Available online 17 March 2023, 151746

Author links open overlay panelAbstract

Congenital diaphragmatic hernia (CDH) is a severe birth anomaly where a defect in the diaphragm allows abdominal organs to herniate into the chest with compression of the intrathoracic structures, specifically the lungs and heart. Pulmonary and left ventricular hypoplasia result in respiratory insufficiency after birth with disordered transition and persistent pulmonary hypertension of the newborn (PPHN). As a result, infants need immediate intervention after birth to support the transition. Delayed cord clamping (DCC) is recommended for all healthy newborns and improves outcomes in infants born preterm and in infants with congenital heart disease; however, DCC may not be feasible in newborns needing immediate intervention after birth. Recent studies have explored resuscitation with intact umbilical cords, to determine feasibility, safety, and efficacy in infants with CDH, with promising results. In this report we discuss the physiologic basis for intact cord resuscitation in infants with CDH and review the above reports with a view to determining optimal timing of umbilical cord clamping in infants with CDH.

Section snippetsSpontaneous Breathing Approach in Infants with CDH

Questioning the age-old paradigm, recommending immediate intubation and mechanical ventilation after birth in infants with CDH, the possibility exists that a subset of infants born with very small diaphragmatic defects, hence mild lung hypoplasia, may not develop severe respiratory insufficiency immediately after birth, and thus mechanical ventilation may not be necessary. Current guidelines for delivery room management do not consider the individual patient's disease severity, and that an

Physiologic Basis for Intact Cord Resuscitation

Removing the low-resistance placental circulation by clamping the umbilical cord decreases LV preload and increases systemic vascular resistance (afterload), reducing cardiac output. Cardiac output is only restored when the pulmonary circulation vasodilates (following lung aeration) to accept the entire output of the right ventricle, leading to a large increase in PBF that can sustain left ventricular preload.5,6 On the other hand, if lung aeration precedes umbilical cord clamping, PBF

Resuscitation with an Intact Cord in Infants with CDH

The French CDH study9 group evaluated the feasibility and safety of intact cord resuscitation in newborn infants with CDH. Forty infants were randomized to intact cord resuscitation (ICR) versus immediate cord clamping (ICC), with 20 infants in each group. In the ICR group the cord was left intact, and initial steps of resuscitation (intubation and initiation of ventilation) performed with the cord intact. The criteria to cut the cord after intubation were cardiorespiratory stabilization

Conclusion

CDH is a complex syndrome that causes severe hypoxemic respiratory failure after birth and is associated with high mortality. Transition to extrauterine life is severely disordered, necessitating immediate intervention after birth with intubation and mechanical ventilation. Immediate intervention, precludes infants with CDH from the benefits of DCC. Current guidelines for delivery room management do not consider the individual patient's disease severity, and the possibility exists that in

Conflict of Interest

None

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