Umbilical Cord Clamping

Katherine Weiss, MDObstetrix Medical Group

Clinical Neonatologist

https://www.placentanetwork.com/your-placenta/delay-cord-clamping/

DISCLOSURE STATEMENTS

Katherine Weiss, MDI have no relevant financial relationships to disclose or conflicts of

interest to resolve.

I will not discuss any unapproved or off-label, experimental or investigational use of a product, drug or device.

OBJECTIVES

Be aware of the history and media coverage of umbilical cord clamping

Understand the physiology of cord clampingBe able to discuss the advantages and disadvantages of delayed

cord clamping and umbilical cord milking for term and preterm infants

Be able to define the current recommendations from major professional organizations on delayed cord clamping

Be able to define the knowledge gaps for delayed cord clamping and umbilical cord milking

HISTORY OF CORD CLAMPING

GREEKS: In the time of Hippocrates the cord was not cut until the placenta was deliveredAt first view the conduct of the ancients appears to be more rational and more physiological than that of the modernsit seems that the placenta ought immediately to follow the foetus, or at least be separated from the uterus before the cord

can be prudently cut; that before it is divided, the circulation ought to be permitted gradually to take on its new type, which soon becomes similar to that of the adult;

Prof. A.A. Velpeau, 1829 (Treatise on Midwifery)

1950s:Early clamping (within 1 minute of birth), late clamping (greater than 5 minutes)

*Delaying clamping less common as studies came out showing that >90% infant blood volume achieved with first few breaths*Virginia APGAR & maternal anesthesia crossing the placenta with delayed clamping; DCC = “slow delivery”

*Erythroblastosis fetalis- prevent “excessive amounts of (maternal) antibody containing blood” into infant

General consensus of all: No inconvenience (and perhaps of benefit) to infant to cut cord early and better for the mother*1960s – Data showing marked bradycardia in term infants with immediate cord clamping (no changes made)

wellroundedmama.blogspot.com

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https://www.pinterest.com/hmbirth/delayed-cord-clamping

CORD CLAMPING IN THE NEWS!!!

NPR 5/26/15 “Delayed Umbilical Cord Clamping May Benefit Children Years Later”

*Children whose cords were cut more than three minutes after birth had slightly higher social skills and fine motor skills than those whose cords were cut within 10 seconds

CNN 5/30/15 “The great umbilical cord-cutting debate”*Medical studies show the positive effect of cord clamping (including one noted

above)*WHO recommends delayed cord clamping between 1-3 minutes after birth*ACOG says most umbilical cords are cut between 15-20 seconds after birth*Andersson, et al. Effect of Delayed Cord Clamping on Neurodevelopment at 4 years of age. JAMA Pediatrics. 2015;169(7):631-638.

PHYSIOLOGY OF CORD CLAMPING

http://www.slideshare.net/Rekhankl/fetal-circulation-32816216

PHYSIOLOGY OF CORD CLAMPING

Transition of blood flow from placenta to infant’s lungs Infant breathes → decrease pulmonary vascular resistance →

increase blood flow to left side heart and increase systemic blood flow

Increased preload helps in this process → more blood from placenta increases and aids in overflow of blood from placenta to lungs to body

Less preload or cutting umbilical cord too early → Pulmonary vascular resistance (PVR) remains high as less blood flow through lungs while systemic BP rises as lose placental circuit→ hypoxia, pulmonary hypertension, decreased cardiac output

LAMB STUDY: PHYSIOLOGY OF DELAYED UMBILICALCORD CLAMPING (UCC) & VENTILATION

Preterm lambs Delayed cord clamping 2-3

minutes Ventilate during UCC and 30

minutes after Measure pulmonary, carotid,

umbilical artery and venous blood flow with catheters/flow probes

https://s-media-cache-ak0.pinimg.com/736x/30/7c/31/307c31cb43c48b1713f8ad27b1be4c30.jpg

LAMB STUDY: PHYSIOLOGY OF DELAYED UMBILICALCORD CLAMPING (UCC) & VENTILATION

Blood flow UCC significantly increased mean, peak systolic and end-diastolic arterial blood pressure (carotid) and heart rate

Breathinginitiation of ventilation has a greater influence on umbilical and cardiovascular blood pressures and flows than changing body position (above or below introitus) Increases pulmonary blood flow, decreases PVR

Cerebral blood flow & oxygenation Clamping prior to ventilation: Doubling of cerebral blood flow (CBF) that

then returned to baseline with ventilation Clamping after ventilation: prevented major increase in CBF and

prevented any fall in cerebral oxygenation (less sudden change in cerebral pressure/flow; perhaps why less IVH)

UMBILICAL FLOW PATTERNS, CORD CLAMPING ANDBREATHING

Measured umbilical artery and venous flow patterns in term spontaneous vaginal delivery with Doppler ultrasound during DCC (at least >60 sec), Boere, Arch Dis Child Fetal Neonatal Ed 2015

Net placental transfusion is complex Breathing (major role)

Intermittent flow initially – increased significantly with large breaths, stopped/reversed flow with crying

Continuous flow to infant once more regular breathing pattern set Oxytocin Gravity – less of a factor, does not seem to have significant role

Delayed Cord Clamping (DCC)

• Definition: delay in clamping the umbilical cord after birth so as to facilitate placental blood flow to the fetus

• Increases volume of blood transferred to fetus• 50-75% of blood available for placenta-to-fetus transfers

within first minute after birth (fastest in first 1-2 minutes)*• Per ACOG: initiate early care of the newborn during this

time• Dry, stimulate• Cover with blanket to maintain temperature, skin-to-skin• Only clear secretions if copious/obstructing airway• Meconium but vigorous baby – cord clamp away!

Umbilical Cord Milking (UCM)

• Definition: actively push blood from unclamped umbilical cord towards fetus

• Pinch cord as close to placenta as possible and milk toward infant over a 2 second duration; then release cord and allow to refill with blood for a brief 1-2 seconds (Finer 2015)

• Milk 20 cm of umbilical cord toward the umbilicus three times (2015 CoSTR) or over 2-3 seconds (Niermeyer 2015 )

• Cut the cord 25 cm from the umbilicus, transfer infant to the resuscitation team, raise the cord and milk the 25 cm toward the infant

No particular method - difference in length of segment milked, repetitions, speed

Why do DCC/UCM

• Advantages• Term

• Higher iron stores at 6 months• Decreases anemia

• Preterm• Stabilize blood pressure and increase urine output acutely• Significant reduction of intraventricular hemorrhage [IVH] (by stabilizing blood

pressure)• Increased iron stores• Decreases anemia and need for transfusions• Possible decline in necrotizing enterocolitis (NEC)

• Disadvantages• Interfere with practice of collecting cord blood for banking• Maternal risks – some concern for postpartum hemorrhage (but not proven)• Increases polycythemia and hyperbilirubinemia

ACOG COMMITTEE OPINION –Dec 2012

• Ideal timing for clamping has yet to be established

• Several studies suggest a 30-60 second delay in umbilical cord clamping for all preterm deliveries, at or below level of placenta

• Evidence is insufficient to confirm or refute benefits Especially in settings with rich resources

ACOG COMMITTEE OPINION – Jan 2017 Given the benefits to most newborns and concordant with other

professional organizations….. now recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30-60 seconds after birth. Does not increase the risk of postpartum hemorrhage or decrease postpartum

hemoglobin (Hgb) level Term infants

Increase Hgb levels and iron stores in first several months of life May have a favorable effect on developmental outcomes Small increase phototherapy need for jaundice – ensure monitoring mechanisms in place

Preterm infants: significant neonatal benefits Improved transitional circulation Decreased need for blood transfusion Lower incidence of necrotizing enterocolitis and intraventricular hemorrhage

Insufficient evidence to either support or refute umbilical cord milking

AMERICAN COLLEGE OF NURSE-MIDWIVES POSITIONSTATEMENT - MAY 2014 Recommend delayed cord clamping for:

Term infants 2-5 minutes Preterm infants 30-60 seconds (reduction in IVH, blood transfusions)

Umbilical milking – if early or immediate cord clamping needed; may benefit term and preterm infants

No increase in maternal hemorrhage, no need to delay oxytocic drug administration to mothers

WHO Guideline- 2012

• Delayed umbilical cord clamping (at least 60 seconds after birth) recommended for term and preterm infants

• Exceptions: if PPV* required, asphyxiated newborn

• If possible, late cord clamping (1-3 minutes) recommended while initiating normal newborn resuscitation

NRP GUIDELINES 2017 Current evidence suggests that cord clamping should be delayed

for at least 30 to 60 seconds for most vigorous term and preterm infants

If placental circulation is not intact (i.e. placental abruption, bleeding placenta previa, bleeding vasa previa or cord avulsion), the cord should be clamped immediately after birth

There is insufficient evidence to recommend an approach to cord clamping for newborns who require resuscitation at birth

2015 INTERNATIONAL LIAISON COMMITTEE ONRESUSCITATION (ILCOR) REVIEW

GOODDelayed cord clamping (>30 seconds) is associated with:Less IVH of any gradeHigher BP and blood volumeLess need for transfusion after birthLess NECBUT, NO evidence of decreased severe IVH or mortality

2015 ILCOR REVIEW

BADStudies low quality -- downgraded for imprecision and very high

risk of bias; small groupsMild increase hyperbilirubinemia with phototherapy needUnknown benefits in infants needing immediate resuscitation

(may benefit the most)

2015 ILCOR REVIEW

Umbilical milking → insufficient evidence; few studiesConcern that rapid change in blood volume may affect ELBW

infants (i.e. increase IVH risk) Suggests AGAINST this for ELBW infants on a routine basis

*OR could it be that…. blood is directed to lungs as pulmonary vascular resistance falls and IVH not affected; this rapid change may be no different than infant cry or uterine contraction pushing blood through at a rapid speed**

2015 ILCOR REVIEW

Overall Recommendations:Suggest DCC for premature infants not requiring immediate

resuscitation after birth Not enough studies on those who were “sicker” and may have

benefitted most from DCC

COCHRANE REVIEWS

Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcome (2012):*15 randomized controlled trials (RCT), 738 infants ranging from 24 to 36 weeks gestation, born via C-section or vaginal delivery

*Delayed cord clamping ranging from 30 to 180 seconds or umbilical cord milking

*Less need transfusion, better circulatory stability, less IVH (all grades), lower risk for NEC

*Insufficient data for comparable effects on all primary outcomes

www.inquisitr.com

COCHRANE REVIEWS

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (2013):

*15 RCTs, 3911 women/infant pairs*No significant difference in

postpartum hemorrhage rates between early and late umbilical cord clamping*Increases early hemoglobin concentrations and iron stores

*Beneficial as long as have access to treat hyperbilirubinemia (i.e. phototherapy)

*More liberal approach or consideration to umbilical cord clamping given growing evidence of benefits http://www.ctvnews.ca/health/edmonton-hospitals-seeing-benefits-from-delayed-umbilical-cord-clamping-in-preemies-1.1546810

KNOWLEDGE GAPS

ContraindicationsPositioningC-section vs. vaginal delivery (VD)Optimal timing of uterotonic agentsDelayed cord clamping vs. cord milkingDelayed vs. immediate cord clamping in premature infants who

need immediate resuscitationBenefits of enhanced placental stem cell transfusionEffect on neurodevelopmental outcome (2+ years down the road..)Developed vs. developing countries

CONTRAINDICATIONS AND CONCERNS FOR DCC/UCM

*Maternal hemorrhagic complications (previa, abruption)*Cord abnormalities/accidents; tight nuchal cord*Neonatal hemolytic disease (increase in antibodies causing

hemolysis)*IUGR/IDM/Pre-eclampsia/High altitude - infant already

polycythemic or at risk

POSITIONING

ACOG 2017 States skin-to-skin care is

appropriate with VD C/S: place on maternal

abdomen/legs or held close to level of placenta

Boere, ADC-FNN, 2015 Infants placed on maternal

chest Direct skin-to-skin contact is

standard of care in Netherlands

http://www.inquisitr.com/wp-content/uploads/2014/04/Baby-on-Mom-at-Birth.jpg

POSITIONING Yao and Lind, Lancet, 1969

Measured residual placenta blood volume; “gravity hastens placental transfusion” Placement 40-60 cm above introitus: decrease placental transfusion similar to ICC (hydrostatic

pressure overrode pressures of contractions) No change when placed 10 cm above or below introitus during uterine contractions

(minimal change in hydrostatic pressure) Vain, Lancet, 2014

Term VD, vigorous - held infants at introitus or abdomen (skin-to-skin) for 2 minutes Measured weight at birth and at 2 minutes after DCC No change in weight; position did not seem to affect placental transfusion Skin-to-skin enhances maternal-infant bonding & may increase OB compliance with DCC

Hooper, ADC-FNN, 2016: Preterm lambs held 10 cm above or 10 cm below introitus Below introitus: umbilical flows reduced & carotid BF increased (signifying more blood in infant,

less in placenta) but no physiological change (no change in PBF, arterial pressure or HR) No change in blood volume in infant whether held above or below Thus, likely small flow difference with gravity and not clinically significant

A GAP SHORTENED…KATHERIA, PEDIATRICS, 2015

*Umbilical cord milking works better in C-section than delayed cord clamping to improve overall blood volume in premature infants

*2 center trial, <32 weeks (mean GA 28 2/7 wks)*Umbilical cord milking (4 strippings, ~20 seconds), delayed cord

clamping (45-60 seconds)*Primary outcome: increased SVC flow (P< 0.05)*UCM in C-section: higher hemoglobin, delivery room temperature,

blood pressure, urine output in first 12-24 hours (not primary outcome, not all statistically significant)

*No statistically significant difference in IVH (trend of less IVH in UCM)

*UCM vs DCC in vaginal deliveries: no differences noted*May be preferable in ELBW infants in whom more immediate

resuscitation is preferred

PREMATURE INFANTS & DCC

Backes, J. of Perinatology, Jan 2016Study evaluating timing of cord clamping in more premature

infants -- big concern is resuscitation and delayRCT 08/2009-12/2013; Ohio State Wexner Medical Center2 groups - Immediate cord clamping (ICC-n 22) or delayed cord

clamping of 30-45 seconds (DCC-n 18) Delayed method: held infant in sterile towel 10-15 inches below

mother’s introitus for vaginal deliveries or level of incision of C-sectionAverage gestational age ~24 4-6/7 weeks

PREMATURE INFANTS & DCC

No increased incidence postpartum hemorrhage in mothers No difference in delivery room or NICU admission markers of

infant safety, i.e. supplementary oxygen need, intubation, surfactant need Trend of higher temperatures at NICU admission in DCC group (wrapped

in warm sterile towels during delayed cord clamping; perhaps more attention overall to maintaining temperature)

No infant in either group developed polycythemia Increased number of blood transfusion in first 28 days for those

in ICC but when evaluating overall hospitalization, no change between 2 groups*

www.aoafamily.com

PREMATURE INFANTS & DCC Higher overall hematocrit in

first 72 hours in those in DCC group

Higher mean arterial pressure in those in DCC group in first 24 hours; 4X increased need of treatment for hypotension in first 24 hours in those in ICC group

Twofold lower risk of severe IVH in DCC group than ICC group (not statistically significant)

• OVERALL MESSAGE: DCC in premature infants is SAFE, FEASIBLE and may provide hematologic/circulatory benefits (especially in first 24-72 hours)

www.stemcord.com

UMBILICAL CORD MILKING

Systematic review and meta-analysis of UCM (Al-Wassia, JAMA, 2015) 7 studies, 501 preterm infants Most compared UCM to ICC Method of UCM varied UCM group: higher Hgb levels, decreased incidence IVH, lower risk of

chronic lung disease RCT of DCC (30 sec) to UCM (4 times); (Rabe H, Obstet Gynecol,

2011) Mean gestational age: 29 weeks Mean Hgb values at 1 hour after birth were the same No significant difference in transfusions needed later in course

UMBILICAL CORD MILKING CONCERNS

Concern over cerebral flow dynamics UCM vs DCC: Similar resistive index, pulsatility index and cerebral blood

flow velocities of MCA between 24 & 48 hours by cranial US (Jaiswal, Indian J Pediatr, 2015)

No long-term adverse effect on neurodevelopmental outcome at 2 and 3.5 years in preterm infants whether they had UCM or DCC (Rabe, Neonatology, 2016)

Breathing Often occurs before first breaths, establishment of respirations &

pulmonary blood flow– thus, diminished benefits?? Enhances earlier onset of breathing

Jaykka, Acta Paediatr, 1958: Alveolar patency occurs in response to the filling of surrounding capillaries

Katheria, Pediatrics, 2015: more infants were breathing by the time the cord was clamped with UCM vs a 45 second DCC

RESUSCITATION DURING DCC; NEURODEVELOPMENTAL OUTCOME

UK CORD Trial - pilot trial at eight sites in UK investigating use of active resuscitation during DCC among very preterm infants (<32 weeks); 03/2013-02/2015 recruitmentConcern that cord clamping delays resuscitationCord clamping within 20 seconds vs > 2 minutes

Initial neonatal care at bedside if > 2 minutesPrimary outcome: death and neurosensory disability at 2 yearsSome recent evidence that establishing ventilation before cord

clamping improves outcomes If respirations set may increase overall blood flow to infant from

umbilicus -->pulmonary system opens and retain more blood volume in infant

261 women/infant pairs; Follow-up women at 1 year, infants at 2 years: results pending

PLATFORM FOR BEDSIDE RESUSCITATION PRIOR TOCLAMPING UMBILICAL CORD (LIVERPOOL WOMEN’SHOSPITAL)

www.researchgate.net

RESUSCITATION PLATFORMS – LIFESTART ON STEROIDS, SAN DIEGO

T-piece resuscitator, air-oxygen blender, oxygen flowmeter, 50 psi air and oxygen hoses (connect any gas supply; no need to carry O2 tank), pulse oximeter, disposable supply bag (water proof cover for stand, ventilation circuit, resuscitation mask, oximeter probe, bulb suction, extension tubing)

Premature (<28 weeks): Chemical mattress, warm sterile towels, sterile polyethylene wrap; if cord too short, place these items on mother

Concerns – umbilical cord cut too short (this decreased with more regular use of LifeStart)

Providing a Placental Transfusion in Newborns Who Need Resuscitation (PDF Download Available). Available from: https://www.researchgate.net/publication/313038232_Providing_a_Placental_Transfusion_in_Newborns_Who_Need_Resuscitation [accessed Mar 5, 2017]

RESUSCITATION PLATFORM: LIFESTART

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263890/figure/F2/

RESUSCITATION PLATFORM

VentFirst (diagrams, picture) -29 infants, median GA 30 weeks, C/S 72%, 2014-2015 Protocol: receive assisted ventilation during 90 seconds of DCC Two neonatal provider approach (nurse, doc; RT behind) OB ceded space to neonatal team for 90 seconds VentFirst pole (C/S)/table (SVD) on wheels: T-piece resuscitator, oxygen and air

tanks, blender, flowmeter C/S: placed on mother’s pelvis/thighs; SVD – placed near introitus after delivery Temperature control: chemical gel warming pad, sterile polyethylene sheet (placed on

mother’s pelvis during C/S) Sterility in C/S: sterile plastic sleeves/bags cover VentFirst; disposable items

previously sterile Feasible and safety but workable items one neonatal provider at table?, have team

work on set-up prior to doing so quicker Doing large multicenter RCT infants< 29 weeks with DCC 120 seconds with assisted

ventilation (control with DCC up to 60 seconds without assisted ventilation)

RESUSCITATION PLATFORM- VENTFIRST

Figure 2. Winter et al. Ventilation of Preterm Infants during Delayed Cord Clamping (VentFirst): A Pilot Study of Feasibilityand Safety. Am J Perinatol 2017. Adopted from: https://pbs.twimg.com/media/Co3rwbeWcAAbOeJ.jpg

A DIFFERENT TYPE OF TRANSFUSION

DCC = enhanced placental stem cell transfer; “Mankind’s first natural stem cell transplant”

Umbilical blood contains pluripotent stem cells Not only “transfused” to infants but also adults Pediatric, genetic, blood, immune, metabolic and oncological disorders

Could stem cells have an effect on neonatal conditions/diseases?? Immediate & long-term immunity, host defense and repair

Downfall: May decrease umbilical cord blood donation yield

RESOURCE-LIMITED SETTINGS

*Large, population-based observational study in Tanzania*12,730 term and preterm infants (presumed to be healthy; no

particular complications)*Association between timing of umbilical cord clamping relative to

onset spontaneous respirations and outcomes of death or admission to a special care area

*Risk of outcome higher if cord clamped prior to spontaneous respirations; decreased by 20% for every 10-second delay in cord clamping after spontaneous respirations up to 2 minutes

*Less risk of iron deficiency anemia; would need phototherapy treatment

IN CONCLUSION: OBJECTIVES

Be aware of the history and media coverage of umbilical cord clamping

Understand the physiology of cord clampingBe able to discuss the advantages and disadvantages of delayed

cord clamping and umbilical cord milking for term and preterm infants

Be able to define the current recommendations from major professional organizations on delayed cord clamping

Be able to define the knowledge gaps for delayed cord clamping and umbilical cord milking

REFERENCES

*Al-Wassia H, Shah PS. Efficacy and safety of umbilical cord milking at birth: a systematic review and meta-analysis. JAMA Pediatr. 2015 Jan;169(1):18-25.*Boere I, Roest AAW, Wallace E, et al. Umbilical blood flow patterns directly after birth before delayed cord clamping. Arch Dis Child Fetal Neonatal Ed 2015; 100:F121-125.*Ceriani JM. Stem cell transfer in newborn infants through placental transfusion via delayed umbilical cord clamping. Arch ArgentPediatr. 2016 Dec 1;114(6):498-499.*CH Backes, H Huang , JD Iams , JA Bauer and PJ Giannone. Timing of umbilical cord clamping among infants born at 22 through 27 weeks’ gestation. Journal of Perinatology (2016) 36, 35–40*Delayed umbilical cord clamping after birth. Committee Opinion No. 684. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129;e5-10.*Delayed Umbilical Cord Clamping. Position Statement. American College of Nurse-Midwives. May 2014.*Ersdal HL, Linde J, Mduma E, Auestad B, Perlman J. Neonatal outcome following cord clamping after onset of spontaneous respiration. Pediatrics. 2014;134(2):265–72.*Hooper SB, Crossley KJ, Zahra VA, et al. Effect of body position and ventilation on umbilical artery and venous blood flows during delayed umbilical cord clamping in preterm lambs. Arch Dis Child Fetal Neonatal Ed. Published Online First: 08/11/2016. doi: 10.1136/archdischild-2016-311159.*Katheria AC, Brown MK, Rich W, Arnell, K. (2017) Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front.Pediatr. 5:1.*Katheria AC, Truong G, Cousins L, Oshiro B, Finer NF. Umbilical Cord Milking Versus Delayed Cord Clamping in Preterm Infants.Pediatrics; originally published online June 29, 2015*McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD004074. DOI:10.1002/14651858.CD004074.pub3.*Niermeyer, S. Maternal Health, Neonatology and Perinatology 2015 1:21. DOI: 10.1186/s40748-015-0022-5. Received: 25 June 2015. Accepted: 20 August 2015 Published: 8 September 2015. A physiologic approach to cord clamping: Clinical issues. http://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-015-0022-5

REFERENCES*Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, Szyld E, Tamura M, Velaphi S; on behalf of the Neonatal Resuscitation Chapter Collaborators. Part 7: neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(suppl 1):S204–S241.*Pushpa-Rajah A, Bradshaw L, Dorling J, Gyte G, Mitchell EJ, Thornton J et al. Cord pilot trial - immediate versus deferred cordclamping for very preterm birth (before 32 weeks gestation): study protocol for a randomized controlled trial. Trials 2014; 15: 258.*Rabe H, Sawyer A, Amess P, Ayers S, Brighton Perinatal Study Group, Neurodevelopmental Outcomes at 2 and 3.5 Years for Very Preterm Babies Enrolled in a Randomized Trial of Milking the Umbilical Cord versus Delayed Cord Clamping. Neonatology. 2016;109 (2):113-9.*Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2012, Issue 8. Art.No.: CD003248. DOI: 10.1002/14651858.CD003248.pub3.*Safarulla A (2017): A review of benefits of cord milking over delayed cord clamping in the preterm infant and future directions of research. The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2016.1269319*Thomas MR, Yoxall CW, Weeks AD, Duley L. Providing newborn resuscitation at the mother's bedside: assessing the safety, usability and acceptability of a mobile trolley. BMC Pediatr. 2014;14:135.*Timing of umbilical cord clamping after birth. Committee Opinion No. 543. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1522–6.*Vain NE, Satragno DS, Gorenstein AN, Gordillo JE, Berazategui JP, Alda MG, et al. Effect of gravity on volume of placental transfusion: a multicentre, randomised, non-inferiority trial. Lancet 2014;384:235-40.*WHO. Guideline: Delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes. Geneva: World Health Organization; 2014.*Winter J, Kattwinkel J, Chisholm C, Blackman A, Wilson S, Fairchild K. et al. Ventilation of Preterm Infants during Delayed Cord Clamping (VentFirst): A Pilot Study of Feasibility and Safety. Am J Perinatol 2017;34:111-116.*Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, Simon WM, Weiner GM, Zaichkin, JG. Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines Update forCardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S543–S560.*Yao, AC, Lind J. Effect of gravity on placenta transfusion. Lancet 1969;2:505-8.