Clamping the umbilical cord reduces preload for the left ventricle and thus reduces cardiac output. Until the lungs aerate and pulmonary blood low increases, the reduced cardiac output will manifest as bradycardia. If cord clamping is delayed until after the lungs have aerated, the transition is smoother and cardiac ouput does not fall (Bhatt, 2013). This understanding has led to interest in delayed (physiological) cord clamping, especially if it can be done after successful inflation of the lung. Randomized trials are currently underway.
The International Liaison Committee on Resuscitation (ILCOR) updated its scientiic review for neonatal delivery room care and resuscitation (Perlman, 2015). The ILCOR scientiic review is used by the American Academy of Pediatrics and the American Heart Association to develop the neonatal resuscitation guidelines for North America (Wyckof, 2015).
Before and during delivery, careful consideration must be given to several determinants of neonatal well-being. hese include: (1) maternal health status; (2) prenatal complications, including any suspected fetal malformations; (3) gestational age; (4) labor complications; (5) duration of labor and ruptured membranes; (6) type and duration of anesthesia; (7) diiculty of delivery; and (8) medications given during labor and their dosages, administration routes, and timing.
When risk factors are present, neonatal resuscitation providers should be present for the delivery. This team readies equipment, ensures that adequate personnel are present, delegates roles and responsibilities, and considers contingency plans to stabilize the newborn. Four questions a neonatal provider will ask pertain to expected gestional age, amnionic fluid color, fetal number, and additional fetal risks. Several conditions are associated with a nonvigorous presentation. These may include immaturity, hypoxemia or acidosis from any cause, sepsis syndrome, recent drugs administered to the mother, and central nervous system developmental abnormalities. Those related to the respiratory tract are lung abnormalities, upper airway obstruction, pneumothorax, and meconium aspiration.
Ideally, obstetrical and pediatric teams discuss plans regarding umbilical cord management. Delayed cord clamping provides transfusion of placental blood to the newborn. In term infants, delay of cord clamping by 30 to 60 seconds raises hemoglobin levels at birth, improves iron stores during infancy, and enhances neurodevelopment at 4 years of age (Katheria, 2017). As discussed in Chapter 33 (p. 625), the only reported negative outcome of delayed cord clamping is hyperbilirubinemia, leading to a higher rate of phototherapy (American College of Obstetricians and Gynecologists, 2017a). In preterm neonates, delayed cord clamping reduces rates of blood transfusion, intraventricular hemorrhage, and necrotizing enterocolitis.
Delayed cord clamping should be performed in preterm and term newborns who do not require resuscitation at birth (American Academy of Pediatrics, 2017 a; American College of Obstetricians and Gynecologists, 2017a; Perlman, 2015). here should be no delay if a newborn requires resuscitation or if the placental circulation is disrupted by abruption, cord avulsion, or bleeding placenta previa or vasa previa.
Approximately 10 percent of newborns require some degree of active resuscitation to stimulate breathing, and 1 percent need extensive care. Perhaps not coincidentally, the risk of death for newborns delivered at home compared with those delivered in hospitals is increased two-to threefold (American College of Obstetricians and Gynecologists, 2017 d).
When deprived of adequate gas exchange, either before or after birth, neonates demonstrate a well-deined sequence of