Ventilation onset prior to umbilical cord clamping (physiological-based cord clamping) improves systemic and cerebral oxygenation in preterm lambs

Graeme R Polglase, Jennifer A Dawson, Martin Kluckow, Andrew W Gill, Peter G Davis, Arjan B Te Pas, Kelly J Crossley, Annie McDougall, Euan M Wallace, Stuart B Hooper, Graeme R Polglase, Jennifer A Dawson, Martin Kluckow, Andrew W Gill, Peter G Davis, Arjan B Te Pas, Kelly J Crossley, Annie McDougall, Euan M Wallace, Stuart B Hooper

Abstract

Background: As measurement of arterial oxygen saturation (SpO2) is common in the delivery room, target SpO2 ranges allow clinicians to titrate oxygen therapy for preterm infants in order to achieve saturation levels similar to those seen in normal term infants in the first minutes of life. However, the influence of the onset of ventilation and the timing of cord clamping on systemic and cerebral oxygenation is not known.

Aim: We investigated whether the initiation of ventilation, prior to, or after umbilical cord clamping, altered systemic and cerebral oxygenation in preterm lambs.

Methods: Systemic and cerebral blood-flows, pressures and peripheral SpO2 and regional cerebral tissue oxygenation (SctO2) were measured continuously in apnoeic preterm lambs (126±1 day gestation). Positive pressure ventilation was initiated either 1) prior to umbilical cord clamping, or 2) after umbilical cord clamping. Lambs were monitored intensively prior to intervention, and for 10 minutes following umbilical cord clamping.

Results: Clamping the umbilical cord prior to ventilation resulted in a rapid decrease in SpO2 and SctO2, and an increase in arterial pressure, cerebral blood flow and cerebral oxygen extraction. Ventilation restored oxygenation and haemodynamics by 5-6 minutes. No such disturbances in peripheral or cerebral oxygenation and haemodynamics were observed when ventilation was initiated prior to cord clamping.

Conclusion: The establishment of ventilation prior to umbilical cord clamping facilitated a smooth transition to systemic and cerebral oxygenation following birth. SpO2 nomograms may need to be re-evaluated to reflect physiological management of preterm infants in the delivery room.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Blood gas parameters during ventilation.
Fig 1. Blood gas parameters during ventilation.
The partial pressure of (A) arterial carbon dioxide (PaCO2), (B) arterial oxygen content (CaO2), (C) the fraction of inspired oxygen (FiO2), (D) alveolar-arterial difference in oxygen (AaDO2) and (E) cerebral oxygen delivery (DO2) in Vent 1st (Black) and clamp 1st (white) preterm lambs. * indicates significant difference Vent 1st vs. Clamp 1st (p<0.05). Vent 1st and Clamp 1st lambs had similar arterial oxygen content and cerebral oxygen delivery, but Clamp 1st lambs had worse PaCO2 and AaDO2 and thus required higher FiO2 to achieve similar tissue levels 5 and 10 minutes after delivery.
Fig 2. Effect of the timing of…
Fig 2. Effect of the timing of ventilation onset relative to umbilical cord clamping.
Representative traces obtained from a lamb in which ventilation was initiated prior to umbilical cord clamping (Vent 1st), and a lamb in which umbilical cord clamping was conducted prior to the initiation of ventilation (clamp 1st). Dashed line indicates when an intervention occurred as labeled on the graphs. Note the difference in time scale. SpO2—arterial oxygen saturation, SctO2—cerebral oxygenation.
Fig 3. Arterial and cerebral oxygen saturation…
Fig 3. Arterial and cerebral oxygen saturation and haemodynamics.
(A) Arterial saturation of oxygen measured by pulse oximetry (SpO2), (B) cerebral oxygenation (SctO2), (C) cerebral blood flow (CBF), (D) cerebral oxygen extraction (COE), (E) arterial pressure measured in a carotid artery (PCA) and (F) heart rate measured in Vent 1st (closed circles) and Clamp 1st (open circles) preterm lambs. First dashed line indicates ventilation onset for Vent 1st lambs or umbilical cord clamping for Clamp 1st lambs; second dashed line indicates umbilical cord clamping for Vent 1st lambs and ventilation onset for Clamp 1st lambs. F = fetal value. * indicates significant difference Vent 1st vs. Clamp 1st (p<0.05). # indicates time difference from fetal (F) value (p<0.05). In the time between umbilical cord clamping and ventilation onset, Clamp 1st lambs significantly reduced arterial and cerebral oxygen saturation, and increased CBF and oxygen extraction to compensate. Ventilation onset increased arterial and cerebral oxygen saturation back to Vent 1st lambs values by 5 min. Vent 1st lambs maintained steady oxygenation and haemodynamics during the same time.

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Source: PubMed

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