DELAYED CORD CLAMPING

Placental Transfusion –

TO DELAY OR NOT

MEAN DURATION OF CORD CLAMPING IN OUR UNIT

8.9 sec

What happens when there is ICC

At mid-term--relatively large size of placenta compared with the fetus, blood is equally distributed between the fetus and placenta

By term -1/3 of the blood flows through the placenta and 2/3 flows through the fetus

What happens when there is ICC ICC results in ~30% of feto- placental

blood volume remaining in the placenta,

DCC reduces residual placental blood to 20% of the feto-placental blood volume by 60 s and to 13% by ~ 3–5 min.2

RELATIONSHIP BETWEEN TIMING OF CORD CLAMPING AND NEONATAL BLOOD VOLUME

What is in Cord Blood?• RBCs

– 15 mL/kg RBCs– Iron: 30 to 75 mg (enough for 3 to 6 mo’s

need)• Stem Cells

– Several million to 1 billion SCs– (and cytokines to direct them)

• Plasma/cells for volume expansion

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• WHY ARE WE AS A PEDIATRICIAN CONCERNED ?

Increased IVH ,Sepsis

IDA and psychomotor retardation

Stem cells loss

Factors Contributing to IVH, Sepsis, and Motor Delay in Preterm Infants with ICC

Blood volume loss which may contribute to Cardiovascular instability Loss of brain blood pressure

autoregulation Poorer perfusion of all tissues -especially

the fragile germinal matrix

Inflammation secondary to blood loss (pro-inflammatory cytokines)

Loss of hematopoietic stem cells and cord blood factors

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IDA Delayed umbilical cord clamping may be particularly relevant

for infants living in low-resource settings with less access to iron-rich foods and thus greater risk of anaemia

Children - vulnerable to iron deficiency anaemia

Children with iron deficiency are more likely to have delayed psychomotor development

Both epidemiological and experimental data suggest that when these impairments occur at an early age, they may be irreversible, even after repletion of iron stores, thus reinforcing the importance of approaches (such as delayed cord clamping) that can prevent this condition

STEM CELLS

Stem Cells: Baby’s First Transplant

“ …a delay in cord clamping may stem cell supply to the baby…innate stem cell therapy…acute benefits in case of NB disease….long term benefits against age-

related diseases” Tolosa JN, Park DH, Eve DJ, Klasko SK, Borlongan CV, Sanberg PR. Mankind’s first natural stem cell transplant. J Cell Mol Med. 2010;14:488-495. Sanberg P, Park, D-H & Borlongan. (2009). Stem Cell Transplants at Childbirth. Stem Cell Rev and Rep

WHAT ARE YOUR CONCERNS•DELAY IN INTIATATION OF RESUSCITATION

• PPH

•ASSIGNMENT OF TIME OF BIRTH

•OTHERS

EVIDENCE

ACOG 2017

WHAT IS EARLY AND

DELAYED

Two guideline development groups were involved

WHO Guidelines on basic newborn resuscitation and WHO recommendations for the prevention and treatment of postpartum haemorrhage

“Early” cord clamping is generally carried out in the first 60 seconds after birth (generally within the first 15–30 seconds), whereas “delayed” umbilical cord clamping is carried out more than 1 min after the birth or when cord pulsation has ceased .

DCC V/S UCM

JAMA Pediatr. 2015

A recent meta-analysis (26) of seven studies that involved 501 preterm infants compared umbilical cord milk- ing with immediate cord clamping (six studies) or with delayed umbilical cord clamping (one study).

Results

Umbilical cord milking was associated with benefits and no adverse effects in the immediate postnatal period in preterm infants (gestational age, <33 weeks); however, further studies are warranted to assess the effect of UCM on neonatal and long-term outcomes.

Fallacies The method of umbilical cord milking

varied considerably in the trials in terms of the number of times the cord was milked, the length of milked cord, and whether the cord was clamped before or after milking

Subgroup analysis comparing umbilical cord milking directly with delayed umbilical cord clamping was not able to be carried out because of small numbers in those groups

WHICH IS BETTER DCC OR UCM Further research is needed for

comparing DCC with UCM

DOUBTFUL CONDITIONS HIV Rh Issoimmunization Compromised feto-placental blood flow Twins

HIV

RH ISOIMMUNIZATION Benefits of Delayed Cord Clamping in Red Blood Cell Alloimmunization

Pediatrics March 2016

MULTIPLE GESTATION At this time, there is not sufficient

evidence to recommend for or against delayed umbilical cord clamping in multiple gestations

MAJOR LIMITATIONS IN PRACTICING DCC

What we are going to follow DCC for minimum 60 seconds

Both Preterm/Term not requiring resuscitation irrespective of type of birth

UCM in case of those requiring resuscitation milking 3 times equal to length of forceps

TOGETHER FOR BETTER MATERNAL AND NEONATAL OUTCOMES