Purpose and Goal: CNEP #2004

  • Learn about the benefits of delayed cord clamping.
  • Recognize the benefits of delayed cord clamping for premature infants.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for successful completion:

  • Successfully complete the post-test.
  • Complete the evaluation form.

Date

  • March 2015 – March 2017

Learning Objectives

  • Describe the risks and benefits of delayed cord clamping.
  • Identify two benefits of delayed cord clamping for premature infants.

Introduction

  • When to clamp the umbilical cord has been debated for years
  • Delayed cord clamping (DCC) used to be the standard in the US
  • Since the 1960s, this practice has not been widely used
  • Several recent studies have shown DCC benefits all infants

History of Cord Clamping

  • Aristotle (384-322 BC) believed early cord clamping was harmful
  • Erasmus Darwin (1731-1802) wrote about cord clamping:
    • Early cord clamping (ECC) was “injurious” to infants
    • Cords should be clamped after pulsation ended
    • ECC left blood in the placenta, not the infant
    • ECC contributed to “weak” infants
  • Pierre Budin studied cord clamping as early as 1875
  • In early 1899, the first surgical cord clamp was introduced
    • The clamp was intended to replace cord ties
    • The clamp was developed to reduce infections
    • Instructions: “apply the clamp after pulsations stopped”
  • In the early 1900s, general anesthesia was routinely used
    • Anesthesia included chloroform and ether
    • Infants had severe respiratory depression
    • Immediate cord clamping was widely initiated
  • In the 1930s-1960s, DCC was the standard in the US
    • It was supported by well-respected obstetricians
  • Over time, DCC became viewed as dangerous and inconvenient
    • There is no scientific evidence to support this view
    • This could be due in part to standard practices
      • More women giving birth in hospitals
      • More obstetricians delivering babies
      • Increasing numbers of surgical births
      • Increasing availability of newborn resuscitation
    • This could also be due to a change in the 1960s
      • Active Management of Third Stage Labor (AMTSL)
      • Introduced to prevent postpartum hemorrhage (PPH)
  • In recent times, the rush to “hand off” infants has resulted in ECC
    • This has become the expectation of newborn providers
    • This has become true for all infants
      • Vigorous and non-vigorous
      • Term and premature

Active Management of Third Stage Labor

  • AMTSL was introduced to prevent PPH
    • PPH is a leading cause of maternal mortality
  • The AMTSL “package” included:
    • Administration of a prophylactic uterotonic agent
    • Clamping the cord shortly after birth
    • Continuous controlled cord traction
  • ECC is still practiced as part of AMTSL
  • Evidence has not shown AMTSL decreases PPH

Physiology of Fetal-to-Newborn Transition

  • ~1/3 of fetal-placental blood is in the placenta at term
    • Total volume of fetal-placental blood is 110-115 ml/kg
    • ~30 ml/kg volume remains in the placenta
  • In utero, the placenta is the organ of respiration
    • Only 10% of fetal cardiac output reaches the lungs
    • > 50% of fetal cardiac output reaches the placenta
  • At birth, the lungs take over as the organ of respiration
    • ~50% of newborn cardiac output reaches the lungs
  • This process requires increased blood volume
  • With DCC, infants receive blood via placental transfusion
    • ~20-35 ml/kg of blood volume
  • With ECC, infants do not receive additional blood

Key Factors that Affect Placental Transfusion

  • Several factors influence placental transfusion
  • These factors include:
    • Time
    • Gravity
    • Uterine contractions
    • Onset of respirations
  • Studies have shown what happens with DCC
    • For infants held at the level of the uterus
      • The beginning rate of transfusion is rapid
      • The transfusion slows in a stepwise manner
      • ~25% of the transfusion occurs in 15-30 seconds
      • ~50-75% of the transfusion occurs by 60 seconds
      • The remaining transfusion occurs by 3 minutes
    • This evidence suggests location of the infant is important
      • Gravity affects the rate of the transfusion
      • Infants placed on the maternal abdomen receive slower transfusions than infants held at the level of the uterus
      • Infants held > 10 cm above the level of the uterus may not receive placental transfusion and reverse flow can occur
  • Uterine contractions will speed up the rate of transfusion
  • The use of uterotonic agents has been shown to be safe
  • The volume of placental transfusion is reduced if the cord is clamped prior to the onset of respirations
    • Placental transfusion is accelerated by onset of breathing

Definition of Delayed Cord Clamping

  • ECC is defined as:
    • Immediate clamping
    • Clamping at < 15 seconds
  • DCC is defined as:
    • Clamping at 30-60 seconds
    • Clamping at 3 minutes (most common)
    • Clamping after the cessation of pulsations
  • Professional Organizations who recommend DCC
    • WHO – World Health Organization
    • ACOG – American College of Obstetricians and Gynecologists
    • AAP – American Academy of Pediatrics
    • SOCG – Society of Obstetricians and Gynaecologists of Canada
    • RCOG – Royal College of Obstetricians and Gynaecologists
    • ILCOR – International Liaison Committee on Resuscitation
  • What happens without intervention?
    • All umbilical vessels occlude shortly after delivery
      • The umbilical artery closes by 45 seconds
      • The umbilical veins close by 2-3 minutes

Maternal Outcomes

  • DCC has not been shown to affect maternal outcomes
  • Outcomes that have been studied include:
    • Postpartum hemorrhage rates
    • Severe postpartum hemorrhage rates
    • Postpartum hemoglobin values
    • Need for therapeutic uterotonic agents

Newborn Outcomes

  • DCC provides an increased blood volume
    • Up to 30% increase in term infants
    • Up to 50% increase in preterm infants
  • DCC also provides other benefits
    • Improved systemic blood pressure
    • Decreased need for inotropic support
    • Increased cerebral blood index
    • Significantly decreased risk of IVH
    • Decreased blood transfusions
    • Decreased incidence of NEC
  • Studies show that DCC leads to:
    • Higher hematocrit levels
      • Up to 60% increase
    • Higher hemoglobin levels
    • Higher ferritin levels at 4-6 months
  • Studies show that ECC leads to:
    • Iron deficiency anemia at 3-6 months

Stem Cells

  • Cord blood contains millions of hematopoietic stem cells
  • Stem cell concentrations are higher in premature infants
  • Stem cells play critical roles in organ development
    • Central nervous system
    • Respiratory system
    • Cardiovascular system
    • Hematologic system
    • Immunologic system
    • Endocrine system
  • Studies show that stem cells help repair damaged tissues
  • Loss of stem cells potentially impacts growth and development

Benefits for Term Infants

  • The main benefit of DCC is reduction of anemia
  • This is especially true for infants born to anemic mothers
  • DCC increases several important levels:
    • Hemoglobin levels at 2-3 months
    • Hematocrit levels at up to 6 months
    • Ferritin levels at up to 6 months
  • Anemia remains an ongoing problem in the US
    • ~9% of US toddlers are anemic
    • Anemia effects children living in poverty
    • Anemia effects children exposed to lead
    • Anemia effects children who were born SGA
  • Studies have shown that children with anemia:
    • Have permanently decreased cognitive function
    • Have permanently decreased motor function
    • Have increased behavioral problems
    • Have lower IQ scores at ages 15-19
  • DCC is a simple intervention that can improve the iron status of children and help prevent cognitive impairment

Benefits for Premature Infants

  • There are several benefits of DCC for premature infants
  • While 1/3 of placental-fetal blood volume is in the placenta at term, 50% of placenta-fetal blood volume is in the placenta prior to term
    • ECC leaves premature infants with ½ of their blood volume
    • A 50% loss of blood volume can lead to hypovolemia
  • Decreased blood volume → poorly oxygenated tissues
  • DCC for 30-45 seconds can increase blood volume by 8-24%
  • Improved blood volumes can lead to:
    • Improved respiratory function
    • Decreased risk of IVH
    • Decreased risk of late onset sepsis
  • Premature infants with DCC have been shown to require:
    • Less surfactant replacement
    • Fewer days of ventilator support
    • Fewer days of supplemental oxygen
    • Fewer red blood cell transfusions
  • Premature infants with DCC have been shown to:
    • Have a decreased risk of IVH
    • Have improved cerebral oxygenation
    • Have less incidence of late onset sepsis
    • Have a significantly decreased risk of NEC
  • Several studies have shown that DCC until after the onset of respirations significantly improved cardiovascular function
    • Premature infants with indications for resuscitation
      • Benefit most from increased blood volume
      • Benefit most from improved cardiovascular function
  • Premature infants with DCC have also been shown to have less anemia from multiple lab draws during their NICU stay

Potential Risks Associated with DCC

  • Several concerns have been raised about DCC
  • Multiple studies have looked at short term outcomes
  • Delayed resuscitation
    • No increased need for intubation
    • No increased need for mechanical ventilation
    • No decreased 5 minute Apgar scores
  • Polycythemia
    • No increased rates of symptomatic polycythemia
    • No increased need for treatment
  • Hyperbilirubinemia
    • No increased rates of hyperbilirubinemia
    • No increased need for phototherapy
  • Rates of NICU care
    • No increased rates of NICU admissions
  • Rates of mortality
    • No increased rates of mortality

Long-Term Benefits Associated with DCC

  • Recent studies have looked at long term outcomes
  • At 4 years of age, DCC has been associated with:
    • Higher social skills
    • Higher fine motor skills
  • Boys scored significantly higher than girls
  • There were no differences in IQ scores

Alternatives to DCC

  • DCC requires a specific length of time after delivery
  • Several concerns have been raised about
    • Delayed resuscitation in ELBW infants
    • Delayed resuscitation in VLBW infants
    • Delayed resuscitation in any infant
  • Umbilical cord milking has emerged as an alternative
  • A few studies have looked at this alternative approach
  • Umbilical cord milking (UCM) is defined as:
    • Gently pushing cord blood towards the infant
    • Milking 20 cm of cord 2-3 times before clamping
    • Milking at a rate of 2 seconds for each
    • Holding the infant at or below the placenta
  • Short term outcomes with UCM:
    • Significantly increased blood pressure
    • Significantly increased hematocrit levels
    • Significantly increased hemoglobin levels
    • Decreased need for blood transfusions
    • No differences were found in rates of morbidity
    • No differences were found in rates of mortality

Implementing DCC

  • Implementing DCC requires a change in thinking
    • It requires a dedicated leadership team
    • It requires a multidisciplinary approach
    • It requires education and training of all staff
  • Discussion of the evidence can help facilitate change
  • Brainstorming should occur prior to any practice change
    • To identify challenges
    • To avoid obstacles
    • To identify safety concerns
    • To motivate staff
    • To work out details
  • A standardized treatment protocol should be developed
  • Practice simulations should be considered prior to change
  • Communication between OB and NICU teams is critical
    • Reminders about DCC can occur during daily huddles
    • Reminders about DCC can occur during a time out
    • Reminders about DCC can occur in a quick pre-delivery discussion or a quick post-delivery debrief
  • Tracking staff compliance and infant outcomes is essential
  • Specific methods for implementation should be ongoing
    • Identifying which infants will be included
    • Identifying a specific time frame for DCC
    • Identifying specific positioning for infants
    • Identifying methods to provide thermal support
    • Identifying methods to provide resuscitation
      • Bringing equipment to the infant
      • An FDA approved unit is currently being trialed
      • Avoiding cord clamping until respirations are established

Cord Blood Collection and DCC

  • Both ACOG and AAP state that cord blood banking should not alter the timing of cord clamping
  • Cord blood banking requires quality, not quantity
    • A minimum of 30-40 ml is needed
    • This volume can easily be obtained after DCC
    • It may be obtained from the cord or the placenta
  • Cord blood banking companies offer resources for support
    • Americord
    • Cord Blood Registry

Summary

  • There is no credible evidence to support routine ECC
  • DCC has been shown to have many benefits for infants
  • It is recommended by many professional organizations
  • Compromised infants can benefit most from DCC and moving towards resuscitation with an intact cord should be supported
  • Ultimately, and most importantly, it not about the cord
  • Ultimately, it is about improved outcomes for all infants

References

  1. Coggins, M. & Mercer, J. 2009. Delayed Cord Clamping: Advantages for Infants. Nursing for Women’s Health, 13 (2), p. 132-139.
  2. McAdams, R. 2014. Time to Implement Delayed Cord Clamping. Obstetrics and Gynecology, 123 (3), p. 549-552.
  3. Kim, A.J.H. & Warren, J.B. 2015. Optimal Timing of Umbilical Cord Clamping: Is the Debate Settled? Part 1 of 2: History, Rationale, Influencing Factors, and Concerns. NeoReviews, 16 (5), p. e263-e269.
  4. Kim, A.J.H. & Warren, J.B. 2015. Optimal Timing of Umbilical Cord Clamping: Is the Debate Settled? Part 2 of 2: Evidence in Preterm and Term Infants, Alternatives, and Unanswered Questions. NeoReviews, 16 (5), p. e270-e277.
  5. Leslie, M.S. 2015. Perspectives on Implementing Delayed Cord Clamping. Nursing for Women’s Health, 19 (2), p. 164-176.
  6. McAdams, R.M., Backes, C.H. and Hutchon, D.J.R. 2015. Steps for Implementing Delayed Cord Clamping in a Hospital Setting. Maternal Health, Neonatology and Perinatology.

Evaluation

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