Download Microsoft PowerPoint - 5. Elisabeth S\346ther, Sen

11/10/2016
History
Cord clamping practices –
“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.”
beneficial for the newborn?
GYNZONE 2016
SYMPOSIUM OM NORMALE FØDSLER
ELISABETH SÆTHER
History
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
Definitions
Immediate cord clamping
(ICC)
Umbilical cord is clamped
in the moment the baby is
born
Photo from
Kvinneklinikken,
Haukeland
hospital in
Norway, around
1960
Demonstrates
invention of new
euipment to clamp
the cord
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.
Early cord clamping
(ECC):
Umbilical cord is clamped
before 30 sec after baby is
born, or before onset of
respiration
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Definitions
The role of
the placenta
Physiologic cord
Keeps the baby alive…
clamping (PhCC)
Produces important
hormones to support
pregnancy
Umbilical cord is cut after
placenta is born
Facilitates gas exchange
and thermo-regulation
Transports oxygen and
nutritients to all organs
LOTUS birth
Transports carbon dioxide
and waste-products away
from the baby
The placenta is attached to
the baby until the cord is
dry and falls off
Protects the baby against
infections
…..until the baby is born
and respiration is well
stablished
Photo: www.regatta.no
Neonatal transition
=
transition from intra-
Current guidelines
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:
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.
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]
Benefits - DCC at term:
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
NICE 2014:
Do not clamp the cord earlier
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
http://www.helsebiblioteket.no/fagprosedyrer/ferdige/avnavling-av-nyfodte
Ref: Andersson O 2011 / 2015, Berglund S 2012.
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Benefits - DCC preemies:
Blood transfer – time and amount
Reduced prevalence of:
Intraventricular hemorrhage
Neonatal sepsis (esp.boys)
Necrotizing enterocolitis (NEC)
Respiratory distress syndrome (RDS)
Improved circulatory stability and cerebral perfusion
Reduced need for blood transfusions
Fewer days on respirator
Kilder: Rabe H et.al 2012, Mercer JS et al. 2006, Mercer JS et al. 2010.
Yao AC et.al: Distribution of blood between the infant and the placenta after birth.
Lancet 1969;2:871-3.
Blood volume and gestational age
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
Total circulating blood volume
in fetus, cord and placenta
is 110-115 ml/kg
GA 30 weeks:
50% in placenta
Amount of blood transferred by DCC accounts for
GA 40 weeks:
30% in placenta
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.
Linderkamp OL: Placental transfusion; determinants and effects. Clin Perinatol 1982;9:559-92
Wardrop 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
DCC - high priority
Infants subject to hypoxia / aspyxia
Blood pressure
Erytrocytes
Oxygen
Umbilical cord compression
Shoulder dystocia
Instrumental deliveries
Breech
Stem cells
Iron
Nutritients
Gentle transition
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.”
The highest concentration of stem cells is at the
end of the transfusion or when strippng the cord
Cord blood donation / banking?
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
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
Boere I, et al. Arch Dis Child Fetal Neonatal Ed 2015;100:F121–F125.
doi:10.1136/archdischild-2014-307144
Hooper, 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
Paradigm shift?
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.”
“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 et al. (2014) Ventilation before umbilical cord clamping improves the physiological
transition at birth. Front. Pediatr. 2:113. doi: 10.3389/fped.2014.00113
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
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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.
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.
LifeStart system
This can however be readily
provided at the side of the
mother with the placental and
cord circulation intact using
specially designed equipment”
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”
On behalf of
generations to
come:
DO
NO
HARM!
D. Hutchon & N.Bettles 2016
Further readings
Scandinavian resources:
https://www.facebook.com/SenAvnavling/
https://www.facebook.com/groups/98718282961/?fref=ts
http://www.helsebiblioteket.no/fagprosedyrer/ferdige/avnavl
ing-av-nyfodte
International resources:
http://www.cordclamping.org/
http://www.bloodtobaby.com/
https://www.facebook.com/Optimal-Cord-ClampingWaitforWhite-414578291919270/?fref=ts
http://cordclamping.info/publications/publications.htm
https://www.facebook.com/delayedcordclamping/?fref=ts
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