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.

9. 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.

10. 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.

11. 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

12. 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.

13. 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.

14. POTENTIAL ADVERSE EFFECTS OF DELAYED CORD
CLAMPING
Delaying resuscitation for compromised newborns and
increasedrisks of polycythemia (high red blood cell
concentration) and jaundice.

15. 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

16. EXCLUSION CRITERIA
A placental abruption
Bleeding placenta previa
Bleeding vasa previa, or cord avulsion
Multiple gestations

17. 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.

18. 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.

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