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6/17/20171

Delayed cord clamping: Not just for preemies

6/17/2017

Kate Norman Frmeta, MS, CNMAssistant Professor, UCSF Division of Maternal-Fetal

Medicine

Nothing to disclose (kind of)

No financial ties Studied with Judith Mercer

*Drop the scissors*

Delayed cord clamping: Not just for preemies2

Do You Intentionally Delay Cord Clamping in Term Neonates?

A. Yes

B. No

6/17/2017Presentation Title and/or Sub Brand Name Here3Y e

s N o7%

93%

If You Delay, How Long Do You Delay?A. 3 minsD. Until the cord stops pulsing

6/17/2017Presentation Title and/or Sub Brand Name Here4

< 1 m i n

u t e1 - 3

m in u t

e s> 3

m in s

U n ti l t h

e c or d s

t o ps p .

. .

13%

42%

5%

40%


6/17/20172

Cord Clamping through time Traditionally the cord was not cut until after the delivery of the placenta First accounts of cutting the cord before delivery of the placenta from

the 17th century

Birthing in bed


The cord, when it has ceased to pulsate be placed between the blades

First cord clamp: 1899 Magennis

cord clamp

Why Delay Cord Clamping?

Why Not???

What is the intervention?

Now in the position of finding evidence to justify our non-interventionwhen the intervention was never justified

Consent for an intervention with ICC? Placental transfusion

Volume of blood that remains in the placenta Immediate: 30% 60 seconds: 20% 3 minutes: 13%


6/17/20173


Where does the blood go? Newborn lung circulation:~10% in utero to ~50% ex utero

Also better perfusion, less hypothermia

fetal heart pumps:

In utero 110ml/k

Ex utero 90ml/k

Why Delay Cord Clamping? Preterm:

-improved blood pressure, increased cerebral oxygen index, reduced number of blood transfusions, less need for inotropic support, lower risk of necrotizing enterocolitis, nearly twofold reduction in risk for intracranial hemorrhage of all types

(ACOG recommended delay in 2012)

Rabe, Diaz-Rossello, Duley, & Dowswell, 2012


Why Delay Cord Clamping?Term:

Up to 30% increase in blood volume

Less Anemia Higher hemoglobin levels at 24 to 48 hours of age increased serum ferritin levels (23-45% higher) at 4 to 6 months. Infants with ICC were twice as likely to be iron deficient at 3 to 6

months.

Results more pronounced in infants of anemic mothers Anemia reduced by 40% at 4 mos and 60% 8 mos.

Blouin, 2013, McDonald et al, 2013


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Why Do We Care About Iron Deficiency? Iron: essential for normal neurogenesis, differentiation of brain cells, brain

metabolism, neurotransmitter function, oligodendrogenesis, and myelination

Anemia: Reduced arborization of dendrites that decrease the complexity ofinterneural connections

Infants with DCC have increased myelin content at 4 month of age in brainregions associated with motor, visual and sensory processing/functioncompared with ICC.

Beard & Connor 2003; Brunette & Tran et al 2010; Georgieff & Rao 2011


Why Do We Care About Iron Deficiency?

Iron deficiency in infancy associated with :

poor school performance,decreased cognitive abilities,less positive affectmore difficult to soothereduced level of engagement with examiners.lower IQs (more pronounced in lower

socioeconomic groups)

less favorable neurodevelopmental outcomesbehavioral problems out to 19 years of age.

*Even after correction*Lozoff et al, 2006; Lozoff et al, 2008; Lozoff et al 2010; Burden et al 2004; Pierano et al, 2010

Why do we care about Iron Deficiency? Anemia in the US: Anemia among participants in federally funded mat-child health and

nutrition programs (2010 data)

33.8% of all mothers

49.5% of all Non-Hispanic African-American mothers

By 6-12 mos 18% of all infants and 23.5% of AA were anemic.

Large state-to-state disparities as well.

Maternal anemia rates are higher than any region outside of Africa.

Dalenius, Brindley, Smith, Reinold, & Grummer-Strawn, 2012


Stem Cells! 10x the amount of bone marrow Neuroprotection

Cotton et al (2014)

-Autologous stem cell transfusion in babies being head-cooled

>85 on Bayley scale: 74% transfused babies

41% control group


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Lack of Harm since 1980, NO published, randomized controlled trial has supported a

relationship between DCC and symptomatic polycythemia orhyperbilirubinemia.


No difference (Term)Maternal

PP hemorrhage Mean blood loss Hgb pp Retained placenta Blood transfusions Duration of 3rd stage Need for uterotonicsMcDonald et al, 2013, Hutton and Hassan, 2007


Neonatal

Apgars, need for resuscitation NICU admission Cord pH respiratory distress Clinical jaundice (no treatment) Polycythemia requiring treatment

Jaundice Requiring Treatment MacDonald and Middleton systematic review (Cochrane) included

weighted results of data from an unpublished dissertation from 1996for the outcome of bili light use.

2.7% increase in bili light use.


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Why Delay Cord Clamping at Term? Because your professional Organization told you to: WHO 2006, 2012, 2014 (1-3 mins) ACNM 2014 (2 mins below introitus, 5 mins skin- to-skin) ACOG 2016 (at least 30-60 secs) NICE 2012 (at least 60 secs) FIGO/ICM 2003 (until pulsations cease - include 1-3 mins of DCC in

AMTSL guidelines)

NRP 2015 (30-60 seconds in vigorous term and preterm infants)

Why Delay Cord Clamping? Because the family told you to


How Long to Delay? Until the cord stops pulsing

Study of 15 infants during DCC using doppler u/s

Stopping of pulsations not correlated with stopping of blood flow.

Venous blood flowed for a median of 4.5 mins in 57% of infants andwas still flowing at 5.25 mins in 33% of infants

Boere et al, 2014


How long to Delay?

Time to cord clamping was varied in studies anywhere from 1 -10 mins

Full transfusion by about 3 mins if below level of placenta but if skin-to-skin may take closer to 5 mins to get full transfusion



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Position of the Neonate Residual Placental Blood Volume (PRBV)with Skin-To-Skin Placement

ICC

DCC x 2

DCC x 5

CM

PRBV ml/kg

Erickson-Owens, Mercer & Thulier, 2012

181125

35

How long to Delay?At least 3 minutes at the perineum

At least 5 minutes on maternal abdomen

Wait for white

Delayed cord clamping: Not just for preemies27 Delayed cord clamping: Not just for preemies28


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Cord Milking A technique used to

accelerate placentaltransfusion when theclinical situationdoesnt allow time forDCC


Cord Milking Use when time and speed are a factor Lower infant and milk cord 4 to 5 times (wait for cord to refill if

possible)

In term and preterm studies results same as DCC Higher H & H, better blood pressure

Higher ferritin levels at 6 weeks to 6 months

No increase in jaundice or symptomatic polycythemia


Barriers to change Tight Nuchal Cord Cord gases AMSTL Cord blood banking

TRADITION Sit on your hands

? Resus


Cord Blood Banking

ACOG Committee Opinion #399 (2008)collection should not alter routine practice for the timing of umbilical cord clamping

Babies arent allowed to be

blood donors!Delayed cord clamping: Not just for preemies32


6/17/20179

Take Home Messages

ICC is an interventionwithout any rationale or evidence to support it.

No longer not enoughevidence to justify

delayed cord clamping.

Delayed cord clamping: Not just for preemies33 Delayed cord clamping: Not just for preemies34


Special thanks to Judith Bishop, CNM and Judy Mercer, CNM

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