Experience with physiological based cord clamping is associated with increased effect size: a post-hoc analysis of the ABC3 trial

the ABC3 Research Group

doi:10.1016/j.resuscitation.2025.110921

Experience with physiological based cord clamping is associated with increased effect size: a post-hoc analysis of the ABC3 trial

the ABC3 Research Group

Research output: Contribution to Journal › Article › Academic › peer-review

Abstract

Background: A preplanned exploratory analysis of the ABC3 trial, performed in all 10 NICU centres in the Netherlands, evaluating the effect of physiological-based cord clamping (PBCC) on intact survival in very preterm infants, found a positive association between intact survival and experience with the PBCC approach.

Objective: To evaluate the effect of PBCC on intact survival in preterm infants in centres with more experience with PBCC and in centres with less experience.

Methods: A post-hoc secondary analysis was performed. Experienced and less experienced centres participating in the ABC3 trial included 669 infants born before 30 weeks of gestation, who were randomized to stabilization with intact cord and clamping after reaching cardiorespiratory stability (PBCC) or clamping after 30–60 s followed by stabilization (time-based delayed cord clamping (TBCC)). Centres were defined as “experienced” when: (1) caregivers were trained in the PBCC approach with evaluation of video and RFM recording; (2) experience in previous studies; (3) early initiation of ABC3 and (4) ≥20 % of inclusions. The primary outcome was intact survival (survival without major cerebral injury and/or necrotizing enterocolitis (NEC)). Outcomes were adjusted for differences in baseline characteristics.

Results: Two centres were classified as “experienced” and the other eight as “less-experienced”, and included 43.1 % and 56.9 % of infants respectively. In experienced centres, intact survival was higher after PBCC compared with TBCC (72 % vs. 59 %; aOR 1.93 (95 %CI 1.73–2.17, P < 0.001)), with lower mortality (10 % vs. 20 %; aOR 0.40 (95 % CI 0.25–0.63, P < 0.001)). In less experienced centres, intact survival was not different (72 % vs. 75 %; aOR 0.94 (95 % CI 0.64–1.39, P = 0.93)), with higher mortality (16 % vs. 9.1 %; aOR 1.92 (95 % CI 1.05–3.50, P = 0.03)).

Conclusions: PBCC was associated with increased intact survival in centres that had more previous experience and exposure to PBCC, but not in centres with less experience. We recommend that the effect of experience and training for new approaches should be taken into consideration in future studies on PBCC.

Original language	English
Article number	110921
Number of pages	9
Journal	Resuscitation
Volume	219
Early online date	17 Dec 2025
DOIs	https://doi.org/10.1016/j.resuscitation.2025.110921
Publication status	Published - Feb 2026

Bibliographical note

Publisher Copyright:
© 2025 The Author(s)

Funding

The trial was funded by The Netherlands Organization for Health Research and Development (project number 852001902). RK received a grant from the Sophia Children's Hospital Foundation (Rotterdam, S17-14)). None had a role in trial design, data collection, analysis, writing of the manuscript or the decision to submit for publication. ABC3 Research Group, Emma Brouwer2, Anton H. van Kaam7,8, Enrico Lopriore2, Irwin K.M. Reiss1, Esther J. d'Haens10, Helene A. Bouma11, Hendrik J. Niemarkt12, Tinta Lebon13, Debbie H. Nuytemans7, Graeme R. Polglase6,16, Sylke J. Steggerda2, 1Division of Neonatology, Department of Neonatal and Pediatric Intensive Care, Sophia Children's Hospital, Erasmus MC University Medical Centre, Rotterdam, The Netherlands, 2Division of Neonatology, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands, 6The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia, 7Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, 8Amsterdam Reproduction & Development, Amsterdam, the Netherlands, 10Department of Neonatology, Isala Women and Children's Hospital, Zwolle, The Netherlands, 11Department of Pediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, The Netherlands, 12Department of Pediatrics, Maxima Medical Centre, Veldhoven, The Netherlands, 13Department of Pediatrics, Maastricht University Medical Centre, Maastricht, The Netherlands, 16Department of Paediatrics, Monash University, Clayton, Victoria, Australia The trial was funded by The Netherlands Organization for Health Research and Development (project number 852001902 ). RK received a grant from the Sophia Children’s Hospital Foundation (Rotterdam, S17-14 )). None had a role in trial design, data collection, analysis, writing of the manuscript or the decision to submit for publication.

Funders	Funder number
6The Ritchie Centre
Department of Neonatal and Pediatric Intensive Care
Leids Universitair Medisch Centrum
Isala Women and Children's Hospital
Hudson Institute of Medical Research
Sophia Children's Hospital Foundation
Monash University
10Department of Neonatology
Erasmus MC University Medical Centre
Sophia Children's Hospital
ZonMw	852001902
Sophia Children’s Hospital Foundation	S17-14

Keywords

Experience
Premature infant
Umbilical cord clamping

Access to Document

10.1016/j.resuscitation.2025.110921

Persistent URL (handle)

Persistent link

Cite this

@article{f2d12fb83c5c4cbc91425c8c983f0066,

title = "Experience with physiological based cord clamping is associated with increased effect size: a post-hoc analysis of the ABC3 trial",

abstract = "Background: A preplanned exploratory analysis of the ABC3 trial, performed in all 10 NICU centres in the Netherlands, evaluating the effect of physiological-based cord clamping (PBCC) on intact survival in very preterm infants, found a positive association between intact survival and experience with the PBCC approach. Objective: To evaluate the effect of PBCC on intact survival in preterm infants in centres with more experience with PBCC and in centres with less experience. Methods: A post-hoc secondary analysis was performed. Experienced and less experienced centres participating in the ABC3 trial included 669 infants born before 30 weeks of gestation, who were randomized to stabilization with intact cord and clamping after reaching cardiorespiratory stability (PBCC) or clamping after 30–60 s followed by stabilization (time-based delayed cord clamping (TBCC)). Centres were defined as “experienced” when: (1) caregivers were trained in the PBCC approach with evaluation of video and RFM recording; (2) experience in previous studies; (3) early initiation of ABC3 and (4) ≥20 \% of inclusions. The primary outcome was intact survival (survival without major cerebral injury and/or necrotizing enterocolitis (NEC)). Outcomes were adjusted for differences in baseline characteristics. Results: Two centres were classified as “experienced” and the other eight as “less-experienced”, and included 43.1 \% and 56.9 \% of infants respectively. In experienced centres, intact survival was higher after PBCC compared with TBCC (72 \% vs. 59 \%; aOR 1.93 (95 \%CI 1.73–2.17, P < 0.001)), with lower mortality (10 \% vs. 20 \%; aOR 0.40 (95 \% CI 0.25–0.63, P < 0.001)). In less experienced centres, intact survival was not different (72 \% vs. 75 \%; aOR 0.94 (95 \% CI 0.64–1.39, P = 0.93)), with higher mortality (16 \% vs. 9.1 \%; aOR 1.92 (95 \% CI 1.05–3.50, P = 0.03)). Conclusions: PBCC was associated with increased intact survival in centres that had more previous experience and exposure to PBCC, but not in centres with less experience. We recommend that the effect of experience and training for new approaches should be taken into consideration in future studies on PBCC.",

keywords = "Experience, Premature infant, Umbilical cord clamping",

author = "Ronny Knol and Vermeulen, \{Marijn J.\} and \{de Boode\}, \{Willem P.\} and Hutten, \{G. Jeroen\} and Prins, \{Sandra A.\} and Mulder, \{Estelle E.M.\} and Hulzebos, \{Christian V.\} and \{van Sambeeck\}, \{Sam J.\} and \{van der Putten\}, \{Mayke E.\} and Zonnenberg, \{Inge A.\} and Willemsen, \{Sten P.\} and \{van den Akker\}, Thomas and DeKoninck, \{Philip L.J.\} and Hooper, \{Stuart B.\} and \{te Pas\}, \{Arjan B.\} and \{the ABC3 Research Group\}",

note = "Publisher Copyright: {\textcopyright} 2025 The Author(s)",

year = "2026",

month = feb,

doi = "10.1016/j.resuscitation.2025.110921",

language = "English",

volume = "219",

journal = "Resuscitation",

issn = "0300-9572",

publisher = "Elsevier Ireland Ltd",

}

TY - JOUR

T1 - Experience with physiological based cord clamping is associated with increased effect size

T2 - a post-hoc analysis of the ABC3 trial

AU - Knol, Ronny

AU - Vermeulen, Marijn J.

AU - de Boode, Willem P.

AU - Hutten, G. Jeroen

AU - Prins, Sandra A.

AU - Mulder, Estelle E.M.

AU - Hulzebos, Christian V.

AU - van Sambeeck, Sam J.

AU - van der Putten, Mayke E.

AU - Zonnenberg, Inge A.

AU - Willemsen, Sten P.

AU - van den Akker, Thomas

AU - DeKoninck, Philip L.J.

AU - Hooper, Stuart B.

AU - te Pas, Arjan B.

AU - the ABC3 Research Group

PY - 2026/2

Y1 - 2026/2

N2 - Background: A preplanned exploratory analysis of the ABC3 trial, performed in all 10 NICU centres in the Netherlands, evaluating the effect of physiological-based cord clamping (PBCC) on intact survival in very preterm infants, found a positive association between intact survival and experience with the PBCC approach. Objective: To evaluate the effect of PBCC on intact survival in preterm infants in centres with more experience with PBCC and in centres with less experience. Methods: A post-hoc secondary analysis was performed. Experienced and less experienced centres participating in the ABC3 trial included 669 infants born before 30 weeks of gestation, who were randomized to stabilization with intact cord and clamping after reaching cardiorespiratory stability (PBCC) or clamping after 30–60 s followed by stabilization (time-based delayed cord clamping (TBCC)). Centres were defined as “experienced” when: (1) caregivers were trained in the PBCC approach with evaluation of video and RFM recording; (2) experience in previous studies; (3) early initiation of ABC3 and (4) ≥20 % of inclusions. The primary outcome was intact survival (survival without major cerebral injury and/or necrotizing enterocolitis (NEC)). Outcomes were adjusted for differences in baseline characteristics. Results: Two centres were classified as “experienced” and the other eight as “less-experienced”, and included 43.1 % and 56.9 % of infants respectively. In experienced centres, intact survival was higher after PBCC compared with TBCC (72 % vs. 59 %; aOR 1.93 (95 %CI 1.73–2.17, P < 0.001)), with lower mortality (10 % vs. 20 %; aOR 0.40 (95 % CI 0.25–0.63, P < 0.001)). In less experienced centres, intact survival was not different (72 % vs. 75 %; aOR 0.94 (95 % CI 0.64–1.39, P = 0.93)), with higher mortality (16 % vs. 9.1 %; aOR 1.92 (95 % CI 1.05–3.50, P = 0.03)). Conclusions: PBCC was associated with increased intact survival in centres that had more previous experience and exposure to PBCC, but not in centres with less experience. We recommend that the effect of experience and training for new approaches should be taken into consideration in future studies on PBCC.

AB - Background: A preplanned exploratory analysis of the ABC3 trial, performed in all 10 NICU centres in the Netherlands, evaluating the effect of physiological-based cord clamping (PBCC) on intact survival in very preterm infants, found a positive association between intact survival and experience with the PBCC approach. Objective: To evaluate the effect of PBCC on intact survival in preterm infants in centres with more experience with PBCC and in centres with less experience. Methods: A post-hoc secondary analysis was performed. Experienced and less experienced centres participating in the ABC3 trial included 669 infants born before 30 weeks of gestation, who were randomized to stabilization with intact cord and clamping after reaching cardiorespiratory stability (PBCC) or clamping after 30–60 s followed by stabilization (time-based delayed cord clamping (TBCC)). Centres were defined as “experienced” when: (1) caregivers were trained in the PBCC approach with evaluation of video and RFM recording; (2) experience in previous studies; (3) early initiation of ABC3 and (4) ≥20 % of inclusions. The primary outcome was intact survival (survival without major cerebral injury and/or necrotizing enterocolitis (NEC)). Outcomes were adjusted for differences in baseline characteristics. Results: Two centres were classified as “experienced” and the other eight as “less-experienced”, and included 43.1 % and 56.9 % of infants respectively. In experienced centres, intact survival was higher after PBCC compared with TBCC (72 % vs. 59 %; aOR 1.93 (95 %CI 1.73–2.17, P < 0.001)), with lower mortality (10 % vs. 20 %; aOR 0.40 (95 % CI 0.25–0.63, P < 0.001)). In less experienced centres, intact survival was not different (72 % vs. 75 %; aOR 0.94 (95 % CI 0.64–1.39, P = 0.93)), with higher mortality (16 % vs. 9.1 %; aOR 1.92 (95 % CI 1.05–3.50, P = 0.03)). Conclusions: PBCC was associated with increased intact survival in centres that had more previous experience and exposure to PBCC, but not in centres with less experience. We recommend that the effect of experience and training for new approaches should be taken into consideration in future studies on PBCC.

KW - Experience

KW - Premature infant

KW - Umbilical cord clamping

UR - https://www.scopus.com/pages/publications/105025804309

UR - https://www.scopus.com/pages/publications/105025804309#tab=citedBy

U2 - 10.1016/j.resuscitation.2025.110921

DO - 10.1016/j.resuscitation.2025.110921

M3 - Article

C2 - 41419025

AN - SCOPUS:105025804309

SN - 0300-9572

VL - 219

JO - Resuscitation

JF - Resuscitation

M1 - 110921

ER -

Experience with physiological based cord clamping is associated with increased effect size: a post-hoc analysis of the ABC3 trial

Abstract

Bibliographical note

Funding

Keywords

Access to Document

Persistent URL (handle)

Other files and links

Fingerprint

Cite this