title: Timing of cord clamping in relation to start of breathing or ventilation among depressed neonates-an observational study.
abstract: OBJECTIVE
  The optimal timing of cord clamping (CC) in nonbreathing neonates needing stabilisation/resuscitation remains unclear. The objective was to describe the relationship between time to CC, initiation of breathing or positive pressure ventilation (PPV) after stimulation/suction and 24-hour neonatal mortality/morbidity.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  A rural Tanzanian referral hospital.
  
  
  METHODS
  Depressed nonbreathing newborns.
  
  
  METHODS
  Trained research assistants have observed every delivery (November 2009 through January 2014) using stop-watches and recorded data including fetal heart rate; time intervals from birth to CC and start of breathing or PPV and perinatal characteristics.
  
  
  METHODS
  Twenty-four-hour neonatal outcome (dead, admitted, normal).
  
  
  RESULTS
  There were 19 863 liveborn infants; 16 770 (84.4%) initiated spontaneous respirations, 3093 (15.6%) received stimulation/suctioning to initiate breathing. However, 1269 (41.0%) neonates failed to breath and received PPV at 98 ± 66 seconds and CC at 39 ± 35 seconds after birth. Adverse outcomes in neonates receiving PPV included 126 (9.9%) deaths and 100 (7.8%) neonatal admissions. In 1146/1269 (90%) neonates, CC occurred before PPV and was associated with 209 (18%) deaths/admissions. In 98 (8%) neonates, CC followed initiation of PPV with 14 (14%) deaths/admissions (P = 0.328). By logistic modelling, initiation of PPV before versus after CC was not associated with death/admission when adjusted for time to PPV. The risk for death/admission increased by 12% for every 30-second delay in PPV (P = 0.001).
  
  
  CONCLUSIONS
  This observational study failed to demonstrate any relationship between time to CC and onset of breathing or initiation of PPV following stimulation/suction, and 24-hour outcome. Delay in initiation of PPV was significantly associated with death/admission.
  
  
  CONCLUSIONS
  No relationship between time to cord clamp, breathing or ventilation and 24-hour deaths in depressed neonates.
authors.affiliation: Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.
authors.forename: H L
authors.initials: HL
authors.lastname: Ersdal
authors.affiliation: Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway.
authors.forename: J
authors.initials: J
authors.lastname: Linde
authors.affiliation: Department of Mathematics and Natural Sciences, University of Stavanger, Stavanger, Norway.|Department of Research, Stavanger University Hospital, Stavanger, Norway.
authors.forename: B
authors.initials: B
authors.lastname: Auestad
authors.affiliation: Department of Research, Stavanger University Hospital, Stavanger, Norway.|Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania.
authors.forename: E
authors.initials: E
authors.lastname: Mduma
authors.affiliation: Department of Research, Haydom Lutheran Hospital, Haydom, Tanzania.
authors.forename: S
authors.initials: S
authors.lastname: Lyanga
authors.affiliation: Centre for International Health, University of Bergen, Bergen, Norway.
authors.forename: E
authors.initials: E
authors.lastname: Svensen
authors.affiliation: Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.
authors.forename: J
authors.initials: J
authors.lastname: Perlman
mesh_terms: D001049:Apnea / Q000628:therapy*; D003250:Constriction; D005260:Female; D006780:Hospitals, Rural; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D011175:Positive-Pressure Respiration; D012151:Resuscitation; D013636:Tanzania; D013997:Time Factors; D014470:Umbilical Cord
keywords: Neonatal mortality and morbidity; resuscitation; umbilical cord clamping