Delayed vs Immediate Cord Clamping Changes Oxygen Saturation and Heart Rate Patterns in the First Minutes after Birth

doi:10.1016/j.jpeds.2020.07.045

The Journal of Pediatrics

Volume 227, December 2020, Pages 149-156.e1

https://doi.org/10.1016/j.jpeds.2020.07.045 Get rights and content

Objective

To build arterial oxygen saturation (SpO₂) and heart rate (HR) percentiles for the first 10 minutes after birth in term infants born after an uneventful gestation, vaginal delivery, and delayed cord clamping (DCC) for ≥60 seconds, and to compare our results with previous ones constructed after immediate cord clamping.

Study design

Preductal SpO₂, HR, and timing of DCC immediately after complete fetal body expulsion were recorded. The pulse-oximeter was adjusted in the right wrist/hand and set at maximal intensity and measurements performed every 2 seconds.

Results

A total of 282 term newborn infants were included. The definitive data set comprised of 70 257 SpO₂ and 79 746 HR measurements. Median and IQR of SpO₂ (%) at 1, 5, and 10 minutes after birth were 77 (68-85), 94 (90-96), and 96 (93-98), respectively. HR (beats per minute) median and IQR at 1, 5, and 10 minutes after birth were 148 (84-170), 155 (143-167), and 151 (142-161), respectively. We found significantly higher SpO₂ for the 10th, 50th, and 90th percentiles compared with the previous reference ranges for the first 5 minutes and HR for the first 1-2 minutes after birth.

Conclusions

Spontaneously breathing term newborn infants born by vaginal delivery who underwent DCC ≥60 seconds achieved higher SpO₂ and HR in the first 5 minutes after birth compared with term neonates born under the same conditions but with immediate cord clamping. Further studies in neonates undergoing cesarean delivery are under way.

Section snippets

Methods

Eligible infants were term newborn babies (≥37 weeks of gestation) born in the Maternity Ward of the University and Polytechnic Hospital La Fe (Valencia) after an uneventful pregnancy and vaginal delivery and not needing resuscitation or oxygen in the DR and whose parents approved participation. We defined birth as the expulsion of the entire fetal body. Babies <37 weeks of gestation, born by cesarean delivery, or needing any type of resuscitation maneuvers, with congenital malformations or

Results

A total of 282 infants completed between July 2018 and September 2019. The final data set included 70 257 SpO₂ and 79 746 HR measurements (Figure 1; available at www.jpeds.com). Table I describes the characteristics of the infants, mothers, and delivery.

Cord clamping was delayed 110 ± 62 seconds after total fetal expulsion (Table I). We determined 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles for SpO₂ and HR. Results are graphically depicted in Figures 2 and 3. Numerical values are

Discussion

We aimed to assess a normality range for SpO₂ and HR using pulse oximetry in babies born at term after an uneventful pregnancy by vaginal delivery and with DCC for ≥60 seconds as presently recommended.²⁵ HR in the first 5 minutes after birth was accurately recorded by Linde et al, with similar results using a dry electrode EKG.³⁶ The cord was kept patent for more than 1 minute (110 ± 62 seconds) according to the 2018 guidelines of the Spanish Society of Obstetrics and Gynecology.²⁵ Normality

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Fetal-to-neonatal transition is characterized by a precise sequence of circulatory and respiratory changes that leads to the establishment of adult-type circulation and airborne respiration. Consequently, there is an abrupt increase in the oxygen availability to tissue to fulfill the increasing energy requirements. Despite the exquisite arrangements of this sequence of events, almost 10% of all newly born infants, and especially those born prematurely, will require interventions to achieve an adequate postnatal adaptation. In the newborn period, resuscitation means fundamentally expanding the lungs, facilitating pulmonary circulation by reducing pulmonary resistance, and achieving a functional residual capacity. All these changes enhance alveolar capillary gas exchange and arterial blood oxygenation. Traditionally, pure oxygen was employed as a gas admixture to ventilate the lungs. In recent years, resuscitation with air has been recommended for term and near-term infants with asphyxia, based on meta-analyses that have reported a significant reduction in mortality in babies resuscitated with air versus 100% oxygen. However, the initial fraction of inspired oxygen needed for stabilization of the preterm infant still constitutes a matter of debate. Extremely preterm infants frequently need oxygen supplementation in the first minutes after birth to avoid hypoxemia. Moreover, those who do not achieve oxygen saturations around 80% in the first 5 minutes after birth are at greater risk of death and/or intraventricular hemorrhage. The present chapter aims to shed light on this intriguing conundrum.
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Citation Excerpt :
However, these ranges are derived from infants receiving early cord clamping. Ongoing studies are investigating whether recommended SpO2 target ranges should be revised for term and preterm infants following DCC, with lower inspired O2 requirement (Fig. 6).36,37 During cardiac arrest, should CC be carried out with 21% or 100% O2?38
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This review will address the deficiencies in knowledge that currently impede our quest to determine the best and safest means to deliver oxygen to sick infants during the first critical minutes of life and suggest practical solutions for current practice while awaiting definitive evidence from large scale, well defined, randomized controlled studies.

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: C.P-S. acknowledges a grant for the development of Clinical and Care Research Projects of the Health Department Valencia-La Fe (02/2019 of May 6, 2019). A.S-G. acknowledges a predoctoral contract by the RETICS funded by the PN 2018-2021 (Spain), ISCIII- Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (FEDER), reference RD16/0022. M.V. acknowledges a research grant PI17/0131 from the Health Research Institute Carlos III (Ministry of Science and Innovation; Kingdom of Spain). The other authors declare no conflicts of interest.

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Original ArticleDelayed vs Immediate Cord Clamping Changes Oxygen Saturation and Heart Rate Patterns in the First Minutes after Birth

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Semin Fetal Neonatal Med

Clin Perinatol

Semin Fetal Neonatal Med

Int J Nurs Stud

Semin Fetal Neonatal Med

J Pediatr

Int J Gynecol Obstet

J Pediatr

J Pediatr

J Pediatr

An Pediatría

Semin Fetal Neonatal Med

Resuscitation

Resuscitation

Resuscitation

Cardiovascular transition at birth: a physiological sequence

Pediatr Res

Defining the reference range for oxygen saturation for infants after birth

Pediatrics

A proposal for a new method of evaluation of the newborn infant

Curr Res Anesth Analg

Clinical assessment of infant colour at delivery

Arch Dis Child Fetal Neonatal Ed

Oxygen saturation monitoring for the preterm infant: The evidence basis for current practice

Pediatr Res

Monitoring arterial oxygen saturation in the neonate

J Perinat Med

Evaluation od arterial oxygen saturation in pregnant patients and their newborns

Obstet Gynecol

Evaluation of oxygen saturation monitoring by pulse oximetry in neonates in the delivery room

Can J Anaesth

Pulse oximetry used for documenting oxygen saturation and right-to-left shunting immediately after birth

Eur J Pediatr

Oxygen saturation in healthy newborn infants immediately after birth measured by pulse oximetry

Arch Gynecol Obstet

Percentiles of oxygen saturations in healthy term newborns in the first minutes of life

Eur J Pediatr

Original Article
Delayed vs Immediate Cord Clamping Changes Oxygen Saturation and Heart Rate Patterns in the First Minutes after Birth