Timing of cord clamping in relation to start of breathing or ventilation among depressed neonates—an observational study

Abstract

Objectives: The optimal timing of cord clamping (CC) in nonbreathing neonates needing stabilisation/resuscitation remains unclear. The objective was to describe the relationship between time to CC, initiation of breathing or positive pressure ventilation (PPV) after stimulation/suction and 24-hour neonatal mortality/morbidity. Design: Observational study. Setting: A rural Tanzanian referral hospital. Population: Depressed nonbreathing newborns. Methods: Trained research assistants have observed every delivery (November 2009 through January 2014) using stop-watches and recorded data including fetal heart rate; time intervals from birth to CC and start of breathing or PPV and perinatal characteristics. Main outcome measures: Twenty-four-hour neonatal outcome (dead, admitted, normal). Results: There were 19 863 liveborn infants; 16 770 (84.4%) initiated spontaneous respirations, 3093 (15.6%) received stimulation/suctioning to initiate breathing. However, 1269 (41.0%) neonates failed to breath and received PPV at 98 ± 66 seconds and CC at 39 ± 35 seconds after birth. Adverse outcomes in neonates receiving PPV included 126 (9.9%) deaths and 100 (7.8%) neonatal admissions. In 1146/1269 (90%) neonates, CC occurred before PPV and was associated with 209 (18%) deaths/admissions. In 98 (8%) neonates, CC followed initiation of PPV with 14 (14%) deaths/admissions (P = 0.328). By logistic modelling, initiation of PPV before versus after CC was not associated with death/admission when adjusted for time to PPV. The risk for death/admission increased by 12% for every 30-second delay in PPV (P = 0.001). Conclusions: This observational study failed to demonstrate any relationship between time to CC and onset of breathing or initiation of PPV following stimulation/suction, and 24-hour outcome. Delay in initiation of PPV was significantly associated with death/admission. Tweetable abstract: No relationship between time to cord clamp, breathing or ventilation and 24-hour deaths in depressed neonates.