The Changing Landscape in Supporting Preterm Infants at Birth

Abstract

Noninvasive ventilation for preterm infants at birth has been recommended and universally adopted. The umbilical cord is often clamped immediately in order to provide the support the infant needs for stabilization. However, recent scientific data from experimental studies that involve animals in transition and human studies using physiological measurements at birth have increased awareness as to how little we know about how these interventions interact and integrate with the infant’s changing physiology. It has become clear that in apneic infants the larynx is closed immediately after birth, which can completely negate the effect of noninvasive ventilation of the lung. For this reason, stimulating and supporting spontaneous breathing could enhance the success of noninvasive ventilation. Animal data also demonstrated that the large swings in blood pressure, blood flow, and oxygenation caused by immediate cord clamping can be avoided by postponing cord clamping until lung aeration has been established. In this review we will focus on these “game changers” that have the potential to completely change the approach used in stabilizing preterm infants at birth.

Extended period of ventilation before delayed cord clamping augments left‐to‐right shunting and decreases systemic perfusion at birth in preterm lambs

“…Our study has three main implications for the birth transition. First, our findings do not support a key assumption underpinning use of an extended period of ventilation prior to DCC, namely that an augmented increase in PA blood flow, via greater pulmonary venous return to the left atrium and ventricle, results in a higher LV output and systemic arterial perfusion (Bhatt et al, 2014;Hooper et al, 2015Hooper et al, , 2019Te Pas et al, 2019). Instead, our experimental findings suggest that perinatal levels of LV output are similar with brief, moderate or extended durations of initial ventilation prior to DCC (Fig.…”

“…Initial ventilation is also a key component of ‘physiological based cord clamping’ (PBCC), a widely promoted DCC variant in which an extended period of ventilation, typically ranging from 3 to 6 min, precedes cord clamping (Bhatt et al., 2013; Blank et al., 2018; Boere et al., 2015; Brouwer et al., 2019; Knol et al., 2020; Polglase et al., 2015). The rationale advanced for this extended initial ventilation is that it augments increases in pulmonary arterial (PA) blood flow and therefore pulmonary venous return to the left atrium, which preserves left ventricular (LV) preload and thereby sustains LV output and systemic arterial perfusion after reduction of right‐to‐left (R→L) shunting across the foramen ovale (FO) with abolition of umbilical venous return by cord clamping (Bhatt et al., 2014; Hooper et al., 2015, 2019; Kluckow & Hooper, 2015; Te Pas et al., 2019).…”

Impact of neonatal resuscitation changes on outcomes of very-low-birth-weight infants

“…Through the years, a change in ventilation strategies has been noted, such that proper ventilation with continuous positive airway pressure was originally emphasized rather than initial intubation 12 – 14 . Noninvasive ventilation was preferred for long-term favorable outcome.…”

FIGO good practice recommendations on delayed umbilical cord clamping

“…In addition, as part of the neonate’s physiological transition naturally occurring during the third stage of labor there is a progressive increase in heart rate, which is now considered the most reliable indicator of normalcy. In this sense, delayed cord clamping provides a safe time lapse to avoid rushing to perform unnecessary interventions 4 …”

“…In this sense, delayed cord clamping provides a safe time lapse to avoid rushing to perform unnecessary interventions. 4 …”