Placental transfusion : Delayed cord clamping

2. TO DELAY OR
NOT

3. MEAN DURATION OF CORD CLAMPING
IN OUR UNIT
8.9 sec

6. What happens when there is
ICC
 At mid-term--relatively large size of
placenta compared with the fetus, blood
is equally distributed between the fetus
and placenta
 By term -1/3 of the blood flows through
the placenta and 2/3 flows through the
fetus

7. What happens when there is
ICC
 ICC results in ~30% of feto- placental
blood volume remaining in the placenta,
 DCC reduces residual placental blood to
20% of the feto-placental blood volume
by 60 s and to 13% by ~ 3–5 min.2

8. RELATIONSHIP BETWEEN TIMING OF CORD
CLAMPING AND NEONATAL BLOOD VOLUME

9. What is in Cord Blood?
• RBCs
– 15 mL/kg RBCs
– Iron: 30 to 75 mg (enough for 3 to 6 mo’s
need)
• Stem Cells
– Several million to 1 billion SCs
– (and cytokines to direct them)
• Plasma/cells for volume expansion
9

10. • WHY ARE WE AS A
PEDIATRICIAN
CONCERNED ?
 Increased IVH
,Sepsis
 IDA and
psychomotor
retardation
 Stem cells loss

11. Factors Contributing to IVH, Sepsis, and
Motor Delay in Preterm Infants with ICC
Blood volume loss which may contribute to
 Cardiovascular instability
 Loss of brain blood pressure
autoregulation
 Poorer perfusion of all tissues -especially
the fragile germinal matrix
Inflammation secondary to blood loss (pro-
inflammatory cytokines)
Loss of hematopoietic stem cells and cord
blood factors
11

12. IDA
 Delayed umbilical cord clamping may be particularly relevant
for infants living in low-resource settings with less access to
iron-rich foods and thus greater risk of anaemia
 Children - vulnerable to iron deficiency anaemia
 Children with iron deficiency are more likely to have delayed
psychomotor development
 Both epidemiological and experimental data suggest that
when these impairments occur at an early age, they may be
irreversible, even after repletion of iron stores, thus
reinforcing the importance of approaches (such as delayed
cord clamping) that can prevent this condition

13. STEM CELLS

15. Stem Cells: Baby’s First Transplant
“ …a delay in cord clamping may  stem cell supply to the
baby…innate stem cell therapy…acute benefits in case of NB
disease….long term benefits against age-related diseases”
Tolosa JN, Park DH, Eve DJ, Klasko SK, Borlongan CV, Sanberg PR. Mankind’s first natural stem cell transplant. J Cell Mol Med.
2010;14:488-495. Sanberg P, Park, D-H & Borlongan. (2009). Stem Cell Transplants at Childbirth. Stem Cell Rev and Rep

16. WHAT ARE YOUR CONCERNS
•DELAY IN INTIATATION
OF RESUSCITATION
• PPH
•ASSIGNMENT OF TIME
OF BIRTH
•OTHERS

17. EVIDENCE

20. ACOG 2017

21. WHAT IS EARLY
AND
DELAYED

23.  Two guideline development groups were
involved
 WHO Guidelines on basic newborn
resuscitation and WHO
recommendations for the prevention and
treatment of postpartum haemorrhage

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

28. DCC V/S UCM


29. JAMA Pediatr. 2015

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

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

32. Fallacies
 The method of umbilical cord milking varied
considerably in the trials in terms of the
number of times the cord was milked, the
length of milked cord, and whether the cord
was clamped before or after milking
 Subgroup analysis comparing umbilical
cord milking directly with delayed umbilical
cord clamping was not able to be carried
out because of small numbers in those
groups

33. WHICH IS BETTER DCC OR
UCM
 Further research is needed for
comparing DCC with UCM

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

35. HIV

36. RH ISOIMMUNIZATION
Benefits of Delayed Cord Clamping in Red
Blood Cell Alloimmunization
Pediatrics March 2016

37. MULTIPLE GESTATION
 At this time, there is not sufficient
evidence to recommend for or against
delayed umbilical cord clamping in
multiple gestations

39. MAJOR LIMITATIONS IN PRACTICING
DCC

40. What we are going to follow
DCC for minimum 60 seconds
Both Preterm/Term not requiring
resuscitation irrespective of type of birth
UCM in case of those requiring
resuscitation
milking 3 times equal to length of forceps

41. TOGETHER FOR BETTER
MATERNAL AND NEONATAL
OUTCOMES