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GYNZONE 2016 SYMPOSIUM OM NORMALE FØDSLER

ELISABETH SÆTHER

Cord clamping practices – beneficial for the newborn?

History“Another thing very injurious to the

child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases.  As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child.”

Erasmus Darwin, �Zoonomia, 1801

History�  1950: Pain relief (morphine) in labour gives

compromised newborns in need of resuscitation�  Shortly after: Early cord clamping becomes the

norm in many western countries�  1970: Active management of labour�  2000: Implementation of STAN-technology�  Fear of litigation prompts documentation of

blood-gases in all labours

History

Photo from Kvinneklinikken, Haukeland hospital in Norway, around 1960

Demonstrates invention of new euipment to clamp the cord

Definitions�  Immediate cord clamping

(ICC)¡  Umbilical cord is clamped

in the moment the baby is born

�  Early cord clamping (ECC):¡  Umbilical cord is clamped

before 30 sec after baby is born, or before onset of respiration

Definitions

�  Delayed cord clamping (DCC):¡  Umbilical cor is clamped after 2-3 minutes or after the

pulsation has ceased and the cord is floppy and white.

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Definitions�  Physiologic cord

clamping (PhCC)¡  Umbilical cord is cut after

placenta is born

�  LOTUS birth¡  The placenta is attached

to the baby until the cord is dry and falls off

The role of the placentaKeeps the baby alive…

Produces important hormones to support pregnancy

Facilitates gas exchange and thermo-regulation

Transports oxygen and nutritients to all organs

Transports carbon dioxide and waste-products away from the baby

Protects the baby against infections

…..until the baby is born and respiration is well stablished

Photo: www.regatta.no

Neonatal transition = transition from intra- to extrauterine life

Older medical and midwifery textbooks emphasizes:�  Physiologic 3rd phase�  Support / stimulate the

natural process �  Minimum intervention�  Placenta has

resuscitating abilities�  The process is individual

WHO 2012: NICE 2014:�  In newly-born term or

preterm babies who do not require positive-pressure ventilation, the cord should not be clamped earlier than one minute after birth

�  Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.

�   Do not clamp the cord earlier than 1 minute… unless there is concern about the integrity of the cord or the baby has a heartbeat below 60 beats/minute that is not getting faster.

�  Clamp the cord before 5 minutes in order to perform controlled cord traction as part of active management.

�  If the woman requests that the cord is clamped and cut later than 5 minutes, support her in her choice. [new 2014]

Current guidelines

Current guidelines

Helsebiblioteket (Norway):�  DCC (1–3 min) is recommended for all births (incl CS

and premature) while providing essential care for the newborn

�  ECC (< 1 min) is not recommended unless the newborn must be moved for intensive resuscitation. When positive pressure ventilation is needed, this can be initiated before cord clamping, provided that personell and equipment are available near the infant (mother)

�  Cord clamping must be performed aseptic in order to avoid infection. Double-clamp the cord and cut 2–3 cm from the skin, and apply rubber band

http://www.helsebiblioteket.no/fagprosedyrer/ferdige/avnavling-av-nyfodte

Benefits - DCC at term:Results in:

÷  45% increase in Se-ferritin / improved iron status

÷  Reduced prevalence of irondeficiency at 4 months (1 vs 10)

÷  Reduced prevalence of neonatal aanemia (2 vs 10)

÷  Improved fine motor skills at age 4

Iron deficiency is associated with:

÷  Poor cognitive development÷  Behavioral problems, autism and

ADHD÷  Iron supplement not always

helpful

Ref: Andersson O 2011 / 2015, Berglund S 2012.

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Benefits - DCC preemies:

Reduced prevalence of:÷ Intraventricula hemorrhage÷ Neonatal sepsis (esp.boys)÷ Necrotising enterocolitis (NEC)÷ Respiratory distress syndrome (RDS)

Improved circulatory stability and cerebral perfusion Reduced need for blood transfusionsFewer days on respirator

Kilder: Rabe H et.al 2012, Mercer JS et al. 2006, Mercer JS et al. 2010.

Blood transfer – time and amount

Yao AC et.al: Distribution of blood between the infant and the placenta after birth. Lancet 1969;2:871-3.

Blood transfer – time and amount

�  Cord clamping after cease of pulsation gives:¡  116g higher birth weight¡  110ml higher blood volume¡  Increased blood volume by 32 ml / kg birth weight¡  21-23 ml placentall residual volume

�  Amount of blood transferred by DCC accounts for 25-20% of potential blood volume at birth regardless of delivery method

Farrar D, Airey R, Law G, Tuffnell D, Cattle B, Duley L. Measuring placental transfusion for term births: weighing babies with cord intact. BJOG 2011;118:70–75.

Blood volume and gestational age

�  Total circulating blood volume in fetus, cord and placenta is 110-115 ml/kg�  GA 30 weeks:

50% in placenta�  GA 40 weeks:

30% in placenta

Linderkamp OL: Placental transfusion; determinants and effects. Clin Perinatol 1982;9:559-92Wardrop C and Holland B: The roles and vital importance of placental blood to the newborn infant. J Perinat Med 1995;23:139-43

ICC / ECC = 30-50% blood loss�

Newborns lose:�  Blood volume �  Blood pressure�  Erytrocytes �  Oxygen �  Stem cells�  Iron�  Nutritients�  Gentle transition

DCC - high priority

Infants subject to hypoxia / aspyxia¡  Umbilical cord compression¡  Shoulder dystocia¡  Instrumental deliveries ¡  Breech

Premature infants¡  50% of baby´s blood is still in the placenta ¡  Extra vulnerable when oxygen delivery is compromised ¡  Resuscitation measures might harm

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Cord blood donation / banking?

DCC – the baby´s first stem cell transplant¡  Stem cells may have important protective, preventive and

repairative functions, not only for the infant, but also later on in life

¡  ACOG: "The routine storage of umbilical cord blood as “biologic insurance” against future disease is not recommended.”

Ethical issue – the newborn as a blood donor?¡  No adult is allowed to donate more than 10%¡  ICC results in donations of 20-30%¡  Children in other settings are not allowed to donate¡  Informed consent?

CORD BLOOD IS BABY BLOOD – DO NO HARM!

New research

�  During DCC: venous and arterial umbilical flow occurs for longer than previously described and is unrelated to cessation of pulsations

�  Placental transfusion: Complex and dependant upon several factors, including breathing, and whether venous and/or arterial flow is still present

Boere I, et al. Arch Dis Child Fetal Neonatal Ed 2015;100:F121–F125. doi:10.1136/archdischild-2014-307144Hooper, SB et al. Arch Dis Child Fetal Neonatal Ed 2015;100:F355-F360 A physiological approach to the timing of umbilical cord clamping at birth

New research

�  Cord clamping after onset of respiration results in significantly better cardio-vascular stability

�  Await umbilical cord clamping until onset of

respiration and the cord is floppy and white

Bhatt S et al.2013 / 2014, Niermeyer S, Velaphi S. 2013, Hutcon DJR. 2015

Paradigm shift?

“That is, instead of delaying cord clamping for a set period of time, these studies indicate that the timing of cord clamping should be based on the infant’s physiology rather than an arbitrary period of time.”

Bhatt S et al. (2014) Ventilation before umbilical cord clamping improves the physiological transition at birth. Front. Pediatr. 2:113. doi: 10.3389/fped.2014.00113

Paradigm shift?

“Indeed, one of the commonest reasons for why umbilical cords are hastily clamped at birth is to initiate respiratory support. However, it could be argued that these infants would receive the greatest benefit if the respiratory support was provided while the umbilical cord remained attached to the placenta”

Bhatt S, Polglase GR, Wallace EM, te Pas AB, Hooper SB. Ventilation before Umbilical Cord Clamping

Improves the Physiological Transition at Birth. Frontiers in Pediatrics. 2014;2:113

Paradigm shift?

“Current recommendations for resuscitation may fail to achieve timely lung aeration in infants born at the borderline of viability, leading to higher mortality and morbidity. Sustained inflation and delayed cord clamping may be effective alternatives”

Lamberska et al (2016): Premature infants born at <25 weeks of gestation may be compromised by currently recommended resuscitation techniques.

Acta Paediatr, 105: e142–e150.

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Implication for the future

”Separation of the vast majority of babies from their mothers at birth is no longer acceptable. The common justification for separation at birth is the need for resuscitation. This can however be readily provided at the side of the mother with the placental and cord circulation intact using specially designed equipment”

LifeStart system

D. Hutchon & N.Bettles 2016

Implication for the future

”Ambubag and mask is usually all that is necessary to start a baby breathing. Providing ventilation of the baby with the cord intact while it lies between the legs of the mother on a clean flat surface on the floor is the obvious low tech solution”

D. Hutchon & N.Bettles 2016

DONO

HARM!

On behalf of generations to

come:

Further readings

Scandinavian resources:�  https://www.facebook.com/SenAvnavling/�  https://www.facebook.com/groups/98718282961/?fref=ts�  http://www.helsebiblioteket.no/fagprosedyrer/ferdige/

avnavling-av-nyfodteInternational resources:�  http://www.cordclamping.org/�  http://www.bloodtobaby.com/�  https://www.facebook.com/Optimal-Cord-Clamping-

WaitforWhite-414578291919270/?fref=ts�  http://cordclamping.info/publications/publications.htm�  https://www.facebook.com/delayedcordclamping/?fref=ts