“Resuscitation of infants at birth has been the subject of many articles. Seldom have there been such imaginative ideas, such enthusiasms, and dislikes, and such unscientific observations and study about one clinical picture. There are outstanding exceptions to these statements, but the poor quality and lack of precise data of the majority of papers concerned with infant resuscitation are interesting.^[1]

Virginia Apgar, writing in 1953, was probably justified in these sentiments. Indeed, in the 1950s, some were still advocating that newborns needing intervention at birth had their stomach inflated with oxygen ^[3], and indeed, Apgar published in 1963 to show that blood oxygen levels improved when the lungs were ventilated ^[3].

But what about today? Stabilisation at delivery has been an area of increasing research focus in recent years, but many aspects of delivery room care remain under-investigated. One intervention that has been researched in multiple trials is optimal cord management, and it is now well established that deferring cord clamping for a period of time after delivery is beneficial both in term and preterm infants who are vigorous after delivery ^[4]. This has led to interest in delivering respiratory support whilst infants are still on the cord, in the hope that these benefits would be available to a wider number of infants, and that this may also improve transition. This intervention has been recently examined in two large randomised controlled trials, neither of which has provided convincing evidence of benefit to this now widely-adopted practice (although meta-analysis may provide further information).

The VentFirst trial ^[5] randomised infants born less than 29 weeks of gestation to either 30-60 seconds of deferred cord clamping followed by standard resuscitation, or 120 seconds of assisted ventilation (CPAP if breathing well, or positive pressure ventilation if not) followed by cord clamping. There was no significant difference between the two groups in rates of IVH or death. In the ABC3 trial ^[6], infants born before 30 weeks of gestation were randomised either to time-based cord clamping (ideally after 30-60seconds) or physiology-based cord clamping, where facemask respiratory support was provided and the cord was clamped once ‘physiological stability’ was reached – defined as heart rate more than 100bpm and saturations above 85%. The infants in this group received between 3 and 10 minutes of deferred cord clamping. There was no significant difference between the two groups in the primary outcome of ‘intact survival at NICU discharge’, but subgroup analysis did suggest potential benefit in male infants. It was noted that infants in the physiology-based cord clamping group were more likely to be hypothermic on admission to the neonatal unit. Admission hypothermia is known to be a significant risk factor for neonatal mortality ^[7], and therefore it may be that this factor could have reduced the potential benefits demonstrated in previous work of a longer duration of cord transfusion prior to clamping.

It has also been shown that application of a facemask at delivery can induce apnoea in babies who were previously breathing ^[8] – it may be that an approach of respiratory support during deferred cord clamping should not be the blanket approach for all infants, and perhaps reserved for those who are non-vigorous – but such an approach should again be evaluated in well-designed studies.

One fundamental question in delivery room stabilisation is how best to support respiratory transition at birth. This is illustrated by the fact that the two major guidelines for neonatal stabilisation at delivery, Newborn Life Support (NLS) and the Neonatal Resuscitation Program (NRP) differ in their recommendations for infants who are not breathing well at birth. NLS guidelines recommend starting with five ‘inflation breaths’ – prolonged inflations lasting 2-3 seconds, followed by ‘ventilation breaths’ – lasting one second at a rate of 30 per minute; whilst NRP recommend positive pressure ventilation at a rate of 40-60 per minute. Monitoring of interventions at delivery has shown that even when aiming to deliver inflation breaths of 2-3seconds, there is a wide range in the actual duration of delivered breaths ^[9], and that stimulation of spontaneous breathing may occur earlier with longer inflation times ^[10]. But how long is too long? Animal work and pilot studies suggested that ‘sustained inflations’ lasting 10-20 seconds might be beneficial, but a large randomised controlled trial assessing this approach compared to standard NRP management was terminated early due to an increased risk of early death in the sustained inflation group^[11]. This again demonstrates the importance of large, properly powered studies in refining neonatal stabilisation.

Whilst we have come a long way from the 1950s, there is still much work to be done.