About 10% of term neonates are transferred to the room side resuscitation equipment when positive pressure ventilation [PPV] is thought to be required [1]. About one third of these neonates start breathing sufficiently before PPV can be provided so that no active care is necessary. Transfer of the apnoeic neonate to the room side resuscitation equipment can only be carried out after immediate cord clamping. Cord clamping before inflation of the lungs is established is not physiological and disrupts the transition from placental to pulmonary respiration [2]. In the asphyxiated neonate this disruption can potentially be avoided by initiating PPV before the cord is clamped [3]. This requires resuscitation with an intact cord at the side of the mother.

Early cord clamping before the onset of breathing is not physiological and the intervention adversely affects transition from placental to pulmonary respiration [4]. A delay of at least one minute after birth is recommended in all major guidelines [1,5]. The most widely confirmed effect is the loss of the placental transfusion and loss of this blood volume results in a variable degree of hypovolaemia. The result of this blood loss is anaemia and iron deficiency in the following months, and the iron deficiency has been linked to impaired neurodevelopment [7-11]. For many years bradycardia has been known to follow early cord clamping [12] and more recently bradycardia and a marked fall in cardiac output in animal studies has been demonstrated [2]. In preterm neonates mortality and the use of blood transfusion are reduced if early cord clamping is avoided [13]. Other studies have shown a reduction in intra ventricular haemorrhage, necrotising enter colitis and late onset sepsis [14]. While there is plenty of evidence to show the harm of early cord clamping in healthy neonates there is also sufficient evidence to support a change in practice for asphyxiated neonates [15,16]. The loss of the placental transfusion can be over 200mls [6]. Dunn and others warned of the risk of severe hypovolaemia with early cord clamping and intra partum cord clamping [17]. Neonates with severe hypovolaemia may not respond to ventilation until the hypovolaemia is corrected with an emergency transfusion of O-nag blood [18]. Outcomes are improved in neonates with congenital heart abnormality [19] and also in neonates with congenital diaphragmatic hernia [20] if early cord clamping is avoided and a physiological transition permitted.
Extrapolating this evidence suggest that providing mother side resuscitation with an intact cord in asphyxiated neonates should result in less morbidity and mortality. Asphyxia is not a single entity but a spectrum from mild to severe and may not be accurately predicted or assessed during the first seconds after birth [21]. If mother side resuscitation is available, neonates who are falsely identified as asphyxiated and in whom this cord clamped immediately to move them to a room side resuscitation trolley, will be spared the harm of early clamping. Feasibility studies have shown that the approach of mother side resuscitation is practical and achievable [22-27].

Normal birth presents the least difficulty in providing mother side neonatal resuscitation with an intact cord. The neonate can remain close to the perineum under one of the mother’s leg [7]. All standards of care a such as open airway and thermoregulation of the neonate during the recommended delay of at least one minute can be provided in the normal routine manner and PPV can be provided by a self-inflating bag and mask when necessary. This level of care is provided by some midwives [26]. These are low risk neonates but there remains a small risk of apnoea at birth and preparation is required in anticipation of the small risk of apnoea.

The temperature of the delivery room is very important to reduce the risk of neonatal hypothermia. It must be well above the normal operating theatre temperature and more aligned with the ambient temperature of the neonatal nursery. The need to ensure that the sterile field is not compromised is a major challenge in providing mother side resuscitation at caesarean section. In addition there is no obvious surface on which to place the neonate and still meet the standard of care for an open airway. A customised solution is required. A modified standard resuscitation trolley can be brought right up to the side operating table but this is cumbersome and may interfere with the position of the surgical team [28]. Since the height of the trolley is fixed and the height of the operating table needs to be adjusted to match the resuscitation trolley. The Life Start is a much smaller customised trolley with a variable height and includes all the normal ventilation equipment [usually PEEP with warmed humidified air] and thermal equipment. The resuscitation platform is covered with a sterile towel to maintain sterility [29]. The Concord is another customised design which incorporates a long extendable platform for the neonate, allowing it to remain close enough to its mother to provide resuscitation with an intact cord [30]. In the Vent first trial, a large multicentre trial of mother side resuscitation in preterm neonates, all the resuscitation equipment is mounted on a mobile pole. A platform for the neonate and warming arrangements are customised locally [31].

The same customised trolley for caesarean birth can be used at an assisted vaginal birth if the platform for the neonate can be low enough to allow the resuscitation team to reach the neonate below the mother’s legs in lithotomy poles. The height adjustable platform is a design feature of the Life Start and Concord trollies.

Such a marked change in practice cannot be undertaken incrementally as has been possible with some other changes in neonatal and obstetric practice. It requires close team work between the two separate disciplines of obstetrics and neonatology. The co-operation needs to be provided during the critical few minutes after birth, often with little notice. The high standard of care which both team members expect to be able to provide cannot be met at mother side neonatal resuscitation unless the procedures and responsibility have carefully prepared and practiced. This is probably just as important as the design of the customised equipment necessary to provide a level of neonatal care and resuscitation normally available at room side resuscitation. When mother side resuscitation is first introduced to a unit it is essential that there is initial training, simulation and assessment [32]. A locally prepared protocol must be available. After each case the equipment and procedures should be reviewed so that any difficulties can be resolved. It has been shown that performance in stressful resuscitation scenarios Human Factors and Ergonomics [HFE] principles are important. They have been successfully applied to the organization of resuscitation equipment for neonates [33].

Active management of the third stage of labour to reduce the risk of postpartum haemorrhage [PPH] originally included the practice of early cord clamping [34]. Early cord clamping was only recently proven to be unnecessary to reduce PPH and as a result early cord clamping has been removed from the recommendations. A delay of at least one minute is recommended in healthy neonates and ventilation is considered the priority in neonates requiring resuscitation. [5]. Ventilation can be provided with an intact cord if the skill and experience is available to provide effective ventilation with an intact cord [35]. To make neonatal resuscitation more in line with physiology, early cord clamping must be avoided [36]. There are many reasons however why mother side resuscitation with an intact cord is likely to be much more effective and safer. It is very much less likely to be associated with neonatal hypovolaemia which occurs with early cord clamping especially severe after intra partum cord compression. In spite of apparently responding well to resuscitation, infants in poor condition at birth have an increased risk of poor functioning in cognitive tests in later life and this could partly be a result of early cord clamping [37]. With current practice a small number of neonates requiring resuscitation fail to respond to ventilation. In some of these hypovolaemia is the underlying problem [14]. With the redistribution of blood from the placenta to the neonate which occurs within the few minutes after birth and before cord clamping, significant hypovolaemia is much less likely. If prolonged ventilation is still required after mother side resuscitation with an intact cord, the cord can be clamped and cut when the placental circulation has ceased and the neonate removed to room side resuscitation equipment. The transition of the circulation will have been close to a physiological transition [3] Parents have accepted removal of their new born baby immediately after birth in the belief that this benefited their baby. Resuscitation with relatives present in other situations is now common. Having the parents so close and seeing every intervention on their new born may put pressure on the carers, or frighten the parents. However the evidence shows that the carers appreciate the close presence of the parents as much as the parents appreciate remaining close to their new born [38]. Neonates may also respond better to resuscitation when they can hear the parents’ voices or feel their touch [39]. Clearly the placental circulation must be intact for the procedure to be beneficial and there are rare contraindications to the approach. Significant bleeding from a vasa Previa prevents an adequate placental circulation. A short cord may prevent the neonate from reaching the resuscitation platform, however with experience it may be possible to get the neonatal platform sufficiently close to the mother even with a short cord. Cord milking may avoid the loss of the placental transfusion but still results in cord clamping before expansion of the lungs and a physiological transition, and clinical evidence is lacking.

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