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Placental transfusion during neonatal resuscitation in an asphyxiated preterm model



Neonatal Resuscitation Program does not recommend placental transfusion in depressed preterm neonates.


Our objectives were to study the effect of delayed cord clamping (DCC) with ventilation for 5 min (DCCV, n-5), umbilical cord milking (UCM) without ventilation (n-6), UCM with ventilation (UCMV, n-6), early cord clamping followed by ventilation (ECCV, n-6) on red cell volume (RCV), and hemodynamic changes in asphyxiated preterm lambs. Twenty-three preterm lambs at 127–128 days gestation were randomized to DCCV, UCM, UCMV, and ECCV. We defined asphyxia as heart rate <100/min.


The UCMV had the highest neonatal RCV as a percentage of fetoplacental volume compared to the other groups (UCMV 85.5 ± 10%, UCM 72 ± 10%, ECCV 65 ± 14%, DCCV 61 ± 10%, p < 0.01). The DCCV led to better ventilation (66 ± 1 mmHg) and higher pulmonary blood flow (75 ± 24 ml/kg/min). The carotid flow was significantly higher in UCM without ventilation. The fluctuations in carotid flow with milking were 25 ± 6% higher from baseline during UCM, compared to 6 ± 3% in UCMV (p < 0.01).


Cord milking with ventilation led to higher RCV than other interventions. Ventilation during cord milking reduced fluctuation in carotid flow compared to UCM alone. DCCV led to better ventilation and pulmonary blood flow but did not increase RCV.


  • The best practice of placental transfusion in a depressed preterm neonate remains unknown.

  • Ventilation with an intact cord improves gas exchange and hemodynamics in an asphyxiated preterm model.

  • Cord milking without ventilation led to lower red cell volume but higher carotid blood flow fluctuations compared to milking with ventilation.

  • Our data can be translated to bedside and could impact preterm resuscitation.

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Fig. 1: The heart rate, placental volume, and oxygen use are depicted in this figure.
Fig. 2: Arterial blood gas results from asphyxia to 5 min in the four groups of lambs.
Fig. 3: The line graph represents the four groups: square—ECCV, circle—DCCV, triangle—UCMV, diamond—UCM.
Fig. 4: Representative hemodynamic chart (from BIOPAC snapshot) with umbilical, carotid, and pulmonary blood flows.
Fig. 5: The bar graph represents the percentage fluctuation during the four milks from the baseline blood flow.
Fig. 6: Graphic summary showing a speculative mechanism for hemodynamic changes when umbilical cord milking is performed with ventilation.

Data availability

Data presented in this manuscript will be available after complete analysis (2-hour data) is done on request.


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This work was financially supported by R01HD104909, R03HD096510, K12 HL138052, AAP NRP grant, Zoll Foundation grant, and University at Buffalo—Dr. Henry C. and Bertha H. Buswell Grant to P.C.; R03HD104062 to M.R.; and R01HD072929 to S.L.

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Authors and Affiliations



P.C.—conceptualization, methodology, data acquisition and analysis, interpretation, writing—original draft, critically reviewing, and editing. S.G., C.K., J.H., L.N., N.B., J.N., D.S., M.B., M.R.—data acquisition, extraction, critical reviewing, and manuscript editing. S.L.—methodology, data interpretation, critically reviewing, editing, and provided illustration. All authors approved the final version for publication.

Corresponding author

Correspondence to Praveen Chandrasekharan.

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Competing interests

S.L. is a neonatal resuscitation program steering committee member. All other authors report no conflicts of interest. The research reported here is not endorsed by the funding institutions or the neonatal resuscitation program.

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Chandrasekharan, P., Gugino, S., Koenigsknecht, C. et al. Placental transfusion during neonatal resuscitation in an asphyxiated preterm model. Pediatr Res 92, 678–684 (2022).

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