A hybrid type I, multi-center randomized controlled trial to study the implementation of a method for Sustained cord circulation And VEntilation (the SAVE-method) of late preterm and term neonates: a study protocol

Neonatal healthcare professionals' experiences of intact cord resuscitation in the mother´s bed- an interview study

BACKGROUND

Intact cord resuscitation in the first three minutes of life improves oxygenation and Apgar scores. The practise of intact cord resuscitation implies the umbilical cord still being connected to the placenta for at least one minute while providing temperature control and equipment for resuscitation. Healthcare professionals described practical challenges in providing intact cord resuscitation. This study aimed to explore neonatal healthcare professionals' experiences of providing intact cord resuscitation in the mother's bed.

METHOD

An interview study with an inductive, interpretative approach was chosen and analysed according to reflexive thematic analysis by Braun & Clarke. An open interview guide was used and 20 individual interviews with neonatal healthcare professionals were performed. The study was conducted at five level I-III neonatal care units. In Sweden, resuscitation is performed either in or outside the labour room.

RESULTS

The results contributed insight into the participants' experiences of prerequisites for providing neonatal care in intact cord resuscitation. The sense of the mother's vulnerability was noticeable, as the participants reported reducing the risk of exposure to protect and preserve the mother's integrity. The practical challenges in the environment involved working in a limited space. The desire for multi-professional team training comprised education and training as well as debriefing to manage intact cord resuscitation.

CONCLUSION

The result of the present study highlights the fact that neonatal healthcare professionals' experiences of providing ICR in the mother's bed were positive and had significant benefits for the neonate, namely zero separation between the neonate and parents and better physical recovery for the neonate. However, the fact that ICR in the mother's bed can be challenging in several ways, such as emotionally, managing environmental circumstances and ensuring effective team collaboration. Therefore, it is of the utmost importance that healthcare professionals are given the opportunity to reflect and train together as a team. Future recommendations are to summarize evidence-based knowledge to design guidelines for ICR situation.

Midwives' Experiences of Intact Cord Resuscitation in Nonvigorous Neonates After Vaginal Birth in Sweden

OBJECTIVE

To describe midwives' experiences of intact cord resuscitation close to the mother for nonvigorous neonates after vaginal birth.

DESIGN

Descriptive qualitative.

SETTING

Four labor wards in Sweden.

PARTICIPANTS

Midwives (N = 13) currently or previously employed in labor wards where the Sustained Cord Circulation and Ventilation (SAVE) study was conducted.

METHODS

We analyzed semistructured interviews using reflexive thematic analysis.

RESULTS

Participants' experiences are presented in an overarching theme: Midwives balance knowledge with doing the right thing in a challenging work environment during intact cord resuscitation. Three primary themes emerged: A New Workflow, Zero Separation: The Big Advantage, and The Midwife: Guardian of Childbirth.

CONCLUSION

The participants were keen to keep the umbilical cord intact even for nonvigorous neonates. They wanted to work with the neonate close to the mother to facilitate zero separation and family participation. Ventilation with an intact umbilical cord was considered a routine to be implemented in the future, but the participants identified certain difficulties with the design of the SAVE study.

Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis

BACKGROUND

Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth.

METHODS

We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640.

FINDINGS

We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality.

INTERPRETATION

This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations.

FUNDING

Australian National Health and Medical Research Council.

Short, medium, and long deferral of umbilical cord clamping compared with umbilical cord milking and immediate clamping at preterm birth: a systematic review and network meta-analysis with individual participant data

BACKGROUND

Deferred (also known as delayed) cord clamping can improve survival of infants born preterm (before 37 weeks of gestation), but the optimal duration of deferral remains unclear. We conducted a systematic review and individual participant data network meta-analysis with the aim of comparing the effectiveness of umbilical cord clamping strategies with different timings of clamping or with cord milking for preterm infants.

METHODS

We searched medical databases and trial registries from inception until Feb 24, 2022 (updated June 6, 2023) for randomised controlled trials comparing cord clamping strategies for preterm infants. Individual participant data were harmonised and assessed for risk of bias and quality. Interventions were grouped into immediate clamping, short deferral (≥15 s to <45 s), medium deferral (≥45 s to <120 s), long deferral (≥120 s), and intact cord milking. The primary outcome was death before hospital discharge. We calculated one-stage, intention-to-treat Bayesian random-effects individual participant data network meta-analysis. This study was registered with PROSPERO, CRD42019136640.

FINDINGS

We included individual participant data from 47 trials with 6094 participants. Of all interventions, long deferral reduced death before discharge the most (compared with immediate clamping; odds ratio 0·31 [95% credibility interval] 0·11-0·80; moderate certainty). The risk of bias was low for 10 (33%) of 30 trials, 14 (47%) had some concerns, and 6 (20%) were rated as having a high risk of bias. Heterogeneity was low, with no indication of inconsistency.

INTERPRETATION

This study found that long deferral of clamping leads to reduced odds of death before discharge in preterm infants. In infants assessed as requiring immediate resuscitation, this finding might only be generalisable if there are provisions for such care with the cord intact. These results are based on thoroughly cleaned and checked individual participant data and can inform future guidelines and practice.

FUNDING

Australian National Health and Medical Research Council.

Stabilisation and resuscitation with intact cord circulation is feasible using a wide variety of approaches; a scoping review

AIM

This scoping review identified studies on approaches to intact cord resuscitation and/or stabilisation (ICR/S) for neonates delivered by Caesarean section (C-section).

METHODS

A systematic literature search was carried out using the PubMed, Web of Science, Scopus, Cochrane and CINAHL databases to identify papers published in English from inception to 14 November 2022.

RESULTS

We assessed 2613 studies and included 18 from 10 countries, covering 1-125 C-sections: the United States, the United Kingdom, Australia, India, Italy, China, France, The Netherlands, New Zealand and Taiwan. The papers were published from 2014 to 2023, and the majority were randomised controlled trials and observational studies. Different platforms, equipment and staff positions in relation to the operating table were described. Options for resuscitation and stabilisation included different bedding and trolley approaches, and maintaining aseptic conditions was mainly addressed by the neonatal team scrubbing in. Hypothermia was prevented by using warm surfaces, polythene bags and radiant heaters. Equipment was kept easily accessible by mounting it on a trolley or a separate mobile pole.

CONCLUSION

We could not reach definitive conclusions on the optimal method for performing ICR/S during a C-section, due to study variations. However, a number of equipment and management options appeared to be feasible approaches.

Mother-newborn couplet care: Nordic country experiences of organization, models and practice

Mother-Newborn Couplet Care is a concept and is defined as the provision of care for a sick or preterm newborn in close proximity to and coupled with the care for the mother from the birth of the infant and for as long as the mother needs hospital care. This concept of care requires system change in both obstetrics and pediatrics in terms of the planning and organization of care, equipment and design of units. Accordingly, strong leadership setting clear goals and emphasizing a culture of cohesive care, supported by targeted education and training is crucial to ensure high-quality care of all mother-newborn dyads without separation. We describe various organizational models of Mother-Newborn Couplet Care used in Sweden and Finland and implementation processes. We envision a future where newborns and mothers are always together, irrespective of medical needs, and form an inseparable center around which healthcare services and providers are organized.

Cord clamping - 'hold on a minute' is not enough, and sample your blood gases while waiting

There is confusion regarding the dynamics of the umbilical cord circulation and the concomitant placental transfusion. How long does it continue, and at what rate? These questions remain an enigma for many. In this article we will address some common misconceptions about the management of cord circulation, try to explain why there is a lack of clarity, and call in to question the conclusions from an influential meta-analysis and a recently published guideline on cord clamping. We will do that partly by reviewing the rather extensive literature published on the subject over the past 50 to 70 years, which is easily forgotten, but worth considering. In this review, we will also address the important subject of why and how to sample cord blood correctly and to interpret umbilical gases with a sustained cord circulation, which is a crucial part of our ongoing multicenter study 'Sustained cord circulation And Ventilation', the SAVE-study.

Cardiac Asystole at Birth Re-Visited: Effects of Acute Hypovolemic Shock

Births involving shoulder dystocia or tight nuchal cords can deteriorate rapidly. The fetus may have had a reassuring tracing just before birth yet may be born without any heartbeat (asystole). Since the publication of our first article on cardiac asystole with two cases, five similar cases have been published. We suggest that these infants shift blood to the placenta due to the tight squeeze of the birth canal during the second stage which compresses the cord. The squeeze transfers blood to the placenta via the firm-walled arteries but prevents blood returning to the infant via the soft-walled umbilical vein. These infants may then be born severely hypovolemic resulting in asystole secondary to the loss of blood. Immediate cord clamping (ICC) prevents the newborn's access to this blood after birth. Even if the infant is resuscitated, loss of this large amount of blood volume may initiate an inflammatory response that can enhance neuropathologic processes including seizures, hypoxic-ischemic encephalopathy (HIE), and death. We present the role of the autonomic nervous system in the development of asystole and suggest an alternative algorithm to address the need to provide these infants intact cord resuscitation. Leaving the cord intact (allowing for return of the umbilical cord circulation) for several minutes after birth may allow most of the sequestered blood to return to the infant. Umbilical cord milking may return enough of the blood volume to restart the heart but there are likely reparative functions that are carried out by the placenta during the continued neonatal-placental circulation allowed by an intact cord.

The Respiratory Management of the Extreme Preterm in the Delivery Room

The fetal-to-neonatal transition poses an extraordinary challenge for extremely low birth weight (ELBW) infants, and postnatal stabilization in the delivery room (DR) remains challenging. The initiation of air respiration and the establishment of a functional residual capacity are essential and often require ventilatory support and oxygen supplementation. In recent years, there has been a tendency towards the soft-landing strategy and, subsequently, non-invasive positive pressure ventilation has been generally recommended by international guidelines as the first option for stabilizing ELBW in the delivery room. On the other hand, supplementation with oxygen is another cornerstone of the postnatal stabilization of ELBW infants. To date, the conundrum concerning the optimal initial inspired fraction of oxygen, target saturations in the first golden minutes, and oxygen titration to achieve desired stability saturation and heart rate values has not yet been solved. Moreover, the retardation of cord clamping together with the initiation of ventilation with the patent cord (physiologic-based cord clamping) have added additional complexity to this puzzle. In the present review, we critically address these relevant topics related to fetal-to-neonatal transitional respiratory physiology, ventilatory stabilization, and oxygenation of ELBW infants in the delivery room based on current evidence and the most recent guidelines for newborn stabilization.