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)
Cord Blood Banking
Erickson-Owens D & Mercer J. (Dec 2014)
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)
Press release from Americord on April 17, 2013
Erickson-Owens D & Mercer J. (Dec 2014)
Umbilical Cord Gas Collection
Erickson-Owens D & Mercer J. (Dec 2014)
Umbilical Cord Blood Gases
• ACOG Clinical Opinion in 1996 & 2006
(reaffirmed in 2012)
• Cord blood samples after 20 min delay is
unreliable
• DCC of 90 secs has little clinical significance on
arterial pH in healthy newborns
• 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
Armstrong & Stenson 2006
Wiberg, Kallen & Olofsson 2008
Lynn & Beeby 2007
Erickson-Owens D & Mercer J. (Dec 2014)
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)
Blood Gas Sampling
Andersson et al 2012
Erickson-Owens D & Mercer J. (Dec 2014)
Neonatal Resuscitation
Erickson-Owens D & Mercer J. (Dec 2014)
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)
“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)
Erickson-Owens D & Mercer J. (Dec 2014)
Nuchal Cord
www.pattiramos.com/
Erickson-Owens D & Mercer J. (Dec 2014)
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)
Somersault Maneuver
Erickson-Owens D & Mercer J. (Dec 2014)
(Schorn & Blanco, 1991)
Nuchal
Cord
Loose
Loop over
head
Loop over
shoulders
Tight
Somersault
Maneuver
Cut and
Clamp
Practice
Recommendation
Erickson-Owens D & Mercer J. (Dec 2014)
Shoulder Dystocia
Erickson-Owens D & Mercer J. (Dec 2014)
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)
“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)
Active Management of
rd
3
Stage
Erickson-Owens D & Mercer J. (Dec 2014)
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)
“CUT & RUN”…Think Milking
Erickson-Owens D & Mercer J. (Dec 2014)
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)
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)
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)
Keep the Cord Intact
Contact Email: debeo@uri.edu
Erickson-Owens D & Mercer J. (Dec 2014)