Providing breathing support before clamping the umbilical cord in preterm babies

Review question: do preterm babies benefit from receiving breathing support before the cord is clamped?

Background: allowing preterm infants to receive blood from the placenta after birth and before clamping the umbilical cord has health benefits for the baby and is not harmful for the mother. Most babies will start breathing or crying (or both) before the cord is clamped. However, some babies do not establish regular breathing during this time. After clamping the cord, most preterm babies are given some form of breathing support like continuous positive airway pressure (CPAP). CPAP applies continuous low air pressure to keep the airways open in babies who can breathe on their own. The question for this review was whether it was beneficial to start the breathing support before the cord is clamped.

Study characteristics: we searched medical databases and found one study for inclusion in this review. Preterm infants born before 32 weeks' gestation (32 weeks from the first day of the woman's last period (menstruation) to the current date) who had clamping of the umbilical cord delayed for 60 seconds after birth were selected at random to enter a group of babies who received breathing support and a group of babies who did not receive breathing support. The breathing support was given after birth of the baby and before the cord was clamped. Breathing support was the use of CPAP for infants breathing on their own or applying intermittent airway pressure to expand the lungs in babies not breathing well on their own. Most of the study infants (83%) were delivered by caesarean section.

Key results: the single study included in the review did not provide sufficient evidence either for or against the use of breathing support before cord clamping.

Quality of evidence: the quality of evidence was low, mainly because more infants need to be studied for definite conclusions.

Authors' conclusions: 

The results from one study with wide CIs for magnitude of effect do not provide evidence either for or against the use of respiratory support before clamping the umbilical cord. A greater body of evidence is required as many of the outcomes of interest to the review occurred infrequently. Similarly, the one included study cannot answer the question of whether the intervention is or is not harmful.

Read the full abstract...

Placental transfusion (by means of delayed cord clamping (DCC), cord milking, or cord stripping) confers benefits for preterm infants. It is not known if providing respiratory support to preterm infants before cord clamping improves outcomes.


To assess the efficacy and safety of respiratory support provided during DCC compared with no respiratory support during placental transfusion (in the form of DCC, milking, or stripping) in preterm infants immediately after delivery.

Search strategy: 

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL, 2017, Issue 5), MEDLINE via PubMed (1966 to 19 June 2017), Embase (1980 to 19 June 2017), and CINAHL (1982 to 19 June 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

Selection criteria: 

Randomized, cluster randomized, or quasi-randomized controlled trials enrolling preterm infants undergoing DCC, where one of the groups received respiratory support before cord clamping and the control group received no respiratory support before cord clamping.

Data collection and analysis: 

All review authors assisted with data collection, assessment, and extraction. Two review authors assessed the quality of evidence using the GRADE approach. We contacted study authors to request missing information.

Main results: 

One study fulfilled the review criteria. In this study, 150 preterm infants of less than 32 weeks' gestation undergoing 60 second DCC were randomized to a group who received respiratory support in the form of continuous positive airway pressure (CPAP) or positive pressure ventilation during DCC and a group that did not receive respiratory support during the procedure. Mortality during hospital admission was not significantly different between groups with wide confidence intervals (CI) for magnitude of effect (risk ratio (RR) 1.67, 95% CI 0.41 to 6.73). The study did not report neurodevelopmental disability and death or disability at two to three years of age. There were no significant differences between groups in condition at birth (Apgar scores or intubation in the delivery room), use of inotropic agents (RR 1.25, CI 0.63 to 2.49), and receipt of blood transfusion (RR 1.03, 95% CI 0.70 to 1.54). In addition, there were no significant differences in the incidences of any intraventricular haemorrhage (RR 1.50, 95% CI 0.65 to 3.46) and severe intraventricular haemorrhage (RR 1.33, 95% CI 0.31 to 5.75). Several continuous variables were reported in subgroups depending on method of delivery. Unpublished data for each group as a whole was made available and showed peak haematocrit in the first 24 hours and duration of phototherapy did not differ significantly. Overall, the quality of evidence for several key neonatal outcomes (e.g. mortality and intraventricular haemorrhage) was low because of lack of precision with wide CIs.