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Re: Resuscitate with the placental circulation intact

Reynolds, like the majority of us neonatologists and obstetricians, would be unable to keep his nerve and delay three minutes before clamping and cutting the cord to be able to proceed with resuscitation. However maintaining a placental circulation may sometimes be all that is required as Aristotle (1) observed “Frequently the child appears to be born dead, when it is feeble and when, before the tying of the cord, a flux of blood occurs into the cord and adjacent parts. Some nurses who have already aquired skill squeeze (the blood) back out of the cord (into the child’s body) and at once the baby, who had previously been as if drained of blood, comes to life again.”

We do not recommend the patience described by Aristotle but some lateral thinking is required. When reversal of tracheal occlusion done in cases of severe congenital diaphragmatic hernias is needed at birth an EXIT (2) procedure is used. Essentially a functional placental circulation is maintained until the tracheal occlusion can be removed and the neonate ventilated.

Resuscitation before the placental circulation has ceased allows some warm oxygenated blood to return to the neonate and supplement oxygenation from the newborns lungs. Indeed as the pulmonary vasculature opens up drawing blood from the rest of the body, the deficit is replaced by redistribution of the returning placental blood. This effect is well recognised as the placental transfusion which occurs in a physiological third stage.(3)

Resuscitation before the cord is clamped and cut takes a little preparation and thought. We have developed a procedure at caesarean section to provide all the normal equipment for resuscitation without compromising the facilities for the neonate or the mother, so that ventilation and pulmonary respiration can be established while the cord remains intact. (4) Precise arrangements may need to be modified according to different theatre layouts. Essentially it involves bringing the resuscitaire up to the side of the operating table. Other approaches are possible. Preparation and cooperation between obstetrician, paediatrician and theatre staff is key to success. There are likely to be substantial benefits for babies with significant hypoxia. When fetal distress is due to cord compression such as with a nuchal cord, the fetus may already be hypovolaemic at birth. Delayed clamping allows time for the placental transfusion to correct the hypovolaemia.