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Implementing intact cord resuscitation in very preterm infants: feasibility and pitfalls

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Abstract

The purpose of this study is to evaluate the feasibility of intact cord resuscitation (ICR) in very preterm infants using a custom-equipped mobile resuscitation trolley (LifeStart®). We collected maternal and neonatal data of all inborn infants < 32 weeks eligible for ICR per our protocol over 9 months from ICR implementation. We compared rates of ICR between the beginning and the end of the study period. We reviewed maternal and neonatal adverse events related to the procedure and direct outcomes. In order to assess potential quality improvements related to the procedure, we collected the same data in the infants born in the 9-month period preceding ICR implementation. Out of 44 infants born < 32 weeks during the period, 27 were eligible for ICR. Failure to initiate ICR occurred in 9/27, exclusively in the first 5.5 months of the study. In one infant, ICR was interrupted prior to 2 min due to placental abruption. No ICR procedure had to be interrupted due to insufficient cord length. Among the 18 infants who completed ICR, cord clamping timing increased significantly over the study period, from 3.0 [2.5–3.5] to 4.2 min [3.1–8.3] (p = 0.02). No significant maternal blood loss or wound complications were noted. No infant deaths were attributable to failure or direct consequence of ICR, and no infant experienced hypoxic respiratory failure (intubation, FiO2 ≥ 0.4), asphyxia (pH < 7.2), or blood pressure instability (< 2 SD) following stabilization. Hemoglobin level after cord clamping was higher in the ICR cohort than in the pre-implementation group. Seven out of 18 infants exposed to ICR had a temperature < 36.5 °C on admission.

  Conclusion: ICR is feasible in very preterm infants. Temperature management requires special attention. Multidisciplinary simulation training before implementation and systematic post-implementation quality improvement meetings may significantly increase ICR program success.

What is Known:

• Because infants born < 32 weeks often require cardiorespiratory resuscitation at birth, they are not offered delayed cord clamping in the majority of neonatal intensive care units.

• Recently, fully equipped mobile trolleys have been developed in order to allow bedside resuscitation with an intact cord.

What is New:

• Variable timing of cord clamping based on the infant’s transition and respiratory stability, i.e., “physiology-based cord clamping,” is safely achievable in very preterm infants.

• Intact cord resuscitation requires specific equipment, operational protocols, and a high level of preparation from both obstetrical and neonatal teams, with a learning curve that can be streamlined by multidisciplinary simulation training.

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Data Availability

Anonymized data supporting the findings of this study are available from the corresponding author on reasonable request.

Abbreviations

ACOG:

American College of Obstetrician and Gynecologists

CPAP:

Continuous positive airway pressure

DCC:

Delayed cord clamping

EMA:

European Medicine Agency

ICR:

Intact cord resuscitation

IVH:

Intraventricular hemorrhage

IQR:

Interquartile range

LISA:

Less invasive surfactant administration

NEC:

Necrotizing enterocolitis

NICU:

Neonatal intensive care unit

PBCC:

Physiological-based cord clamping

PDA:

Patent ductus arteriosus

PPV:

Positive pressure ventilation

PPROM:

Prolonged premature rupture of membranes

PRBC:

Packed red blood cell

ROP:

Retinopathy of prematurity

WHO:

World Health Organization

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Acknowledgements

We thank Damien Moerman for his help in statistics analysis.

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Authors and Affiliations

  1. Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium

    Catheline Hocq, Katherine Carkeek, Bénédicte Van Grambezen, Fiammetta Piersigilli & Olivier Danhaive

  2. Division of Obstetrics, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium

    Aurianne Van Grambezen & Frédéric Debiève

  3. Division of Neonatology, Liverpool Women’s Hospital, Liverpool, UK

    Charles William Yoxall

  4. Division of Neonatology, Benioff Children’s Hospital, University of California , San Francisco, CA, USA

    Olivier Danhaive

Authors
  1. Catheline Hocq
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  2. Aurianne Van Grambezen
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  3. Katherine Carkeek
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  4. Bénédicte Van Grambezen
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  5. Charles William Yoxall
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  6. Frédéric Debiève
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  7. Fiammetta Piersigilli
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  8. Olivier Danhaive
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Contributions

Catheline Hocq, Charles William Yoxall, Fiammetta Piersigilli, and Olivier Danhaive collaborated to the study conception and design. Data collection and analysis were performed by Catheline Hocq and Aurianne Van Grambezen. The draft of the manuscript was written by Catheline Hocq and all authors contributed to revision and editing. All authors read and approved the final version.

Corresponding author

Correspondence to Catheline Hocq.

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This review was approved by our institutional review board and ethics committee. Due to its retrospective character, an exemption of informed consent was accepted by the ethics committee.

Competing interests

The authors declare no competing interests.

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Communicated by Daniele De Luca

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Hocq, C., Van Grambezen, A., Carkeek, K. et al. Implementing intact cord resuscitation in very preterm infants: feasibility and pitfalls. Eur J Pediatr 182, 1105–1113 (2023). https://doi.org/10.1007/s00431-022-04776-2

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  • DOI: https://doi.org/10.1007/s00431-022-04776-2

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