Role of Sustained Inflation and Delayed Cord Clamping in Resuscitation after Asphyxia

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Birth asphyxia, according to the World Health Organization (WHO), accounts for an estimated 900 000 deaths each year and is one of the primary causes of early neonatal morbidity and mortality. Ventilation constitutes the critical step in resuscitation of asphyxiated newborns. Current neonatal resuscitation guidelines recommend initiating ventilation if required after 30 sec of initial steps. Early onset of ventilation may have beneficial effects. A sustained inflation breath may help in establishing adequate functional residual capacity and may improve physiological parameters quickly during resuscitation. Delaying cord clamping is now recommended for all preterm infants. WHO also supports delayed cord clamping in normal term infants, however its role in birth asphyxia has not been well studied. The need for resuscitation often prevents the practitioner from delaying cord clamping in this population. Establishing ventilation with an intact cord, prior to clamping, helps to stabilize cerebral and pulmonary blood flows in preterm lambs. Improving cerebral blood flow may be critical in asphyxia. In this proposal, we plan to study initiation of ventilation with an intact cord and delayed cord clamping together, in near term lambs asphyxiated by cord occlusion. It would theoretically combine the advantages of placental transfusion and prompt resuscitation. A randomized controlled trial evaluating SI or PPV prior to delayed cord clamping in asphyxiated human infants is ideal. However, ethical concerns about proper consent, and feasibility of real time measurements of cerebral oximetry, flow and pressure limit the ability to perform such a study. Relevance to current practice in neonatal resuscitation: Sustained Inflation and Positive Pressure Ventilation prior to delayed cord clamping is a simple intervention that does not require sophisticated equipment or training and could be performed by personnel in low resource settings as well. This study will provide critical insight into the optimal approach to cord management and ventilation and influence future recommendations for management of the asphyxiated human neonate at delivery.