Research Review: Newborn Resuscitation with an Intact Umbilical Cord Shows Better Outcomes

As childbirth educators and other perinatal professionals, we often talk to the families we work with about the benefits of delayed cord clamping for the healthy newborn (Mercer, 2018). There are also known benefits for delayed cord clamping for the preterm infant as well. (Fogarty, 2018). Note: Isn’t the intervention “early cord clamping” and the physiological norm “delayed cord clamping”, yet many discussions make it seem like the delay is not the biological norm.

A new study, “Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III) – a randomized clinical trial”  found that the newborn’s oxygen saturation (Sp02) and APGAR scores were higher at several measured points after birth along with other benefits such as both initiation of breathing and respiration rate when a necessary resuscitation was done bedside with the cord intact on an infant who was not breathing at birth.

How was the study done

This study was conducted at the low risk-Maternal and Neonatal Service Centre (MNSC) at Paropakar Maternity and Women’s Hospital in Kathmandu, Nepal. The criteria to participate in the study included “uncomplicated pregnancies, no complication at admission, healthy mothers (no clinical history of hypertension, infection, diabetes, or chronic medical condition), expected vaginal delivery, gestational age between 34 and 41 weeks, and singleton pregnancy.”

The birthing person was randomized at admission, and final inclusion was determined at the time of birth. “Newborns were eligible and included if they had reached a gestational age ≥ 33 weeks, were in need of resuscitation according to the HBB algorithm, that is: no breathing despite thorough drying and additional stimulation within 30 s after birth.”

If the infants qualified for resuscitation (see above), they were randomized to receive care at the bedside with the cord intact or having the cord clamped and cut, so the newborn could be taken to a resuscitation table in the room for treatment.  The intact cord group did not have their cord clamped for at least 180 seconds.

What was being measured

The oxygen saturation at birth, the time of the first breath, when regular breathing was established, the APGAR score and when the cord was clamped were all recorded.  The primary outcome was O2 saturation 10 minutes after birth as measured by a pulse oximeter.  Secondary outcomes were the 02 saturation at 5 minutes, the amount of time it took to reach > 90% Sp02, the newborn’s heart rate at one, five and ten minutes after birth and the APGAR scores at the same intervals. Researchers also documented the timing of the first breathing effort and when regular breathing was established. 

Additionally, rectal temperature was recorded at between 10-20 minutes, the Bilirubin levels at discharge and the newborn’s health status the day after birth (alive or deceased).

Ultimately 231 newborns participated in the study, after having been determined to meet the inclusion criteria.  134 were allocated to resuscitation with the cord intact and 97 were in the immediate clamping and resuscitation group.

What were the results?

The newborns who were resuscitated with the cord intact had significantly higher oxygen saturation levels at 10 minutes after birth.  In the intact cord group, 57 (44%) had oxygen saturation < 90% after 10 min, compared to 93 (100%) in the early cord clamping group.

The intact cord infants also had higher oxygen at one and five minutes after birth. At 5 min, the intact cord group, 70 (54%) had oxygen saturation < 85% compared to 85 (91%) in the early cord clamping group.

Heart rate was lower in the intact cord group at one and five minutes and slightly higher at ten minutes which are considered significant findings.  Apgar score was significantly higher at one, five and ten minutes. At 5 min, 23 (17%) had APGAR score < 7 in the intact cord group compared to 26 (27%) in the early cord clamping group.

Time of initiating resuscitation was later in the intact cord group while newborns started breathing and established regular breathing earlier. There was no difference in rectal temperature between the groups.  Bilirubin measured transcutaneously at discharge did not differ.

In the intact cord group, 16 (11.9%) newborns were transferred to the Neonatal intensive care unit, not significantly different from 13 (13.4%) in the early cord clamping group.  The mortality rate before discharge was 0 (0.0%) in the intact cord resuscitation group versus 3 (3.1%) in the early cord clamping group.

Conclusions

The researchers concluded that for term newborns “resuscitation with an intact umbilical cord did not raise any safety concerns and was associated with a better recovery than routine resuscitation after clamping and cutting the cord.”  They acknowledge that further testing is needed in different birth settings and a larger number of participants may reveal additional information.  They also would like to see long-term neurodevelopmental follow-up which was not included in this study.

Most hospital labor & birth rooms (at least in the US) are not equipped to treat the newborn who needs some breathing assistance at the bedside.  There has been discussion and research about the benefits of using the “resuscitation trolley” at the bedside (Thomas, 2014).

How is this useful for perinatal professionals?

As we speak to the families in our classes and practices, professionals can share that delayed cord clamping is not only beneficial to the healthy term newborn, and the premature infant, but for babies who may need resuscitation at birth for a variety of reasons, leaving the cord intact while the initial resuscitation is performed (the study included at least 180 seconds) appears to benefit the newborn.

Most hospital labor & birth rooms (at least in the US) are not equipped to treat the newborn who needs some breathing assistance at the bedside.  There has been discussion and research about the benefits of using the “resuscitation trolley” at the bedside (Thomas, 2014).

Encouraging families to ask about support for the non-breathing infant on the chest or bed with the cord intact can be requested.  As we know, change is slow to happen.  When families understand the benefits of leaving the cord intact for the non-breathing newborn, they can make their wishes known.  Supporting hospitals who are being innovative and bringing in resuscitation trolleys in order to support leaving the cord intact is another area where perinatal professionals can focus.

References

Andersson, O., Rana, N., Ewald, U., Målqvist, M., Stripple, G., Basnet, O., ... & Ashish, K. C. (2019). Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III)–a randomized clinical trial. Maternal Health, Neonatology and Perinatology, 5(1), 1-11.

Fogarty, M., Osborn, D. A., Askie, L., Seidler, A. L., Hunter, K., Lui, K., ... & Tarnow-Mordi, W. (2018). Delayed vs early umbilical cord clamping for preterm infants: a systematic review and meta-analysis. American journal of obstetrics and gynecology, 218(1), 1-18.

Mercer, J. S., Erickson-Owens, D. A., Deoni, S. C., Dean III, D. C., Collins, J., Parker, A. B., ... & Padbury, J. F. (2018). Effects of delayed cord clamping on 4-month ferritin levels, brain myelin content, and neurodevelopment: A randomized controlled trial. The Journal of pediatrics, 203, 266-272.

Thomas, M. R., Yoxall, C. W., Weeks, A. D., & Duley, L. (2014). Providing newborn resuscitation at the mother’s bedside: assessing the safety, usability and acceptability of a mobile trolley. BMC pediatrics, 14(1), 135.

University of Rhode Island. (2019, February 11). Benefits of delayed cord clamping in healthy babies. ScienceDaily. Retrieved September 5, 2019 from www.sciencedaily.com/releases/2019/02/190211105402.htm

Published: September 05, 2019

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