Respiratory support after delayed cord clamping: a prospective cohort study of at-risk births at ≥35+0 weeks gestation

Badurdeen, Shiraz; Santomartino, Georgia A; Thió, Marta; Heng, Alissa; Woodward, Anthony; Polglase, Graeme R.; Hooper, Stuart B.; Blank, Douglas A; Davis, Peter G

doi:10.1136/archdischild-2020-321503

Cited by 5 publications

(8 citation statements)

References 37 publications

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“…The difference in the early HR curves likely represents the relative hypoxia of infants in the randomised arms, reflecting appropriate randomisation of infants who required resuscitation versus infants in the observational arm who were less hypoxic at birth and therefore able to transition unassisted. This observation further supports the argument for a more nuanced appreciation of HR as an early marker of successful transition beyond the traditional dichotomisation around 100 bpm [30]. HR values previously considered to be in the tachycardic range (>180 bpm) appear to be a normal physiological adaption in the first minutes after birth and may be associated with a lower risk of requiring resuscitation [30].…”

Section: Plos Medicinesupporting

confidence: 67%

“…This observation further supports the argument for a more nuanced appreciation of HR as an early marker of successful transition beyond the traditional dichotomisation around 100 bpm [30]. HR values previously considered to be in the tachycardic range (>180 bpm) appear to be a normal physiological adaption in the first minutes after birth and may be associated with a lower risk of requiring resuscitation [30].…”

Section: Plos Medicinesupporting

confidence: 67%

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Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation

et al. 2022

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Background Globally, the majority of newborns requiring resuscitation at birth are full term or late-preterm infants. These infants typically have their umbilical cord clamped early (ECC) before moving to a resuscitation platform, losing the potential support of the placental circulation. Physiologically based cord clamping (PBCC) is clamping the umbilical cord after establishing lung aeration and holds promise as a readily available means of improving early newborn outcomes. In mechanically ventilated lambs, PBCC improved cardiovascular stability and reduced hypoxia. We hypothesised that PBCC compared to ECC would result in higher heart rate (HR) in infants needing resuscitation, without compromising safety. Methods and findings Between 4 July 2018 and 18 May 2021, infants born at ≥32+0 weeks’ gestation with a paediatrician called to attend were enrolled in a parallel-arm randomised trial at 2 Australian perinatal centres. Following initial stimulation, infants requiring further resuscitation were randomised within 60 seconds of birth using a smartphone-accessible web link. The intervention (PBCC) was to establish lung aeration, either via positive pressure ventilation (PPV) or effective spontaneous breathing, prior to cord clamping. The comparator was early cord clamping (ECC) prior to resuscitation. The primary outcome was mean HR between 60 to 120 seconds after birth, measured using 3-lead electrocardiogram, extracted from video recordings blinded to group allocation. Nonrandomised infants had deferred cord clamping (DCC) ≥120 seconds in the observational study arm. Among 508 at-risk infants enrolled, 123 were randomised (n = 63 to PBCC, n = 60 to ECC). Median (interquartile range, IQR) for gestational age was 39.9 (38.3 to 40.7) weeks in PBCC infants and 39.6 (38.4 to 40.4) weeks in ECC infants. Approximately 49% and 50% of the PBCC and ECC infants were female, respectively. Five infants (PBCC = 2, ECC = 3, 4% total) had missing primary outcome data. Cord clamping occurred at a median (IQR) of 136 (126 to 150) seconds in the PBCC arm and 37 (27 to 51) seconds in the ECC arm. Mean HR between 60 to 120 seconds after birth was 154 bpm (beats per minute) for PBCC versus 158 bpm for ECC (adjusted mean difference −6 bpm, 95% confidence interval (CI) −17 to 5 bpm, P = 0.39). Among 31 secondary outcomes, postpartum haemorrhage ≥500 ml occurred in 34% and 32% of mothers in the PBCC and ECC arms, respectively. Two hundred ninety-five nonrandomised infants (55% female) with median (IQR) gestational age of 39.6 (38.6 to 40.6) weeks received DCC. Data from these infants was used to create percentile charts of expected HR and oxygen saturation in vigorous infants receiving DCC. The trial was limited by the small number of infants requiring prolonged or advanced resuscitation. PBCC may provide other important benefits we did not measure, including improved maternal–infant bonding and higher iron stores. Conclusions In this study, we observed that PBCC resulted in similar mean HR compared to infants receiving ECC. The findings suggest that for infants ≥32+0 weeks’ gestation who receive brief, effective resuscitation at closely monitored births, PBCC does not provide additional benefit over ECC (performed after initial drying and stimulation) in terms of key physiological markers of transition. PBCC was feasible using a simple, low-cost strategy at both cesarean and vaginal births. The percentile charts of HR and oxygen saturation may guide clinicians monitoring the transition of at-risk infants who receive DCC. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000621213.

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Section: Plos Medicinesupporting

confidence: 67%

Section: Plos Medicinesupporting

confidence: 67%

Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation

et al. 2022

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“…Corresponding with this, the HR percentiles we recently reported from the Baby-DUCC cohort were substantially higher than those previously described by Dawson et al, which were derived from low-risk births with ECC. 17,19,29…”

Section: Discussionmentioning

confidence: 99%

“…Non-randomised infants who went on to receive respiratory support in the delivery room were excluded. 19…”

Section: Methodsmentioning

confidence: 99%

Blood Pressure and Cerebral Oxygenation with Physiologically-based Cord Clamping: A Sub-Study of the BabyDUCC Trial

Badurdeen,

Blank,

Hoq

et al. 2023

Preprint

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Background Cord-clamping strategies may modify blood pressure (BP) and cerebral tissue oxygen saturation (rStO2) immediately after birth. Methods We conducted a sub-study nested within the Baby-Directed Umbilical Cord-Clamping trial. Infants ≥32+0 weeks gestation assessed as requiring resuscitation were randomly allocated to either physiologically-based cord clamping (PBCC), where resuscitation commenced prior to umbilical cord clamping, or standard care where cord clamping occurred early (ECC). In this single-site sub-study, we obtained additional measurements of pre-ductal BP and rStO2. In a separate observational arm, non-randomised vigorous infants received 2 minutes of deferred cord clamping (DCC) and contributed data for reference percentiles. Results Among 161 included infants, n=55 were randomly allocated to PBCC (n= 30) or ECC (n= 25). The mean (SD) BP at 3-4 minutes after birth (primary outcome) in the PBCC group was 64 (10) mmHg compared to 62 (10) mmHg in the ECC group, mean difference 2 mmHg (95% confidence interval -3 to 8 mmHg, p= 0.42). BP and rStO2 were similar across both randomised arms and the observational arm (n=106). Conclusion We found no difference in BP or rStO2 with the different cord clamping strategies. We report reference ranges for BP and rStO2 for late-preterm and full-term infants receiving DCC.

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“…HR is regarded as the most important marker of infant well-being after birth [1, 7, 8] and is a major determinant of cardiac output [9]. While a low HR can indicate hypoxia, other factors that modify HR include vagally mediated parasympathetic activation (including the TCR), sympathetic activation from peri-partum hypoxic-ischaemia, and alterations in cardiac preload [10].…”

Section: Introductionmentioning

confidence: 99%

Heart Rate Changes following Facemask Placement in Infants Born at ≥32+0 Weeks of Gestation

Badurdeen,

Brooijmans,

Blank

et al. 2023

Neonatology

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Introduction: Recent reports have raised concerns of cardiorespiratory deterioration in some infants receiving respiratory support at birth. We aimed to independently determine whether respiratory support with a facemask is associated with a decrease in heart rate (HR) in some late-preterm and term infants. Methods: Secondary analysis of data from infants born at ≥32+0 weeks of gestation at 2 perinatal centres in Melbourne, Australia. Change in HR up to 120 s after facemask placement, measured using 3-lead electrocardiography, was assessed every 3 s until 60 s and every 5 s thereafter from video recordings. Results: In the 15 s after facemask placement, 10/68 (15%) infants had a decrease in mean HR by >10 beats per minute (bpm) compared with their individual baseline mean HR in the 15 s before facemask placement. In 4 (6%) infants, HR decreased to <100 bpm. Nine out of 68 (13%) infants had an increase in mean HR by >10 bpm; 7 of these infants had a baseline HR <120 bpm. In univariable comparisons, the following characteristics were found not to be risk factors for a decrease in HR by >10 bpm: prematurity; type of respiratory support; hypoxaemia; early cord clamping; mode of birth; HR <120 bpm before mask placement. Six out of 63 infants (10%) who had HR ≥120 bpm after facemask placement had a late decrease in HR to <100 bpm between 30 and 120 s after facemask placement. Conclusion: Facemask respiratory support at birth is temporally associated with a decrease in HR in a subset of late-preterm and term infants.

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Respiratory support after delayed cord clamping: a prospective cohort study of at-risk births at ≥35⁺⁰ weeks gestation

Cited by 5 publications

References 37 publications

Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation

Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation

Blood Pressure and Cerebral Oxygenation with Physiologically-based Cord Clamping: A Sub-Study of the BabyDUCC Trial

Heart Rate Changes following Facemask Placement in Infants Born at ≥32+0 Weeks of Gestation

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