Procedures
EPP, RECRUITMENT, STERILE, ALD, UTERUS
Infants randomized to the control group (DCC) were born by cesarean delivery, placed in a sterile plastic suit (NeoHelp, Vygon), and gently stimulated by rubbing the back or feet if apneic until breathing commenced. Infants were held at placental level during the DCC procedure (eFigure in Infants randomized to the intervention group (EPP) were born by cesarean delivery with gentle detaching of the placenta from the uterus along with the infant and intact umbilical cord. All involved obstetricians and surgical staff (including B.G.) were experienced in this technique. After delivery, infants with the placenta still attached were placed in a sterile plastic suit by the obstetrician. The time to detach the placenta in the EPP cohort was not recorded but comprised only a few seconds. While mothers received oxytocin directly after delivery of the placenta, infants were immediately transferred to the resuscitation unit, where the neonatal staff (including B.K., A.K., and A.O.) resuscitated the infant according to the same protocol as described in control group. The placenta was placed in a bowl, covered with a sterile plastic bag, and held 40 to 50 cm above the babies’ heart level while lung recruitment by respiratory support was performed (eFigure in Placental weight was measured immediately after initiation of neonatal resuscitation and after umbilical cord clamping. Furthermore, onset of breathing or first crying and time from delivery until clamping of the umbilical cord were recorded in the intervention group.Oxygen saturation as measured by pulse oximetry (SpoWhen possible, a New Life Box ALD resuscitation monitor (Advanced Life Diagnostics) additionally recorded respiratory rate, airway pressure, and tidal volume in both groups during neonatal resuscitation. In all twin births, only the second newborn was randomized to the control or intervention group, while the firstborn was always intended to have a DCC of at least 30 seconds.