Delayed cord clamping and Cord milking and resuscitation

[satyen75]

I have heard many speakers about the resuscitation trolly on which baby can be resuscitated while cord is not clamped . I want to know what is the status as of now, is it being in development phase, which company is making it and has some research /data come on this. Also is umbilical cord milking feasible or advisable when the baby is born non vigorous and practically ( in terms of amount of blood transferred /time required ) what is the difference between the two methods

[Nathan Sundgren]

DCC has several advantages for our preterm babies. Probably most important is that DCC allows the heart to fill and maintain preload from the placental circulation while the lung vascular system is opening and being filled. Animal studies show a compelling improved stability on cerebral blood flow and pressures. Blood transfusion from the placenta to the baby increasing blood volume or hematocrit may actually be the less important effect of DCC in our preterm babies. The greatest advantage appears to be if DCC is delayed until after the baby starts breathing and the lung vasculature opens up.

Cord milking in animal studies can produce a highly unstable cerebral blood flow pattern with alternating high and low blood flow with each "milk". It concerns me that this is a set up for IVH. But, the human study from Dr. Katheria showed no harm from cord milking compared to DCC and the neurodevelopmental follow up actually looked somewhat better for cord milking. So perhaps cord milking can be used, especially on babies that waiting 60 seconds for DCC is deemed unsafe.

As for resuscitation on an open cord - where resuscitation is done while the cord is unclamped, Dr. Katheria has helped us there, too. He randomized babies to receive resuscitation vs only drying and stimulation while DCC was performed for 60 seconds. No difference. Most amazing from this study was that even in a high risk preterm population, 92% of the baies breathed spontaneously before the cord was clamped. This seems to have greatly negated the need for PPV for many of these babies and CPAP can be applied instead.

I think this is a very exciting area. We are working with our OB colleagus to more frequently use DCC. I am still discouraging cord milking because I believe more research needs to be done to assess safety. Right now I don't see the advantage to the resuscitation trolley. If the placental-baby circulation is intact and uncompromised, the delay of 60 seconds to start resuscitation efforts appears safe to wait on resuscitation efforts and perhaps as 90%+ will start breathing in this time, we may find we do less interventions. 

[Stefan Johansson]

@Nathan Sundgren  great post! I agree that the major benefit from delaying clamping seems to be *until* breathing starts off. Heard a pretty convincing talk about that on jENS.

The study by Katheria et al was commented by EBNEO on: https://ebneo.org/2015/12/does-umbilical-cord-milking-result-in-higher-measures-of-systemic-blood-flow-in-preterm-infants/

We "only" practise delayed clamping (60 sec) for term and preterm infants in reasonably good shape, but we do not have trolleys to start resusc with the cord intact.

BTW - at our next Meetup in Copenhagen 7-10 April 2019, Ola Andersson will lecture about "Cord Clamping , 1.0 and 2.0"