Delayed cord clamping: Studied with Judith Mercer Not just for - PowerPoint PPT Presentation

Nothing to disclose (kind of) � No financial ties “Delayed” cord clamping: � Studied with Judith Mercer Not just for preemies *Drop the scissors* Kate Norman Fr ό meta, MS, CNM Assistant Professor, UCSF Division of Maternal-Fetal Medicine 6/17/2017 2 “Delayed” cord clamping: Not just for preemies Do You Intentionally Delay Cord Clamping in Term If You Delay, How Long Do You Delay? Neonates? A. <1 minute 42% 40% 93% A. Yes B. 1-3 minutes C. > 3 mins B. No D. Until the cord stops pulsing 13% 5% 7% <1 minute 1-3 minutes > 3 mins Until the cord stops p... No Yes 3 Presentation Title and/or Sub Brand Name Here 6/17/2017 4 Presentation Title and/or Sub Brand Name Here 6/17/2017 1 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Cord Clamping through time � Traditionally the cord was not cut until after the delivery of the placenta First cord � First accounts of cutting the cord before delivery of the placenta from clamp: 1899 the 17 th century Magennis • Birthing in bed cord clamp “The cord, when it has ceased to pulsate be placed between the blades” 5 “Delayed” cord clamping: Not just for preemies Why Delay Cord Clamping? Volume of blood that remains in the placenta � Immediate: 30% � Why Not??? � 60 seconds: 20% � 3 minutes: 13% • What is the intervention? ‒ Now in the position of finding evidence to justify our non-intervention when the intervention was never justified ‒ Consent for an intervention with ICC? ‒ Placental transfusion 2 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Where does the blood go? � Newborn lung circulation: ~10% in utero to ~50% ex utero Also better perfusion, less hypothermia fetal heart pumps: In utero 110ml/k Ex utero 90ml/k 9 Delayed” cord clamping: Not just for preemies Why Delay Cord Clamping? Why Delay Cord Clamping? � Term : � Preterm: • Up to 30% increase in blood volume -improved blood pressure, increased cerebral oxygen index, • Less Anemia reduced number of blood transfusions, less need for inotropic support, ‒ Higher hemoglobin levels at 24 to 48 hours of age lower risk of necrotizing enterocolitis, nearly twofold reduction in risk for intracranial hemorrhage of all types ‒ increased serum ferritin levels (23-45% higher) at 4 to 6 months. (ACOG recommended delay in 2012) ‒ Infants with ICC were twice as likely to be iron deficient at 3 to 6 months. ‒ Results more pronounced in infants of anemic mothers � Anemia reduced by 40% at 4 mos and 60% 8 mos. Rabe, Diaz-Rossello, Duley, & Dowswell, 2012 Blouin, 2013, McDonald et al, 2013 11 Delayed” cord clamping: Not just for preemies 3 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Why Do We Care Why Do We Care About Iron Deficiency? Iron deficiency in infancy associated with : About Iron � poor school performance, � Iron: essential for normal neurogenesis, differentiation of brain cells, brain Deficiency? metabolism, neurotransmitter function, oligodendrogenesis, and myelination � decreased cognitive abilities, � less positive affect � Anemia: Reduced arborization of dendrites that decrease the complexity of interneural connections � more difficult to soothe � Infants with DCC have increased myelin content at 4 month of age in brain � reduced level of engagement with examiners. regions associated with motor, visual and sensory processing/function � lower IQs (more pronounced in lower compared with ICC. socioeconomic groups) � less favorable neurodevelopmental outcomes � behavioral problems out to 19 years of age. Beard & Connor 2003; Brunette & Tran et al 2010; Georgieff & Rao 2011 *Even after correction* Lozoff et al, 2006; Lozoff et al, 2008; Lozoff et al 2010; Burden et al 2004; Pierano et al, 2010 13 Delayed” cord clamping: Not just for preemies Why do we care about Iron Deficiency? Stem Cells! � Anemia in the US: � 10x the amount of bone marrow � Anemia among participants in federally funded mat-child health and � Neuroprotection… nutrition programs (2010 data) • 33.8% of all mothers Cotton et al (2014) • 49.5% of all Non-Hispanic African-American mothers -Autologous stem cell transfusion in babies being head-cooled •By 6-12 mos 18% of all infants and 23.5% of AA were anemic. >85 on Bayley scale: 74% transfused babies Large state-to-state disparities as well. 41% control group Maternal anemia rates are higher than any region outside of Africa. Dalenius, Brindley, Smith, Reinold, & Grummer-Strawn, 2012 15 Delayed” cord clamping: Not just for preemies 4 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Lack of Harm No difference (Term) Maternal Neonatal � since 1980, NO published, randomized controlled trial has supported a relationship between DCC and symptomatic polycythemia or � PP hemorrhage � Apgars, need for resuscitation hyperbilirubinemia. � Mean blood loss � NICU admission � Hgb pp � Cord pH � Retained placenta � respiratory distress � Blood transfusions � Clinical jaundice (no treatment) � Duration of 3 rd stage � Polycythemia requiring treatment � Need for uterotonics McDonald et al, 2013, Hutton and Hassan, 2007 17 Delayed” cord clamping: Not just for preemies 18 Delayed” cord clamping: Not just for preemies Jaundice Requiring Treatment McDonald’s Dissertation � MacDonald and Middleton systematic review (Cochrane) included • Did not report bilirubin levels or weighted results of data from an unpublished dissertation from 1996 guidelines for jaundice tx, no for the outcome of bili light use. blinding. Has not been peer reviewed. • 2.7% increase in bili light use. • <2% in 2013 update • Without this data results no longer significant • Increased light use not seen in Hutton and Hassan, 2007 19 Delayed” cord clamping: Not just for preemies 20 Delayed” cord clamping: Not just for preemies 5 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Why Delay Cord Clamping at Term? Why Delay Cord Clamping? � Because the family told you to ☺ � Because your professional Organization told you to: � WHO 2006, 2012, 2014 (1-3 mins) � ACNM 2014 (2 mins below introitus, 5 mins skin- to-skin) � ACOG 2016 (at least 30-60 secs) � NICE 2012 (at least 60 secs) � FIGO/ICM 2003 (until pulsations cease - include 1-3 mins of DCC in AMTSL guidelines) � NRP 2015 (30-60 seconds in vigorous term and preterm infants) 22 Delayed” cord clamping: Not just for preemies How Long to Delay? How long to Delay? � “Until the cord stops pulsing” � Time to cord clamping was varied in studies anywhere from 1 -10 mins • Study of 15 infants during DCC using doppler u/s • Stopping of pulsations not correlated with stopping of blood flow. � Full transfusion by about 3 mins if below level of placenta but if skin-to- • Venous blood flowed for a median of 4.5 mins in 57% of infants and skin may take closer to 5 mins to get full transfusion was still flowing at 5.25 mins in 33% of infants Boere et al, 2014 23 Delayed” cord clamping: Not just for preemies 24 Delayed” cord clamping: Not just for preemies 6 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Position of the Neonate Residual Placental Blood Volume (PRBV) with Skin-To-Skin Placement ICC DCC x 2 DCC x 5 CM 35 25 18 11 Erickson-Owens, Mercer & Thulier, 2012 PRBV ml/kg How long to Delay? At least 3 minutes at the perineum At least 5 minutes on maternal abdomen “Wait for white” 27 Delayed” cord clamping: Not just for preemies 28 Delayed” cord clamping: Not just for preemies 7 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Cord Milking Cord Milking � A technique used to � Use when time and speed are a factor accelerate placental � Lower infant and milk cord 4 to 5 times (wait for cord to refill if transfusion when the possible) clinical situation doesn’t allow time for � In term and preterm studies – results same as DCC DCC • Higher H & H, better blood pressure • Higher ferritin levels at 6 weeks to 6 months • No increase in jaundice or symptomatic polycythemia 29 Delayed” cord clamping: Not just for preemies 30 Delayed” cord clamping: Not just for preemies Barriers to change Cord Blood Banking � Tight Nuchal Cord � ACOG Committee Opinion #399 (2008) � Cord gases “collection should not alter routine � AMSTL practice for the timing of umbilical cord � Cord blood banking clamping” � TRADITION • Sit on your hands � Babies aren’t allowed to be • ? Resus blood donors ! 31 Delayed” cord clamping: Not just for preemies 32 Delayed” cord clamping: Not just for preemies 8 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Take Home Messages � ICC is an intervention without any rationale or evidence to support it. � No longer “not enough evidence” to justify delayed cord clamping. 33 Delayed” cord clamping: Not just for preemies 34 Delayed” cord clamping: Not just for preemies Special thanks to Judith Bishop, CNM and Judy Mercer, CNM 35 Delayed” cord clamping: Not just for preemies 9 6/17/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]