Clinical Challenges to Cord Clamping

1. Clinical Challenges to Cord Clamping Cord Blood Banking Umbilical Cord Gases Neonatal Resuscitation Dealing with a Nuchal Cord Active Management & the 3rd Stage When you are in a “cut & run” situation Erickson-Owens D & Mercer J. (Dec 2014)

2. Cord Blood Banking Erickson-Owens D & Mercer J. (Dec 2014)

3. Cord Blood Banking A hot commodity…no longer just medical waste • AAP (2007) recommendations (Retired May 2012): • Do not collect in complicated deliveries • Cord blood collection “should not alter routine practice for the timing of umbilical cord clamping” • Avoid banking when directed for later personal/family use • Concern regarding anemia of infancy • Lack of true informed consent • Avoid a “large” harvest; Consider a smaller volume of blood • Mankind’s first natural stem cell transplant (Toloso et al. J Cell Mol Med 2010; 14: 488-95) Erickson-Owens D & Mercer J. (Dec 2014)

4. Press release from Americord on April 17, 2013 Erickson-Owens D & Mercer J. (Dec 2014)

5. Umbilical Cord Gas Collection Erickson-Owens D & Mercer J. (Dec 2014)

6. ACOG Clinical Opinion in 1996 & 2006 (reaffirmed in 2012) Cord blood samples after 20 min delay is unreliableArmstrong & Stenson 2006 DCC of 90 secs has little clinical significance on arterial pH in healthy newborns Wiberg, Kallen & Olofsson 2008 Sampling can be postponed for up to 15 mins after birth Paerregaard, Nickelsen, Brandi & Andersen 1987 Delay in sampling can result in abnormal findings by 30 mins Lynn & Beeby 2007 Umbilical Cord Blood Gases Erickson-Owens D & Mercer J. (Dec 2014)

7. Clinical Situations Warranting Cord Blood Gas Sampling(ACOG 2006/ reaffirmed in 2012) • Venous and arterial cord blood samples are recommended by ACOG in the following clinical situations: • Cesarean Section for fetal compromise • Low 5-min Apgar score • Severe IUGR • Abnormal FHR tracing • Maternal thyroid disease • IP fever • Multifetal gestations Erickson-Owens D & Mercer J. (Dec 2014)

8. Blood Gas Sampling Andersson et al 2012 Erickson-Owens D & Mercer J. (Dec 2014)

9. Neonatal Resuscitation Erickson-Owens D & Mercer J. (Dec 2014)

10. Circulation….Airway….Breathing…. Circulation Airway Breathing will begin when lungs have perfused from placental transfusion Ewy G, Kern K, Sanders A, Newburn D (2006) Am J Med, 119:6-9 Erickson-Owens D & Mercer J. (Dec 2014)

11. “Bringing the resuscitation to the baby, rather than the baby to the resuscitation…” Hutcheon D & Bewley S. (2008). Support transition by keeping the placental circulation intact. Arch Dis Child Fetal Neonatal Ed; 93:F334-6 The LifeStart System http://www.inditherm.com/ Erickson-Owens D & Mercer J. (Dec 2014)

12. Erickson-Owens D & Mercer J. (Dec 2014)

13. Nuchal Cord www.pattiramos.com/ Erickson-Owens D & Mercer J. (Dec 2014)

14. What happens with a NC ? • When a cord tightens around neck it can lead to hypovolemia • Soft walled vein more easily compressed • Thick walled arteries continue to send blood to the placenta • Blood backs up in placenta • Problem worse if time short between contractions • Gets hypoxic as well as hypovolemic • Worse if oligiohydramnios and/or multiple loops of cord Erickson-Owens D & Mercer J. (Dec 2014)

15. Somersault Maneuver (Schorn & Blanco, 1991) Erickson-Owens D & Mercer J. (Dec 2014)

16. Practice Recommendation Erickson-Owens D & Mercer J. (Dec 2014)

17. Shoulder Dystocia Erickson-Owens D & Mercer J. (Dec 2014)

18. A Common Obstetrical Practice… Cutting the cord prior to shoulders and rushing (if needed) to the warmer for resuscitation Erickson-Owens D & Mercer J. (Dec 2014)

19. “Infants experiencing a traumatic birth involving shoulder dystocia are often severely compromised, even when labor was uncomplicated.” “Resuscitate at the perineum with an intact cord” Mercer J, Erickson-Owens D & Skovgaard R. (2009). Cardiac asystole at birth: Is hypovolemic shock the cause? Medical Hypotheses, 72: 458-63. Erickson-Owens D & Mercer J. (Dec 2014)

20. Active Management of 3rd Stage Erickson-Owens D & Mercer J. (Dec 2014)

21. Red Circle = Leveling off of BV & RCV No Overtransfusion Rate of placental transfusion of 195 term infants whose mothers had methylergonovine IV stat after infant’s birth. Yao et al 1968 Erickson-Owens D & Mercer J. (Dec 2014)

22. “CUT & RUN”…Think Milking Erickson-Owens D & Mercer J. (Dec 2014)

23. What is cord milking? • Grasp the cord between your thumb and forefinger and milk the length of cord towards infant’s umbilicus 4-5 times • Vaginal birth-start at introitus • Cesarean birth-start near insertion site on placenta • Challenges: • Cord is slippery • Can be tightly coiled and difficult to milk entire cord • Potential to tear (rare) Erickson-Owens D & Mercer J. (Dec 2014)

24. Practice Recommendations • Cord blood banking….you don’t need to alter your cord clamping practice • Umbilical Cord Gases can co-exist with a delay or milking of the cord • Resuscitation may be improved with “CAB” and an intact cord • Somersault Maneuver avoids ICC with nuchal cord Erickson-Owens D & Mercer J. (Dec 2014)

25. Practice Recommendations • With shoulder dystocia be aware of hypovolemia and its negative consequences • Uterotonics accelerate transfer of blood to the infant but does not lead to overtranfusion • Cord Milking is an important when you must “cut and run” Erickson-Owens D & Mercer J. (Dec 2014)

26. Keep the Cord Intact Contact Email: debeo@uri.edu Erickson-Owens D & Mercer J. (Dec 2014)