventilation via T piece for 30 s, whilst standard management consists of 30 s of positioning and gentle stimulation. The cord is clamped at 50 s in both groups. The primary outcome is the proportion of infants in each group receiving blood transfusion during the neonatal admission. Secondary outcomes include requirement for resuscitation, the assessment of circulatory status and neonatal outcomes. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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11 pages, 1932 KiB  
Article
Resuscitation with an Intact Cord Enhances Pulmonary Vasodilation and Ventilation with Reduction in Systemic Oxygen Exposure and Oxygen Load in an Asphyxiated Preterm Ovine Model
Children 2021, 8(4), 307; https://doi.org/10.3390/children8040307 - 17 Apr 2021
Cited by 9 | Viewed by 3058
Abstract
(1) Background: Optimal initial oxygen (O2) concentration in preterm neonates is controversial. Our objectives were to compare the effect of delayed cord clamping with ventilation (DCCV) to early cord clamping followed by ventilation (ECCV) on O2 exposure, gas exchange, and [...] Read more.
(1) Background: Optimal initial oxygen (O2) concentration in preterm neonates is controversial. Our objectives were to compare the effect of delayed cord clamping with ventilation (DCCV) to early cord clamping followed by ventilation (ECCV) on O2 exposure, gas exchange, and hemodynamics in an asphyxiated preterm ovine model. (2) Methods: Asphyxiated preterm lambs (127–128 d) with heart rate <90 bpm were randomly assigned to DCCV or ECCV. In DCCV, positive pressure ventilation (PPV) was initiated with 30–60% O2 and titrated based on preductal saturations (SpO2) with an intact cord for 5 min, followed by clamping. In ECCV, the cord was clamped, and PPV was initiated. (3) Results: Fifteen asphyxiated preterm lambs were randomized to DCCV (N = 7) or ECCV (N = 8). The inspired O2 (40 ± 20% vs. 60 ± 20%, p < 0.05) and oxygen load (520 (IQR 414–530) vs. 775 (IQR 623–868), p-0.03) in the DCCV group were significantly lower than ECCV. Arterial oxygenation and carbon dioxide (PaCO2) levels were significantly lower and peak pulmonary blood flow was higher with DCCV. (4) Conclusion: In asphyxiated preterm lambs, resuscitation with an intact cord decreased O2 exposure load improved ventilation with an increase in peak pulmonary blood flow in the first 5 min. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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Review

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6 pages, 195 KiB  
Review
The Use of Foetal Doppler Ultrasound to Determine the Neonatal Heart Rate Immediately after Birth: A Systematic Review
Children 2022, 9(5), 717; https://doi.org/10.3390/children9050717 - 13 May 2022
Cited by 4 | Viewed by 1479
Abstract
Determining the neonatal heart rate immediately after birth is unsatisfactory. Auscultation is inaccurate and provides no documented results. The use of foetal Doppler ultrasound has been recognised as a possible method of determining the neonatal heart rate after birth over the last nine [...] Read more.
Determining the neonatal heart rate immediately after birth is unsatisfactory. Auscultation is inaccurate and provides no documented results. The use of foetal Doppler ultrasound has been recognised as a possible method of determining the neonatal heart rate after birth over the last nine years. This review includes all published studies of this approach, looking at accuracy, speed of results, and practical application of the approach. Precordial Doppler ultrasound has been shown to be as accurate as ECG and more accurate than oximetry for the neonatal heart rate, and provides quicker results than either ECG or oximetry. There is the potential for a much improved determination and documentation of the neonatal heart rate using this approach. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
13 pages, 1957 KiB  
Review
Making the Argument for Intact Cord Resuscitation: A Case Report and Discussion
Children 2022, 9(4), 517; https://doi.org/10.3390/children9040517 - 06 Apr 2022
Cited by 6 | Viewed by 6954
Abstract
We use a case of intact cord resuscitation to argue for the beneficial effects of an enhanced blood volume from placental transfusion for newborns needing resuscitation. We propose that intact cord resuscitation supports the process of physiologic neonatal transition, especially for many of [...] Read more.
We use a case of intact cord resuscitation to argue for the beneficial effects of an enhanced blood volume from placental transfusion for newborns needing resuscitation. We propose that intact cord resuscitation supports the process of physiologic neonatal transition, especially for many of those newborns appearing moribund. Transfer of the residual blood in the placenta provides the neonate with valuable access to otherwise lost blood volume while changing from placental respiration to breathing air. Our hypothesis is that the enhanced blood flow from placental transfusion initiates mechanical and chemical forces that directly, and indirectly through the vagus nerve, cause vasodilatation in the lung. Pulmonary vascular resistance is thereby reduced and facilitates the important increased entry of blood into the alveolar capillaries before breathing commences. In the presented case, enhanced perfusion to the brain by way of an intact cord likely led to regained consciousness, initiation of breathing, and return of tone and reflexes minutes after birth. Paramount to our hypothesis is the importance of keeping the umbilical cord circulation intact during the first several minutes of life to accommodate physiologic neonatal transition for all newborns and especially for those most compromised infants. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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Other

7 pages, 12950 KiB  
Brief Report
A Feasibility Study of a Novel Delayed Cord Clamping Cart
Children 2021, 8(5), 357; https://doi.org/10.3390/children8050357 - 29 Apr 2021
Cited by 4 | Viewed by 3029
Abstract
Delaying umbilical cord clamping (DCC) for 1 min or longer following a neonate’s birth has now been recommended for preterm and term newborns by multiple professional organizations. DCC has been shown to decrease rates of iron deficiency anemia, intraventricular hemorrhage (IVH), necrotizing enterocolitis [...] Read more.
Delaying umbilical cord clamping (DCC) for 1 min or longer following a neonate’s birth has now been recommended for preterm and term newborns by multiple professional organizations. DCC has been shown to decrease rates of iron deficiency anemia, intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and blood transfusion. Despite these benefits, clinicians typically cut the umbilical cord without delay in neonates requiring resuscitation and move them to a radiant warmer for further care; this effectively prevents these patients from receiving any benefits from DCC. This study evaluated the feasibility of a delayed cord clamping cart (DCCC) in low-risk neonates born via Cesarean section (CS). The DCCC is a small, sterile cart designed to facilitate neonatal resuscitation while the umbilical cord remains intact. The cart is cantilevered over the operating room (OR) table during a CS, allowing the patient to be placed onto it immediately after birth. For this study, a sample of 20 low-risk CS cases were chosen from the non-emergency Labor and Delivery surgical case list. The DCCC was utilized for 1 min of DCC in all neonates. The data collected included direct observation by research team members, recorded debriefings and surveys of clinicians as well as surveys of patients. Forty-four care team members participated in written surveys; of these, 16 (36%) were very satisfied, 12 (27%) satisfied, 13 (30%) neutral, and 3 (7%) were somewhat dissatisfied with use of the DCCC in the OR. Feedback was collected from all 20 patients, with 18 (90%) reporting that they felt safe with the device in use. This study provides support that utilizing a DCCC can facilitate DCC with an intact umbilical cord. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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11 pages, 799 KiB  
Study Protocol
Efficacy of Intact Cord Resuscitation Compared to Immediate Cord Clamping on Cardiorespiratory Adaptation at Birth in Infants with Isolated Congenital Diaphragmatic Hernia (CHIC)
Children 2021, 8(5), 339; https://doi.org/10.3390/children8050339 - 26 Apr 2021
Cited by 12 | Viewed by 3257
Abstract
Resuscitation at birth of infants with Congenital Diaphragmatic Hernia (CDH) remains highly challenging because of severe failure of cardiorespiratory adaptation at birth. Usually, the umbilical cord is clamped immediately after birth. Delaying cord clamping while the resuscitation maneuvers are started may: (1) facilitate [...] Read more.
Resuscitation at birth of infants with Congenital Diaphragmatic Hernia (CDH) remains highly challenging because of severe failure of cardiorespiratory adaptation at birth. Usually, the umbilical cord is clamped immediately after birth. Delaying cord clamping while the resuscitation maneuvers are started may: (1) facilitate blood transfer from placenta to baby to augment circulatory blood volume; (2) avoid loss of venous return and decrease in left ventricle filling caused by immediate cord clamping; (3) prevent initial hypoxemia because of sustained uteroplacental gas exchange after birth when the cord is intact. The aim of this trial is to evaluate the efficacy of intact cord resuscitation compared to immediate cord clamping on cardiorespiratory adaptation at birth in infants with isolated CDH. The Congenital Hernia Intact Cord (CHIC) trial is a prospective multicenter open-label randomized controlled trial in two balanced parallel groups. Participants are randomized either immediate cord clamping (the cord will be clamped within the first 15 s after birth) or to intact cord resuscitation group (umbilical cord will be kept intact during the first part of the resuscitation). The primary end-point is the number of infants with APGAR score <4 at 1 min or <7 at 5 min. One hundred eighty participants are expected for this trial. To our knowledge, CHIC is the first study randomized controlled trial evaluating intact cord resuscitation on newborn infant with congenital diaphragmatic hernia. Better cardiorespiratory adaptation is expected when the resuscitation maneuvers are started while the cord is still connected to the placenta. Full article
(This article belongs to the Special Issue Neonatal Resuscitation with Placental Circulation Intact)
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