Physiological Neonatal Resuscitation at Birth

Hutchon DJ R

Published on: 2019-09-10

Abstract

About 10% of term neonates are transferred to the room side resuscitation equipment when positive pressure ventilation [PPV] is thought to be required. About one third of the neonates transferred start breathing sufficiently before PPV can be provided so that no active care is necessary. Transfer to the room side resuscitation equipment can only be carried out after immediate cord clamping. Transition after early cord clamping is not physiological and cord clamping abruptly removes the placental circulation before the pulmonary circulation has been established which disrupts a smooth transition. Those neonates who are truly asphyxiated benefit from the intervention of positive pressure ventilation but all the babies removed from their mother for room side ventilation will have suffered the consequences of early cord clamping. Reversal of the asphyxia will only occur after a good respiratory exchange has taken place within the lungs. In addition to expansion of the lungs and establishment of the functional residual capacity an adequate circulation is essential. However the marked increase in afterload of the heart and the reduction in preload and cardiac output caused by early cord clamping may reduce the pulmonary circulation. Thus the condition of the asphyxiated neonate who is not ventilated until after the cord has been clamped will be further compromised by cord clamping. Cord clamping is an intervention with no proof of benefit in the apnoeic neonate apparently requiring resuscitation. It might be considered a pragmatic solution in the asphyxiated neonate, as there is limited experience of resuscitation at the mother’s side with an intact cord. However, from the limited experience that there is, we do know that resuscitation can be carried out effectively with an intact placental circulation by the side of the mother. The procedures need to be clearly understood, practiced and co-ordinated by the whole team of obstetricians, neonatologists and midwives before the clinical benefits for the neonate can be realised. This paper will summarise the physiological arguments for resuscitation with an intact cord, and provide a range of novel procedures and equipment which can avoid the further intervention of cord clamping and mother side neonatal resuscitation with an intact cord. Thus the benefits of delayed or physiological cord clamping will be available to all neonates at all modes of birth.