|Year : 2019 | Volume
| Issue : 2 | Page : 41-45
The golden minute after birth – beyond resuscitation
Meenakshi Girish1, Girish Subramaniam2
1 Department of Pediatrics, All India Institute of Medical Sciences, Ramdaspeth, Nagpur, Maharashtra, India
2 Department of Pediatrics, Children Hospital, Midas Heights, Ramdaspeth, Nagpur, Maharashtra, India
|Date of Submission||22-Jul-2019|
|Date of Acceptance||08-Nov-2019|
|Date of Web Publication||2-Jan-2020|
101, Shubham Enclave, Darda Marg, Rahate Colony, Nagpur - 440 022, Maharashtra
Source of Support: None, Conflict of Interest: None
In tackling the unconscionably high neonatal mortality rate much has been done, but much more remains to be done. The 1st minute after birth sets the foundation for the individual's future quality of life, and any intervention which facilitates the smooth transition from the cocooned fetal life to the independent adult life will quickly find worldwide acceptance. However, it is imperative that we also look for resource neutral interventions so that a neonate even in the most resource-challenged setting gets an opportunity to smile. The interventions we have elaborated upon in this article fall in this category. They are simple, easily applied in all settings, and are evidence-based.
Keywords: Delayed cord clamping, golden minute after birth, skin-to-skin contact, umbilical cord milking
|How to cite this article:|
Girish M, Subramaniam G. The golden minute after birth – beyond resuscitation. Int J Adv Med Health Res 2019;6:41-5
| Introduction|| |
While neonatal mortality, defined as number of deaths among all live births during the first 28 days of life expressed per 1000 live births, contributes to nearly 70% of the infant mortality and more than 50% of the under 5 mortality in India,, the under-seven days neonatal deaths alone account for approximately 45% of total under-five deaths., Much progress toward neonatal health and survival has been made in the last decade. High-risk neonates have benefited from new evidence-based advances in resuscitative procedures such as use of noninvasive ventilation and titration of the inspiratory fraction of oxygen in the first few minutes of birth to facilitate the physiologic transition taking place with minimal harm. However, the need of the hour is evidence-based interventions which can be implemented in resource-constrained settings. Some of such interventions in the recent and not too recent past which have had a major impact are: the use of antenatal corticosteroids for all mothers between 240/7 and 336/7 weeks of gestation who are at risk of preterm delivery within a week to primarily decrease the risk of respiratory distress syndrome in the neonate; magnesium sulfate injection for pregnant women at <32 weeks who have imminent preterm delivery within the next 24 h to decrease the risk of cerebral palsy; and a course of antibiotics for those with preterm premature rupture of membranes to mitigate the risk of neonatal sepsis. These recommendations have been widely embraced by the medical profession.
The golden minute after birth in newborn care is analogous to the golden hour after trauma in emergency medicine. The 1st minute after birth provides a critical window period for interventions with impact on immediate and long-term survival of the newborn. Other than cardiopulmonary resuscitation, there are two other interventions which should become the standard of care across the world, to be performed immediately at birth. In this article, we highlight the two interventions which are bolstered by adequate research evidence and should be easy to implement on a wider scale than is being practiced presently., Importantly, they need to be performed within the first few minutes of birth and thus require well-established local policy and practice for transfer of benefits to neonates. We hope this article will provide impetus to the readers toward formulation of local guidelines to implement them in obstetric-neonatal practice.
| Achievement of Neutral Thermal Environment|| |
It is ironical that while induced hypothermia as an intervention for asphyxiated babies has caught the fancy of all pediatricians, simple measures to prevent hypothermia in all babies immediately after birth are still neglected.
Hypothermia is a very important cause of morbidity and mortality in neonates, especially preterm and low birth weight babies because of their thin skin, large surface area to body mass ratio, lack of subcutaneous fat for insulation, and inability to generate heat by shivering. In utero fetal temperature is maintained at 0.5° higher than the maternal core temperature by the placenta and immediately after birth all babies lose heat through evaporation from their wet bodies and by radiant and convective loss to environment and the walls of the room. Neonates have limited ability to dissipate heat in warm environment or to maintain their body temperature in response to cold, thus their body needs to be maintained within a narrow range of temperature for optimum transition from intrauterine to extrauterine life. This range becomes narrower with decreasing gestational age at birth. To maintain this thermoneutral zone, neonates spend almost 8% of their total energy expenditure in thermoregulation even when the environmental temperature is kept optimum. There are several alternatives available to provide optimal thermal conditions to the newly born, but the most natural, the most appropriate, with the least harm and with no extra cost remains immediate skin contact with the mother.
Skin-to-skin contact (SSC) constitutes a key first golden minute intervention. Placing the naked baby onto the mother's bare abdomen or chest immediately at birth has been shown to regulate newborn temperature through a process called as “thermal synchrony,” in which the mother's chest temperature increases to warm a cold neonate and decreases to cool a neonate who is too warm. Immediate, continuous, and uninterrupted SSC has also proven benefits beyond thermoregulation. A 2016 Cochrane Review of more than 80 randomized controlled trials on early SSC, including babies born by cesarean section, has found that infants who received immediate SSC have higher stability of the cardiorespiratory system, and higher blood glucose levels. Immediate benefits to mother were reduced bleeding and earlier expulsion of placenta and lowered maternal stress levels. Early initiation of lactation and successful completion of exclusive breastfeeding period have been the other major long term benefits of early SSC., SSC provides the extra tactile, olfactory, and thermal cues which help to establish a chemical and neurobehavioral communication between the mother-baby dyad making the 1st minute after birth the golden minute for both. This period is also considered a “sensitive period” (defined as a developmental phase in which a human who has a built-in competence for a specific behavior has the best opportunity to exhibit that behavior) for another unique phenomenon, the “breast crawl.” Neonates, when allowed to remain in contact with their mothers at the time of birth, instinctively crawl towards the mother's breast within the 1st h our and spontaneously initiate feeding.
It is unfortunate that neonatal assessment, administration of vitamin K, and weighing often take precedence in delivery room practices, more so after cesarean deliveries despite a very strong recommendation for early SSC in the 2018 revision of the ten steps to successful breastfeeding by the WHO/UNICEF and studies reporting feasibility even after cesarean section. SSC requires minimal organizational effort or cost of implementation [Box 1], and its important health impact on mother and baby has been shown to save money in neonatal units. But barriers to SSC implementation are many and uptake of these interventions remains suboptimal.,, An awake mother, responsive to her baby, and a vigorous newborn (pink, crying, and alert baby) are the only requirements for the implementation of this practice, and where it is not possible for medical reasons, father can be an alternative person.,,
Kangaroo mother care is a form of SSC but generally used in the neonatal intensive care unit (NICU) for the care of preterm or low birth weight babies.
Another low-cost intervention for thermoregulation, especially for preterm and low birth weight babies, in whom hypothermia is an independent contributor to morbidity and mortality and who need immediate transport to intensive care, is the use of polythene bag for covering their body. Placing newborns under radiant warmer and drying them with towels appears to be inadequate for small babies (very preterm and very-low birth weight). When preterm or low birth weight babies are placed into plastic bags or wraps immediately after birth, without drying, they were found to have better core body temperature at the time of transport and admission to the NICU.,, Immediate wrapping in a plastic bag creates humidity and prevents heat loss by evaporation and any delay in placement in a plastic bag without drying would cause the baby to quickly become hypothermic. This was also found to be true for term infants, especially in low-income countries where other heat sources such as the radiant warmer and thermal mattresses may not be available or affordable. Use of food grade polythene bags as part of routine care in preterm deliveries has been endorsed by neonatal advanced life support courses in several countries. Wrapping preterms in this way does not interfere with resuscitative measures; pulse oximeter can be attached, heart rate easily monitored, and even umbilical line can be inserted through an incision made in the bag.
However, impact of this intervention is restricted to thermoregulation, and there is a lack of good evidence on its impact on mortality and morbidity.
| Delayed Cord Clamping or Umbilical Cord Milking|| |
Timing of umbilical cord clamping at birth has come full circle over a period of about 2000 years. Two contrasting approaches – active versus expectant – have contrasting impact on maternal and neonatal survival. Decline in the incidence of postpartum hemorrhage, the most common cause of maternal mortality even today, was seen when management of third stage of labor underwent a paradigm shift from expectant to active management. On the other hand, virtues of expectant or delayed clamping of cord as opposed to early (active) clamping of the cord are now emerging. According to Dunn, “Early cord clamping after birth is one of those errors in practice that has nothing to plead in its favor but custom” and the custom is so entrenched that withholding the act of immediate cord clamping, or “doing nothing,” is also considered an intervention and such is the case with delayed cord clamping (DCC).
Two mechanisms underlie the benefits of deferring cord clamping – first, placental transfusion and second, facilitating a more physiologic sequential circulatory transition. The concept of DCC first began with a focus on the volume of placental transfusion (~25 ml/kg) and then to more physiological consequences, including prevention of low cardiac output syndrome. DCC (>60 s) is considered a more physiological approach facilitating circulatory transition at birth. Physiological-based cord clamping refers to the phenomenon by which the left ventricular preload, which drives cardiac output, is allowed to switch from umbilical venous return to pulmonary venous return. Pulmonary venous return becomes adequate only when lungs aerate fully and any clamping of cord prior to this event will cause a fall in cardiac output and a large swing in arterial pressure and cerebral blood flow.
Early cord clamping is also associated with double the risk of iron deficiency at 3–6 months of age in term babies, and there is nearly 60% reduction in risk with every minute that cord cutting is delayed. It is of great relevance in India, where we are overwhelmed by the high prevalence of iron deficiency anemia and where exclusive breastfeeding in the first 6 months is strongly advocated. Especially in this setting, DCC could prove to be a low cost, easy to implement strategy to reduce the burden of IDA. In preterms too, DCC has been shown to improve hematocrit at 24–48 h of birth, thereby reducing the need for red blood cell transfusion later, often seen in such babies. A systematic review in 2018 has shown that DCC reduced neonatal mortality by 30% (risk ratio 0.68; 95% confidence interval [CI] 0.52–0.90; number needed to benefit 33, 95% CI 20–100) and significantly reduced incidence of intraventricular hemorrhage and necrotizing enterocolitis, conditions with direct implications in preterm morbidity and long-term survival.
Two troubling questions come to mind when DCC is considered, its status in HIV and feasibility in depressed babies. Concerns about the former, that is, DCC increasing the risk of mother to infant HIV virus transmission at birth have been put to rest by 2014 WHO guidelines,, which state that “the proven benefits of at least a 1–3 min delay in clamping the cord outweigh the theoretical, and unproven, harms. DCC is recommended even among women living with HIV or women with unknown HIV status.” For the latter, the American Academy of Paediatrics and the American College of Obstetrics and Gynecology recommend DCC only in vigorous babies.,, However, the new understanding about the physiology of timing of cord clamping challenges the notion that an apneic baby must be quickly separated from the mother to allow initiation of resuscitation as a priority. The WHO now states that cord should not be clamped and cut to facilitate resuscitation. Instead, it recommends that for basic newborn resuscitation, “if there is experience in providing effective positive-pressure ventilation without cutting the umbilical cord, ventilation can be initiated before cutting the cord.“ Barriers, including physical space adjustments required, need to be addressed for this guideline to be implemented.
As an alternative to DCC, umbilical cord milking (UCM) is now gathering evidence as a procedure which retains the benefits of DCC in term and preterm neonates and overcomes the constraints of keeping the baby close to the delivery table in contact with the mother during resuscitation. A pilot study comparing UCM with immediate cord clamping did not show any delay in the initiation of resuscitation or increased morbidity in the NICU. In another pilot study, comparing UCM with DCC, milking was shown to initiate spontaneous breathing earlier. While DCC is a first golden minute “nonintervention,” UCM constitutes an “interventional” alternative to DCC. However, UCM is still a “work in progress,” and further studies are needed to evaluate the acute effects of milking on neonatal hemodynamics. As of now, the long-term safety profile of UCM is unknown and the International Liaison of Committee on Resucitation recommended against the routine use of UCM in newborns <29 weeks gestation. Compromised placental integrity such as abruption, placenta previa, and cord avulsion are other contraindications to DCC and UCM.
| Conclusion|| |
While establishment of breathing and oxygenation is rightfully the most important first golden minute intervention, we also need to look beyond, to make a dent in the unconscionably high neonatal mortality rate and the interventions should be simple, easy to implement (hence applicable even in resource-poor settings), and evidence based. The interventions we have elaborated upon fall precisely in this category. SSC in all stable babies and use of polythene bags for transport of unstable babies will help maintain the thermoneutral environment, lack of which can have major short-term and long-term adverse consequences.
Similarly, DCC/cord milking has been backed by ample evidence to show its benefits in transitional circulation and the advantages of the hematocrit augmentation. The golden minute after birth gives us a small window of hope and opportunity to make a major impact with lifelong consequences.
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Conflicts of interest
There are no conflicts of interest.
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