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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.

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Presentation on theme: "Clinical Challenges to Cord Clamping Cord Blood Banking Umbilical Cord Gases Neonatal Resuscitation Dealing with a Nuchal Cord Active Management & the."— Presentation transcript:

1 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 D & Mercer J. (Dec 2014)

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

3 Cord Blood Banking 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: ) A hot commodity…no longer just medical waste Erickson-Owens D & Mercer J. (Dec 2014)

4 Press release from Americord on April 17, 2013 Erickson-Owens D & Mercer J. (Dec 2014)

5 Umbilical Cord Gas Collection 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 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 Erickson-Owens D & Mercer J. (Dec 2014)

8 Blood Gas Sampling Andersson et al 2012 Erickson-Owens D & Mercer J. (Dec 2014)

9 Neonatal Resuscitation Erickson-Owens D & Mercer J. (Dec 2014)

10 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)

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:F The LifeStart System Erickson-Owens D & Mercer J. (Dec 2014)

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13 Nuchal Cord 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 Erickson-Owens D & Mercer J. (Dec 2014)

15 Somersault Maneuver (Schorn & Blanco, 1991) Erickson-Owens D & Mercer J. (Dec 2014)

16 Nuchal Cord Loose Loop over head Loop over shoulders Tight Somersault Maneuver Cut and Clamp 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 “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: “Resuscitate at the perineum with an intact cord” Erickson-Owens D & Mercer J. (Dec 2014)

20 Active Management of 3 rd Stage Erickson-Owens D & Mercer J. (Dec 2014)

21 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 & RCV No Overtransfusion Erickson-Owens D & Mercer J. (Dec 2014)

22 “CUT & RUN”…Think Milking 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 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” Erickson-Owens D & Mercer J. (Dec 2014)

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


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