The time of birth and clamping the umbilical

NRP RECOMMENDATION

1. The time of birth and clamping the umbilical cord DR TAREK S KOTB nrp instructor

2. Recommendation/Evidence  Class I = strong recommendation (Benefit >>>Risk )  Class IIa = moderate recommendation (Benefit >>Risk)  Class IIb = weak recommendation (Benefit ≥ Risk)  Class III = no benefit (Benefit = Risk)  Class III Harm = (Risk > Benefit )  LOE – A = evidence from >1 or meta-analysis of high quality RCTs  LOE – BR = evidence from >1 or meta-analysis of moderate quality RCTs  LOE – BNR = evidence from >1 or meta-analysis of moderate quality nonrandomized studies, observational studies.  LOE – CLD = evidence from or meta-analysis of randomized and nonrandomized studies, observational studies with limitations of design/execution .  LOE – CEO = expert opinion consensus based on clinical experiences.

3. The majority of this placental blood transfusion occurs during the first minute after birth and may play an important role in the transition from fetal to neonatal circulation.

4. At the time of birth, a large volume of blood remains in the placenta. If maternal blood is still flowing to the placenta and the umbilical cord is intact, placental gas exchange will continue while additional blood flows to the baby through the umbilical vein.

5. 7th Edition Changes OF NRP Required Implementation ? # January 1st 2017 - all institutions and learners should be utilizing the 7th edition of the NRP.

6. CURRENT EVIDENCE Cord Clamping: evidence suggests that cord clamping should be delayed for at least 30 to 60 seconds for most vigorous term and preterm newborns. Insufficient evidence for recommendation for infants who require resuscitation or who have known risk factors for decreased placental circulation. (Class IIa , LOE C-LD)

7. ACOG Recommends Delayed Umbilical Cord Clamping for All Healthy Infants December 21, 2016 The latest  Committee Opinion  is an update to ACOG’s 2012 guidance. The revision is based on more recent research that shows that, while preterm infants are likely to benefit the most from the additional blood volume gained from the placenta, term infants can also benefit and these benefits may have a favorable effect on developmental outcomes.

8. Recommendations The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice makes the following recommendations regarding the timing of umbilical cord clamping after birth : In term infants , delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes. in preterm infants Delayed umbilical cord clamping is associated with significant neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage .

9. RECOMMENDATIONS Given the benefits to most newborns and concordant with other professional organizations, the American College of Obstetricians and Gynecologists now recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30–60 seconds after birth. There is a small increase in the incidence of jaundice that requires phototherapy in term infants undergoing delayed umbilical cord clamping. Consequently, obstetrician–gynecologists and other obstetric care providers adopting delayed umbilical cord clamping in term infants should ensure that mechanisms are in place to monitor and treat neonatal jaundice. Delayed umbilical cord clamping does not increase the risk of postpartum hemorrhage .

10. Mark the time of birth by starting a timer when the last fetal part emerges from the mother’s body The ideal time for clamping the umbilical cord is the subject of ongoing research

11. Potential benefits of delayed cord clamping for preterm newborns Decreased mortality High blood pressure and blood volume less need for blood transfusion after birth Fewer brain hemorrhages A lower risk of necrotizing enterocolitis .

12. Potential benefits of delayed cord clamping for term newborns Delayed cord clamping may decrease the chance of developing iron-deficiency anemia and may improve neurodevelopmental outcomes.

13. Potential adverse effects of delayed cord clamping Delaying resuscitation for compromised newborns and increased risks of polycythemia (high red blood cell concentration) and jaundice .

14. The current evidence that clamping should be delayed for at least 30 to 60 seconds for most vigorous term and preterm newborns If cord clamping is delayed, the baby should be placed skin-to-skin on the mother’s chest or abdomen, or held securely in a warm, dry towel or blanket. Very preterm newborns may be wrapped in a warm blanket or polyethylene plastic to help maintain their temperature. During the interval between birth and umbilical cord clamping, the obstetric provider and neonatal team should evaluate the baby’s tone and breathing effort and begin the initial steps of newborn care

15. Exclusion criteria A placental abruption Bleeding placenta previa B leeding vasa previa , or cord avulsion M ultiple gestations

16. Other scenarios where safety data on delayed cord clamping are limited may benefit from a discussion between the neonatal and obstetric providers to plan whether cord clamping should be delayed . These scenarios may include fetal intrauterine growth restriction (IUGR), abnormal umbilical artery Doppler measurements, abnormal placentation, and other situations where utero-placental perfusion or umbilical cord blood flow are affected .

17. There is not enough evidence to make a definitive recommendation whether umbilical cord clamping should be delayed in newborns who are not vigorous . If the placental circulation is intact, it may be reasonable to briefly delay cord clamping while the obstetric provider clears the airway and gently stimulates the baby to breathe . If the baby does not begin to breathe during this time, additional treatment may be required . The cord should be clamped and the baby brought to the radiant warmer.

18. MESSAGE Before birth, establish the plan for the timing of umbilical cord clamping with the obstetric providers.