8/13/2014. Blood, Sweat (and Tears): Delayed Cord Clamping and Delivery Room Temperature. Delayed Cord Clamping

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1 8/13/2014 Blood, Sweat (and Tears): Delayed Cord Clamping and Delivery Room Temperature James F. Smith, Jr., MD Professor and Chair Obstetrics and Gynecology Creighton University School of Medicine The American Collegeof Obstetriciansand Gynecologists WOMEN SHEALTH CAREPHYSICIANS C O M M IT T E E O P IN IO N Committee on Obstetric Practice This Committee Opinion was developed by the Committee on Obstetric Practice with the assistance of the American Academy of Pediatrics. The American Academy of Pediatrics endorses this document. This information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Timing of Umbilical Cord Clamping After Birth A B S T R A C T : The optimal timing for clamping the umbilical cord after birth has been a subject of controversy and debate. Although many randomized controlled trials in term and preterm infants have evaluated the benefits of delayed umbilical cord clamping versus immediate umbilical cord clamping, the ideal timing for cord clamping has yet to be established. Several systematic review s have suggested that clamping the umbilical cord in all births should be delayed for at least seconds, w ith the infant maintained at or below the level of the placenta because of the associated neonatal benefits, including increased blood volume, reduced need for blood transfusion, decreased incidence of intracranial hemorrhage in preterm infants, and low er frequency of iron deficiency anemia in term infants. Evidence exists to support delayed umbilical cord clamping in preterm infants, w hen feasible. The single most important clinical benefit for preterm infants is the possibility for a nearly 50% reduction in intraventricular hemorrhage. How ever, currently, evidence is insufficient to confirm or refute the potential for benefits from delayed umbilical cord clamping in term infants, especially in settings w ith rich resources. Delayed Cord Clamping 1950: Early clamping Late clamping less than 1 minute more than 5 minutes 90% of blood volume achieved within first few breadths after delivery Interval shortened 1

2 Position of infant Yao, Lind. Lancet 1969;2: cm above or below introitus 3 min 80 cc 40 cm below introitus 30 sec 80 cc 60 cm above introitus 3 min 0 cc Gabbe, 2012 The American College of Obstetricians and Gynecologists WOMEN SHEALTH CAREPHYSICIANS C O M M IT T E E O P IN IO N Committee on Obstetric Practice This Committee Opinion was developed by the Committee on Obstetric Practice with the assistance of the American Academy of Pediatrics. The American Academy of Pediatrics endorses this document. This information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Timing of Umbilical Cord Clamping After Birth A B S T R A C T : The optimal timing for clamping the umbilical cord after birth has been a subject of controversy and debate. Although many randomized controlled trials in term and preterm infants have evaluated the benefits of delayed umbilical cord clamping versus immediate umbilical cord clamping, the ideal timing for cord clamping has yet to be established. Several systematic reviews have suggested that clamping the umbilical cord in all births should be delayed for at least seconds, with the infant maintained at or below the level of the placenta because of the associated neonatal benefits, including increased blood volume, reduced need for blood transfusion, decreased incidence of intracranial hemorrhage in preterm infants, and lower frequency of iron deficiency anemia in term infants. Evidence exists to support delayed umbilical cord clamping in preterm infants, when feasible. The single most important clinical benefit for preterm infants is the possibility for a nearly 50% reduction in intraventricular hemorrhage. However, currently, evidence is insufficient to confirm or refute the potential for benefits from delayed umbilical cord clamping in term infants, especially in settings with rich resources. 2

3 Delayed Cord Clamping ACOG Committee Opinion Number 543 December 2012 Timing of Umbilical Cord Clamping After Birth Delayed Cord Clamping Now Commonly done within seconds Delayed seconds What Happens? After delivery: 1 minute 3 minutes 80 ml 100 ml Extra iron: mg/kg (In addition to 70 mg/kg already present) Extra volume ( ml/kg ideal for premie) 3

4 Cord pulsations--cessation In utero umbilical blood flow 240 cc/min (!) Temperature, arterial response 3 minutes, 18 C (65 F) Mediated by: 5-hydroxytryptamine Thromboxane A2 What Happens? Increased blood volume Reduced transfusions Decreased ICH in preterm infants Decreased iron deficiency in term infants Ig and stem cells may improve organ repair Single Most Important Finding Reduction in IVH RR about 0.5! Plausibly related to early volume status Potential for improved neurologic outcomes Steroids Mag for neuro-protection Now, delayed cord clamping 4

5 Potential risks Jeopardize resuscitation Excessive blood transusion Polycythemia (DM, IUGR, high altitude, etc.) Technical difficulties Interferes with cord blood collection Passive Drainage vs. Milking Technique Variously described 20 cm, three swift movements Long single movement Etc. Outcomes Obstet Gynecol 2011;117:

6 Conclusions Delayed Cord Clamping Term infants Insufficient evidence to support routine use Increased iron, but increased phototherapy Preterm infants Improved transitional circulation RBC volume decreased transfusion 50% reduction in IVH (!) What we don t know: Potential effects at Term How (if) to manage at cesarean Clinical circumstances of most benefit Clinical circumstances of most risk Optimum technique 6

7 Cord clamping? Room temperature? 7