delayed cord clamping sept 2013.pdf
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8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 140
Prof Jayashree Ramasethu MD FAAP
Director of Neonatal Perinatal Medicine Fellowship Program
Georgetown University Hospital Washington DC USA
bull MD Degree at Christian Medical College University of Madras
Vellore Tamil Nadu India
bull Postgraduate training at Department of Pediatrics Childrenrsquos
National Medical Center George Washington University
Washington DC
bull Neonatal fellowship at Department of Perinatal Medicine -
Westmead Hospital University of New South Wales Sydney
Australiabull Neonatal Perinatal Medicine fellowship at Childrenrsquos National
Medical Center George Washington University Washington DC
USA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 240
ldquoDelayedrdquo Cord Clamping
Jayashree Ramasethu MD FAAP
Division of Neonatal Perinatal MedicineMedStar Georgetown University Hospital
Washington DC
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 340
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 440
ACOG Practice Bulletins 127216348
(1989-2006)
ldquoActiverdquo management of labor and delivery
ldquoImmediately after delivery of the neonate asegment of the umbilical cord should be
doubly clampedrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 540
gt200 years ago
ldquo Another thing very injurious to the child is the tying
and cutting of the navel string too soon which shouldalways be left until the child has not only repeatedly
breathed but till all pulsation in the cord ceases
As otherwise the child is much weaker than it ought tobe a part of the blood being left in the placenta which
ought to have been in the childhelliphelliprdquo
Erasmus Darwin
1801
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 640
The length of the human umbilical cord Walker CW Pye BG BMJ 1960
We submit the theory that the human cord is longin order to allow the mother to pick up her helpless
newborn child and carry it away from danger
without exerting harmful traction on the placenta
Further that a cord of more than 18 in (46 cm)will allow the child to be put to the breast with the
placenta in utero and that the reflex stimulation of
suckling may promote an easy and bloodless third
stage
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 740
Placental transfusion-rate and uterine contraction
Yao AC et al Lancet 1968
~16 mlkg
~ 10 mlkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 840
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 240
ldquoDelayedrdquo Cord Clamping
Jayashree Ramasethu MD FAAP
Division of Neonatal Perinatal MedicineMedStar Georgetown University Hospital
Washington DC
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 340
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 440
ACOG Practice Bulletins 127216348
(1989-2006)
ldquoActiverdquo management of labor and delivery
ldquoImmediately after delivery of the neonate asegment of the umbilical cord should be
doubly clampedrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 540
gt200 years ago
ldquo Another thing very injurious to the child is the tying
and cutting of the navel string too soon which shouldalways be left until the child has not only repeatedly
breathed but till all pulsation in the cord ceases
As otherwise the child is much weaker than it ought tobe a part of the blood being left in the placenta which
ought to have been in the childhelliphelliprdquo
Erasmus Darwin
1801
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 640
The length of the human umbilical cord Walker CW Pye BG BMJ 1960
We submit the theory that the human cord is longin order to allow the mother to pick up her helpless
newborn child and carry it away from danger
without exerting harmful traction on the placenta
Further that a cord of more than 18 in (46 cm)will allow the child to be put to the breast with the
placenta in utero and that the reflex stimulation of
suckling may promote an easy and bloodless third
stage
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 740
Placental transfusion-rate and uterine contraction
Yao AC et al Lancet 1968
~16 mlkg
~ 10 mlkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 840
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 340
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 440
ACOG Practice Bulletins 127216348
(1989-2006)
ldquoActiverdquo management of labor and delivery
ldquoImmediately after delivery of the neonate asegment of the umbilical cord should be
doubly clampedrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 540
gt200 years ago
ldquo Another thing very injurious to the child is the tying
and cutting of the navel string too soon which shouldalways be left until the child has not only repeatedly
breathed but till all pulsation in the cord ceases
As otherwise the child is much weaker than it ought tobe a part of the blood being left in the placenta which
ought to have been in the childhelliphelliprdquo
Erasmus Darwin
1801
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 640
The length of the human umbilical cord Walker CW Pye BG BMJ 1960
We submit the theory that the human cord is longin order to allow the mother to pick up her helpless
newborn child and carry it away from danger
without exerting harmful traction on the placenta
Further that a cord of more than 18 in (46 cm)will allow the child to be put to the breast with the
placenta in utero and that the reflex stimulation of
suckling may promote an easy and bloodless third
stage
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 740
Placental transfusion-rate and uterine contraction
Yao AC et al Lancet 1968
~16 mlkg
~ 10 mlkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 840
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 440
ACOG Practice Bulletins 127216348
(1989-2006)
ldquoActiverdquo management of labor and delivery
ldquoImmediately after delivery of the neonate asegment of the umbilical cord should be
doubly clampedrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 540
gt200 years ago
ldquo Another thing very injurious to the child is the tying
and cutting of the navel string too soon which shouldalways be left until the child has not only repeatedly
breathed but till all pulsation in the cord ceases
As otherwise the child is much weaker than it ought tobe a part of the blood being left in the placenta which
ought to have been in the childhelliphelliprdquo
Erasmus Darwin
1801
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 640
The length of the human umbilical cord Walker CW Pye BG BMJ 1960
We submit the theory that the human cord is longin order to allow the mother to pick up her helpless
newborn child and carry it away from danger
without exerting harmful traction on the placenta
Further that a cord of more than 18 in (46 cm)will allow the child to be put to the breast with the
placenta in utero and that the reflex stimulation of
suckling may promote an easy and bloodless third
stage
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 740
Placental transfusion-rate and uterine contraction
Yao AC et al Lancet 1968
~16 mlkg
~ 10 mlkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 840
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 540
gt200 years ago
ldquo Another thing very injurious to the child is the tying
and cutting of the navel string too soon which shouldalways be left until the child has not only repeatedly
breathed but till all pulsation in the cord ceases
As otherwise the child is much weaker than it ought tobe a part of the blood being left in the placenta which
ought to have been in the childhelliphelliprdquo
Erasmus Darwin
1801
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 640
The length of the human umbilical cord Walker CW Pye BG BMJ 1960
We submit the theory that the human cord is longin order to allow the mother to pick up her helpless
newborn child and carry it away from danger
without exerting harmful traction on the placenta
Further that a cord of more than 18 in (46 cm)will allow the child to be put to the breast with the
placenta in utero and that the reflex stimulation of
suckling may promote an easy and bloodless third
stage
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 740
Placental transfusion-rate and uterine contraction
Yao AC et al Lancet 1968
~16 mlkg
~ 10 mlkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 840
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 640
The length of the human umbilical cord Walker CW Pye BG BMJ 1960
We submit the theory that the human cord is longin order to allow the mother to pick up her helpless
newborn child and carry it away from danger
without exerting harmful traction on the placenta
Further that a cord of more than 18 in (46 cm)will allow the child to be put to the breast with the
placenta in utero and that the reflex stimulation of
suckling may promote an easy and bloodless third
stage
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 740
Placental transfusion-rate and uterine contraction
Yao AC et al Lancet 1968
~16 mlkg
~ 10 mlkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 840
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 740
Placental transfusion-rate and uterine contraction
Yao AC et al Lancet 1968
~16 mlkg
~ 10 mlkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 840
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 840
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 940
Definitions of Early and Late Clamping of
Umbilical cord
bull lt15 seconds
bull lt30 seconds
bull lt60 seconds
bull gt1 minutebull gt2 minutes
bull gt 3 minutes
bull gt 5 minutesbull After cord pulsationsstop
New Term ldquoPlacental Transfusionrdquo
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1040
Effect of cord clamping in Term Infants
(vaginal delivery) Yao AC et al Lancet 1969
Cord clamping
time
Residual
Placental
blood volume
mLkg
Infant
Circulating
blood volume
mLkg
Red cell volume
mLkg
5 seconds 347 703 306
15 seconds 283 771 361
90 seconds 205 855 434
180 seconds 138 928 483
20 mLkg
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1140
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1240
Effect of cord clamping on hematocrit
in term infants
Author Gestation Cord
clamping
time
Cord
HCT
24 hr
HCT
Yao 1969 term lt5 seconds 50 50
1 minute 50 59
Saigal 1972 term lt5 seconds 48 44
5 minutes 48 63
Philip 1973 term lt15 seconds 54 52
micro94 seconds 52 62
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1340
Long term effect of cord clamping on
hematocrit and iron stores in term infantsGupta amp Ramji Indian Pediatrics 2002
Hemoglobin gL Ferritin mcgL
Cord clampingtime Cord 3 mths Cord 3 mths
Early 139 88 143 80 (15-180)
Delayed 141 99 116 105 (30-500)
New Delhi Anemic mothers HB lt100gL
plt0001 plt002
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1440
Long term effect of cord clamping on hematocrit and
iron stores in term infants Chaparro et al Lancet 2006
Early
clamping
Delayed
clamping
RR ( 95CI) P
Delivery
(seconds)
16 94 lt00001
Newborn Hb gL 193 199 0007
HCTgt70 8 13 06 (03 to 12) 015
6 months age
Hb gL 127 127 088
Ferritin microgL 35 47 00002
Iron deficiency 8 2 50 (1 to 24) 005
Mexico City 358 mother ndash infant pairs randomized
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1640
Implications of iron deficiency
in infancy
Congdon EL et al Iron deficiency in infancy is associated with alteredneural correlates of recognition memory at 10 years
J Pediatr 2012 Jun160(6)1027-33
Algariacuten C et al Iron deficiency anemia in infancy
long-lasting effects on auditory and visual system functioning
Pediatr Res 2003 Feb53(2)217-23
Lozoff B et al Poorer behavioral and developmental outcome
more than 10 years after treatment for iron deficiency in infancy
Pediatrics 2000 Apr105(4)E51
Algariacuten C et al Iron-deficiency anemia in infancy and poorer cognitive
inhibitory control at age 10 years
Dev Med Child Neurol 2013 May55(5)453-8
Carter RC et al Iron deficiency anemia and cognitive function in infancy
Pediatrics 2010 Aug126(2)e427-34
Shafir T et al Iron deficiency and infant motor development
Early Hum Dev 2008 Jul84(7)479-85
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1740
Effect of timing of umbilical cord clamping on
maternal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
15 trials 3911 women and infant pairs
No significant difference in Early vs Late cord clamp
bull Severe post- partum hemorrhage gt1000ml
bull Post partum hemorrhage gt500 mlbull Mean blood loss
bull Maternal post- partum Hb
bull Need for blood transfusion
bull Need for manual removal of placentabull Length of third stage of labor
bull Therapeutic uterotonics
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1840
Effect of timing of umbilical cord clamping of term
neonates on neonatal outcomesMcDonald SJ et al Cochrane Database of Systematic Reviews July 2013
bull No significant difference in Early vs Late cord clamp ndash Neonatal mortality
ndash Apgar score lt 7 at 5 minutes of age
ndash Admission to SCN or NICU
ndash Respiratory distress ndash Polycythemia
ndash Clinical jaundice
bull Late cord clamping group
ndash uarr Birth weight (101 g)
ndash uarr Hemoglobin at 24- 48 hrs (149 gdL)
ndash uarr Jaundice requiring phototherapy (436 vs 274)
ndash uarr Iron stores at 3-6 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 1940
Infantsrsquo blood volume in a controlled trial of placental
transfusion at preterm delivery Aladangady N et al Pediatrics 2006
bull 56 neonates 24 to lt33 w
bull RBC volume measured
by fetal Hb dilution or by
biotin labeled autologous
red cell dilution
Delayed
clamp
Early clamp P value
Mean Blood volume (MBV) 74 mlkg 63 ml kg lt0001
MBV for vaginal delivery 81 mlkg 61 mlkg lt0001
MBV for C section 70 mlkg 64 ml kg ns
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2040
Effect of cord clamping on hematocrit
in preterm infants
Author Gestation N Cord clamping
time
1st day HCT
Saigal
1972
28 to 35
weeks
36 immediate 45
33 1 minute 55
33 5 minutes 61
Kinmond
1993
27 to 33
weeks 19 lt10 seconds 51
17 gt30 seconds 56
Ibrahim 2000 24 to 28
weeks
16 immediate 39
16 20 seconds 50
Mercer
2003
24 to 33
weeks
16 lt10 seconds 42 (17-62)
16 30 to 45 seconds 44 (22 to 58)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2140
Effect of Umbilical Cord Clamping and other strategies
to influence placental transfusion at preterm birth on
infant outcomes Cochrane Database Syst Rev 2012
Delayed Cord clamping or cord milking vs immediate cord
clamping15 studies 738 infants GA 24 to 36 weeks
No difference between the two groups
bull Apgar scores at 1rsquo 5rsquo or 10rsquo
bull Hypothermia on admission to special care unit
3 studies 143 infantsbull Death of the baby
10319 (31) vs 17349 (49)
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2340
Delayed Cord Clamping Cord Milking vs
Immediate Cord Clamping in Preterm Infants
Cardiovascular Outcomes
Infants with more placental transfusion
bull Less need for inotropic support
(RR 042 95CI 023 -077 )
bull Deceased need for transfusion for low BP
(RR 052 95 CI 024-111)
bull Mean arterial BP higher at birth and at 4 hours
( MD 352 95 CI 06 to 645)
bull No difference in treatment for PDA
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2440
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2540
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants GI outcomesCochrane Review 2012
Reduced rates of necrotizing enterocolitis
5 trials 241 infants
RR 062 95 CI 043-090
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2640
Delayed Cord Clamping Cord Milking vs Immediate
Cord Clamping in Preterm Infants CNS OutcomesCochrane Review 2012
Intraventricular hemorrhage all grades
RR 059 95 CI 041-085
bull Severe IVH grade 3 or4RR 068 (95CI 023-196)
bull Periventricular leukomalacia
- only 2 studies 3 cases in 71 infantbull Neurodevelopmental disability
- only 1 study no difference at 7 months
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2740
60 seconds is a looooooooooong timehelliphelliphellip
Umbilical Cord MilkingHosono S et al Arch Dis Child Fetal Neonatal Ed 2008
ndash 40 preterm infants 24-28 weeks
ndash immediate cord clamping ( 20) vs umbilical cord milking (20)
ndash 20 cms 2-3 times
darr need for transfusion
darr number of transfusions
uarr initial Hemoglobin
uarr mean BP at admission
darrduration of ventilation
darroxygen days
No difference in IVH rate
No diff in max bilirubin
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2840
Umbilical Cord Milking
Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 2940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3040
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3140
Umbilical Cord Milking in Extremely Preterm Infants March MI et al J Perinatol July 2013
Eastern Virginia Med School Hospital Preterm 24 to 28 weeks randomized
Cord milking
n=36
Cord clamping
n=39
P value
Hemoglobin initial gL 149 136 0005
Transfusions lt 28 days 833 974 005
Transfusions lt 14 days 528 769 004
IVH 25 513 002
IVH grade 3 or 4 33 30
Peak bilirubin mgdL 52 55RDS 100 100
Chronic lung disease 25 10 009
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3240
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3340
If the baby needs resuscitation
the baby needs the placental transfusionhellip
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3440
Transitional circulation at birth
Lung expansion and uarrpAO2rarr darrPVR
Clamping Umbilical Cord
Umbilical vein occluded darr RA filling
darr RV output
Umbilical arteries occluded
uarr Systemic vascular resistance
uarr LV afterload
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3540
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3640
SVC blood flow over the course of the study mean plusmn SD (ANOVA Groups P = 003)
Hemodynamic effects of delayed cord clamping on preterm
infants Sommers et al Pediatrics 2012
uarrRV stroke volume
uarrRV output
No diff in
MCA velocitySMA velocity
PDA rates
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3740
Resuscitating a baby with delayed cord clamping
Decide and design with your OB friend
ahead of time
how you are going toResuscitate a term babyResuscitate a preterm baby
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3840
bull All these bodies
recommend delay incord clamping for at
least 30 seconds
(and up to 2 minutes)in
ndash All births (WHO)
ndash Preterm (SOGC ECG) ndash ILCOR (preterm when
possible)
European Consensus
Guidelines
ILCOR
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 3940
8102019 Delayed Cord Clamping Sept 2013pdf
httpslidepdfcomreaderfulldelayed-cord-clamping-sept-2013pdf 4040
Terima Kasih
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