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Clinical Challenges to Cord Clamping

Cord Blood Banking. Umbilical Cord . Gases. Neonatal Resuscitation. Dealing with a Nuchal Cord. Active Management & the 3. rd. Stage. When you are in a “cut & run” situation. . Erickson-Owens .

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Clinical Challenges to Cord Clamping

Presentation on theme: "Clinical Challenges to Cord Clamping"— Presentation transcript:


Clinical Challenges to Cord Clamping

Cord Blood BankingUmbilical Cord GasesNeonatal ResuscitationDealing with a Nuchal CordActive Management & the 3rd StageWhen you are in a “cut & run” situation


D & Mercer J. (Dec 2014) Slide2

Cord Blood Banking

Erickson-Owens D & Mercer J. (Dec 2014) Slide3

Cord Blood Banking

AAP (2007) recommendations (Retired May 2012):Do not collect in complicated deliveriesCord 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 infancyLack of true informed consentAvoid 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)


hot commodity…no longer just medical waste

Erickson-Owens D & Mercer J. (Dec 2014) Slide4

Press release from

Americord on April 17, 2013Erickson-Owens D & Mercer J. (Dec 2014) Slide5

Umbilical Cord Gas Collection

Erickson-Owens D & Mercer J. (Dec 2014) Slide6

Umbilical Cord Blood Gases

ACOG Clinical Opinion in 1996 & 2006 (reaffirmed in 2012) Cord blood samples after 20 min delay is unreliable Armstrong & Stenson 2006DCC of 90 secs has little clinical significance on arterial pH in healthy newborns Wiberg, Kallen & Olofsson 2008Sampling can be postponed for up to 15 mins after birth Paerregaard, Nickelsen, Brandi & Andersen 1987Delay in sampling can result in abnormal findings by 30 mins Lynn & Beeby 2007

Erickson-Owens D & Mercer J. (Dec 2014) Slide7

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 compromiseLow 5-min Apgar scoreSevere IUGRAbnormal FHR tracingMaternal thyroid diseaseIP feverMultifetal gestationsErickson-Owens D & Mercer J. (Dec 2014) Slide8

Blood Gas Sampling

Andersson et al 2012Erickson-Owens D & Mercer J. (Dec 2014) Slide9

Neonatal Resuscitation

Erickson-Owens D & Mercer J. (Dec 2014) Slide10


Breathing….CirculationAirwayBreathingwill 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) Slide11

“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;



The LifeStart System

Erickson-Owens D & Mercer J. (Dec 2014) Slide12

Erickson-Owens D & Mercer J. (Dec 2014) Slide13

Nuchal Cord

www.pattiramos.com/Erickson-Owens D & Mercer J. (Dec 2014) Slide14

What happens with a NC ?

When a cord tightens around neck it can lead to hypovolemiaSoft walled vein more easily compressedThick walled arteries continue to send blood to the placentaBlood backs up in placentaProblem worse if time short between contractionsGets hypoxic as well as hypovolemicWorse if oligiohydramnios and/or multiple loops of cordErickson-Owens D & Mercer J. (Dec 2014) Slide15

Somersault Maneuver (Schorn & Blanco, 1991)

Erickson-Owens D & Mercer J. (Dec 2014) Slide16

Practice Recommendation

Erickson-Owens D & Mercer J. (Dec 2014) Slide17

Shoulder Dystocia

Erickson-Owens D & Mercer J. (Dec 2014) Slide18

A Common Obstetrical Practice…

Cutting the cord prior to shoulders and rushing (if needed) to the warmer for resuscitationErickson-Owens D & Mercer J. (Dec 2014) Slide19

“Infants experiencing a traumatic birth involving shoulder dystocia are often severely compromised, even when labor was uncomplicated.”

Mercer J, Erickson-Owens D & Skovgaard R. (2009). Cardiac asystole at birth: Is hypovolemic shock the cause? Medical Hypotheses, 72: 458-63.“Resuscitate at the perineum with an intact cord”Erickson-Owens D & Mercer J. (Dec 2014) Slide20

Active Management of 3

rd StageErickson-Owens D & Mercer J. (Dec 2014) Slide21

Rate of placental transfusion of 195 term infants whose mothers had methylergonovine IV stat after infant’s birth. Yao et al 1968

Red Circle = Leveling off of BV & RCVNo Overtransfusion

Erickson-Owens D & Mercer J. (Dec 2014) Slide22

“CUT & RUN”…Think Milking

Erickson-Owens D & Mercer J. (Dec 2014) Slide23

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 introitusCesarean birth-start near insertion site on placentaChallenges: Cord is slippery

Can be tightly coiled and difficult to milk entire cord

Potential to tear (rare)

Erickson-Owens D & Mercer J. (Dec 2014) Slide24

Practice Recommendations

Cord blood banking….you don’t need to alter your cord clamping practiceUmbilical Cord Gases can co-exist with a delay or milking of the cordResuscitation may be improved with “CAB” and an intact cordSomersault Maneuver avoids ICC with nuchal cord

Erickson-Owens D & Mercer J. (Dec 2014) Slide25

Practice Recommendations

With shoulder dystocia be aware of hypovolemia and its negative consequencesUterotonics accelerate transfer of blood to the infant but does not lead to overtranfusionCord Milking is an important when you must “cut and run” Erickson-Owens D & Mercer J. (Dec 2014) Slide26

Keep the Cord Intact

Erickson-Owens D & Mercer J. (Dec 2014) Contact Email: debeo@uri.edu