1. 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
This series of slides address clinical challenges in maintaining an intact cord at the time of birth.
Obstetric and pediatric care givers usually have very strong opinions about when to clamp and cut the cord.
These opinions may or may not be based in research evidence.
So how can we take the available research and apply it to clinical practice?
These are some common clinical situations that challenge maintaining an intact cord. In these situations immediate cord clamping is the usual practice.
This review offers suggestions to support an intact cord to allow Placental Transfusion (delayed cord clamping and cord milking).
Please acknowledge Debra Erickson-Owens, PhD, CNM and Judith Mercer, PhD, CNM, FACNM (& the 2014 Hattie Hemschemeyer award winner) when presenting this slide show to your colleagues.
If you have any questions please Deb Erickson-Owens at
Thanks for spreading the word!
Erickson-Owens D & Mercer J. (Dec 2014)

2. Cord Blood Banking
Erickson-Owens D & Mercer J. (Dec 2014)

3. A hot commodity…no longer just medical waste
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: )
Historically, cord blood has been considered medical waste. It is only recently stem cells have taken on an role of importance.
In 2007 the American Academy of Pediatrics (AAP) made recommendations regarding cord blood banking. (Note: this recommendation was retired in May 2012)
This can pose an ethical dilemma. Especially in regards to the potential for infant anemia with immediate cord clamping.
How can we tell parents the baby needs it’s own cord blood and then perform cord blood collection, especially in a compromised infant.
Many parents choose not to do it when they learn all the facts.
New techniques are being developed where companies that process stem cells will need a smaller volume.
A reminder about Stem Cells--it is important to mention their significant role in healing and repair. Human umbilical cord stem cells play a significant role as a reservoir of pluripotent stem cells to produce a variety of stem cells such as hematopoietic stem cells, endothelial cell precursors, mesenchymal progenitors and multipotent/pluripotent lineage stem cells.
Theoretically, a full placental transfusion can facilitate > a million stem cells.
When cord blood is banked, the infant will not receive it’s first stem cell transplant at birth. (Toloso et al. J Cell Mol Med 2010; 14: )
Erickson-Owens D & Mercer J. (Dec 2014)

4. Press release from Americord on April 17, 2013
Current industry benchmarks for cord blood collections are a minimum of 50 ml of blood. Given the amount of blood likely to flow out of the placenta at the time of birth, there is typically plenty to be stored for later use. Delayed clamping can provide important value to the baby immediately, and stem cells from cord blood can provide long-term protection. To date, more than 80 diseases have been treated using cord blood stem cells, and they have also be used in transplant medicine in lieu of a bone marrow transplant for leukemia. Growing evidence supports the fact that parents can both delay clamping and store stem cells from cord blood, without choosing one over the other.
In a statement on Friday, Americord CEO Martin Smithmyer said, "It is exciting to see the growing evidence that expecting parents can both delay clamping and bank their baby's cord blood. We are happy to say that, with Americord, we have seen little negative impact on cord blood banking from delayed cord clamping." Americord's collection policy further supports parents interested in delayed clamping. With Americord, if a collection falls below the industry benchmark, parents are given the option to store their cord blood, and are not charged if they decide not to store. Americord supports those parents who elect to delay the clamping of their baby's umbilical cord.
Contact:
Andrew Flook Americord Registry
Press release from Americord on April 17, 2013
Erickson-Owens D & Mercer J. (Dec 2014)

5. Umbilical Cord Gas Collection
In some institutions, umbilical cord gas collection is a routine at all births. This implies immediate cord clamping.
Erickson-Owens D & Mercer J. (Dec 2014)

6. Umbilical Cord Blood Gases
ACOG Clinical Opinion in 1996 & 2006 (reaffirmed in 2012)
Cord blood samples after 20 min delay is unreliable Armstrong & Stenson 2006
DCC of 90 secs has little clinical significance on arterial pH in healthy newborns Wiberg, Kallen & Olofsson 2008
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 Lynn & Beeby 2007
ACOG clinical opinion “Umbilical cord blood gas analysis at delivery” published in 1996 recommended ICC for cord gas collection suggesting DCC may  significant  in arterial blood pH and  arterial PCO2 and base deficit (based on a 1984 study by Lievaart and colleagues); The 2006 literature is different. No longer says do not delay clamping; Lists clinical situations which cord blood samples should be collected (next slide). There have been 10 RCTS (Ceriani Cernadas06, Chaparro06, van Rheenen07, Venancio08, Jahazi08, Jaleel09, Shirvani10, Andersson11, Begum12, Al-Tawil12) & 3 systematic reviews (Hutton07, Mathew11, McDonald13) published since the publication of the 2006 document reporting the benefit of placental transfusion;
The literature has examined the effects of DCC on arterial blood gases (ABG). None have made a strong clinical recommendation but have stressed blood gas values begin to lose their reliability after mins. Placental transfusion is usually complete before 5 minutes.
This is a developing issue with placental transfusion. If a cord gas is needed immediately as part of a policy at your facility, there are 2 suggestions:
Collection of ABG within several minutes after birth
Consider cord milking
Erickson-Owens D & Mercer J. (Dec 2014)

7. 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
ACOG does not state cord blood gas sampling should be done routinely
The language in the 2006 document states Cord gas collection is recommended in the following clinical situations:
C/Sec for fetal compromise
Low Apgar at 5 mins
Severe growth restriction
Abnormal FHR tracing
Maternal thyroid disease
IP fever
Mutlifetal gestations
“immediately after delivery of the neonate , a segment of umbilical cord should be double-clamped, divided, and placed on the delivery table pending assignment of the 5-min Apgar.
Erickson-Owens D & Mercer J. (Dec 2014)

8. Blood Gas Sampling Andersson et al 2012
It is possible to collect cord gases and still maintain an intact cord.
Per conversation with the Swedish neonatology researcher-Ola Andersson- in a randomized clinical trial comparing immediate and delayed cord clamping (~400 women and their term healthy infants). Cord gases are routinely collected at his institution and delayed clamping is routinely done. Cord gases can be collected near the umbilicus using the normal cord gas collection equipment. It requires 2 people. One to hold the infant and the other to collect the cord gas.
Andersson et al 2012
Erickson-Owens D & Mercer J. (Dec 2014)

9. Neonatal Resuscitation
When Hypovolemia is suspected at birth…..
Consider the additional support of placental transfusion
Hypovolemia is the most frequent caused of a failed resuscitation
Erickson-Owens D & Mercer J. (Dec 2014)

10. Circulation….Airway…. Breathing….
will begin when lungs have perfused from placental transfusion
The current guidelines of NRP focuses on Airway, Breathing, Circulation
We want to propose a new approach-Circulation, Airway, Breathing
Neonatal Resuscitation Program recommendations (2010)-For uncomplicated births both term and preterm not requiring
resuscitation – delay cord clamping by at least 1 minute
We propose-Steps of NRP can be followed with an intact cord
Placental transfusion provides needed BV and RBC. There is no substitute for the infant’s own blood
Avoid cutting a nuchal cord before birth
Adult CPR now focuses now on circulation
Ewy G, Kern K, Sanders A, Newburn D (2006) Am J Med, 119:6-9
Erickson-Owens D & Mercer J. (Dec 2014)

11. “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
Immediate cord clamping is the usual practice in the US for an infant in need of resuscitation.
Two obstetricians from the United Kingdom suggest the benefit of keeping the cord intact during a resuscitation and performing the resuscitation at the bedside (the labor room or the OR)
Keeping the cord intact during the resuscitation allows the additional support of the placenta and available PRBV (with iron-rich blood cells) for improved oxygenation.
“The LifeStart system provides a stable, warmed platform for resuscitation of the newborn baby. The system is very compact and has electrically operated, hands-free height adjustment. Suction, blender and CPAP ventilation with PEEP can all be easily mounted on the unit. A timer, with audio alerts, allows staff to keep track of the post-delivery period. Integrated medirails allow the user to add other equipment such as pulse oximeter and to configure all items to suit local practice.” (
Clinical Considerations
“In order to resuscitate with the cord intact the height of the platform can be adjusted to position the baby correctly in relation to the placenta. The very compact design and easy maneuverability allow the unit to be positioned very close to the bed or operating table, well within limits of umbilical cord length. The ergonomic layout ensures access for the clinical team is not compromised and the newborn baby’s airway can be easily established.
In addition to resuscitation the unit provides a suitable environment for less critical treatment of the baby. It allows the newborn infant to stay close to its mother, helping to reduce parental anxiety in the initial period following delivery.” (
The LifeStart System
Erickson-Owens D & Mercer J. (Dec 2014)

12. This review article is in the JMWH Nov/Dec 2014 issue
Meant to create thinking around whether it is time to consider neonatal resuscitation with an intact umbilical cord.
Erickson-Owens D & Mercer J. (Dec 2014)

13. Nuchal Cord
Can occur up to a 1/3 of all births 8 – 35.5% of pregnancies have a nuchal cord (Ogueh et al, 2006)
Nuchal cords form & resolve over the course of a pregnancy/NCs are dynamic “they come and go”
The incidence of Nuchal cord increases with gestational age 42 weeks 29% of births have nuchal cord present)
More frequent with
-Long cords
-Active fetuses
-Vertex presentation (usually cords > length than breech)
Nuchal cord is a fairly common event during pregnancy and at birth and is benign for most infants.
However, a tight nuchal cord is often associated with hypovolemia after birth.
Management of a nuchal cord can have consequences as the fetus transitions to neonatal life.
Erickson-Owens D & Mercer J. (Dec 2014)

14. 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
When pressure on the cord and compression increases, the soft walled vein easily compresses and the thicker, muscular walled arteries continue to send blood to the placenta. Return of blood via the easily compressible umbilical vein is impeded and the infant can become hypovolemic. If recovery time between contractions is short, the loss of blood volume can be severe. The infant can become hypoxic as well as hypovolemic.
Oligiohydramnios worsens the effects of nuchal cord on fetal status during labor as well as multiple cord encirclements
Neonatal status may be compromised by the uncorrected physiologic effects of hypoxia as well as reduced blood volume
Erickson-Owens D & Mercer J. (Dec 2014)

15. Somersault Maneuver (Schorn & Blanco, 1991)
Infants with NCs have the potential to lead to hypovolemia and possible hypoxia.
Many providers have been taught to double clamp a tight nuchal cord
An intact cord allows placental TFX and physiologically can adjust the situation in the 1st few minutes after birth.
The Somersault Maneuver is all about keeping the cord intact Cite: Schorn & Blanco. (1991). Management of a Nuchal Cord. J Nurs Midw. 36(2): 131-2
A nuchal cord is noted after the head delivers. It is not easily reducible over the head and is too tight to push down over the shoulders
As the infant is born, the head is kept as close to the perineum (or thigh) as possible “folding” the baby up towards the symphysis as it is born.
The cord is gently unwound from around the neck.
If the baby has poor tone or is very pale, the infant should be placed on the bed, dried and stimulated while s/he receives placental transfusion and resus and until tone returns and the infant is breathing. Most resuscitation can be done at the perineum.
Once the infant has good tone and color, the infant can be placed on the maternal abdomen without cutting the cord
Erickson-Owens D & Mercer J. (Dec 2014)

16. Practice Recommendation
Nuchal Cord
Loose
Loop over head
Loop over
shoulders
Tight
Somersault
Maneuver
Cut and Clamp
Do not recommend double clamp and cutting the cord.
This takes a distinct departure from the practice of double clamping and cutting the cord before birth of the shoulders.
Once a nuchal cord is identified you can either :
If Loose: Do nothing
Slip cord over head, if loose
Slip baby through cord as birth happens
If Tight: Somersault maneuver
Practice Recommendation
Erickson-Owens D & Mercer J. (Dec 2014)

17. Shoulder Dystocia
Erickson-Owens D & Mercer J. (Dec 2014)

18. 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)

19. “Resuscitate at the perineum
“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:
Erickson-Owens D & Mercer J. (Dec 2014)

20. Active Management of 3rd Stage
Traditionally active management of the 3rd stage (AMTSL) meant administering a uterotonic just before birth of the shoulders or after birth, immediate clamping of the umbilical cord and traction to hasten 3rd stage.
Recent recommendations from the FIGO and ICM suggest DCC can co-exist with AMTSL however many care givers are concerned about the risk of maternal hemorrhage as well as overtransfusion of the infant after administration of an uterotonic such as oxytocin.
New findings conclude there is no risk of maternal PPH with DCC and a classic study by Yao and colleagues (1968) demonstrate there is no overtransfusion of the infant. NEXT SLIDE
Erickson-Owens D & Mercer J. (Dec 2014)

21. No Overtransfusion Red Circle = Leveling off of BV & RCV
Figures In parens indicate the number of infants studied at each time frame. Values are expressed as mean + SE
Uterotonics can be safely used during the 3rd stage.
You can see at approximately 3 (180 secs) mins after birth, the blood volume and RCV “level” off and there is no evidence of overtransfusion.
Important to note is at CC secs: The BV is < 75 ml/kg and the RCV is 35 ml/kg
CC 3 mins: The BV is >85 ml/kg and the RCV is 45 ml/kg
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)

22. “CUT & RUN”…Think Milking
Milking the umbilical cord is a substitute for DCC when speed and time are critical. Cord milking mechanically accelerates placental transfusion.
Serves as an alternative to DCC for “Cut & RUN” situations such as:
C/Sec: Time, speed challenge DCC at the time of birth (Erickson-Owens et al J of Perinatology)
Neonatal Resus: To avoid Hypovolemia -Nuchal Cord, Shoulder Dystocia
The review of the literature supports the technique is safe and results in higher neonatal hemoglobin levels and red cell volume at birth.
Erickson-Owens D & Mercer J. (Dec 2014)

23. 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)

24. 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
Practices Recommendations to consider:
Cutting a nuchal cord before the shoulders deliver can be harmful. The Somersault Maneuver protects an intact cord and can assist with physiologic transfer of BV immediately after birth.
Rethink the alphabet. Circulation in addition to airway and breathing.
When the clinical situation requires you to cut and run, milk first.
The AAP does not recommend routine cord blood banking. Families need information about the risks and benefits
Umbilical Cord Gas can co-exist with placental transfusion
Finally, Contractions facilitate the transfer of BV and RBCs to the infant. Uterotonics accelerate this transfer but do not overtranfuse the infant
Erickson-Owens D & Mercer J. (Dec 2014)

25. 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”
Practices Recommendations to consider:
Cutting a nuchal cord before the shoulders deliver can be harmful. The Somersault Maneuver protects an intact cord and can assist with physiologic transfer of BV immediately after birth.
Rethink the alphabet. Circulation in addition to airway and breathing.
When the clinical situation requires you to cut and run, milk first.
The AAP does not recommend routine cord blood banking. Families need information about the risks and benefits
Umbilical Cord Gas can co-exist with placental transfusion
Finally, Contractions facilitate the transfer of BV and RBCs to the infant. Uterotonics accelerate this transfer but do not overtranfuse the infant
Erickson-Owens D & Mercer J. (Dec 2014)

26. Keep the Cord Intact
Contact
Erickson-Owens D & Mercer J. (Dec 2014)