Delayed Cord Clamping Sept 2013.pdf

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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



ldquoDelayedrdquo Cord Clamping

Jayashree Ramasethu MD FAAP

Division of Neonatal Perinatal MedicineMedStar Georgetown University Hospital

Washington DC





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



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



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



Placental transfusion-rate and uterine contraction

Yao AC et al Lancet 1968

~16 mlkg

~ 10 mlkg





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



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





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



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



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





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



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



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



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




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)



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)





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





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




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



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



Umbilical Cord Milking

Hosono S et al Arch Dis Child Fetal Neonatal Ed 2008







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


IVH 25 513 002

IVH grade 3 or 4 33 30

Peak bilirubin mgdL 52 55RDS 100 100

Chronic lung disease 25 10 009





If the baby needs resuscitation

the baby needs the placental transfusionhellip



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





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



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



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





Terima Kasih



ldquoDelayedrdquo Cord Clamping

Jayashree Ramasethu MD FAAP

Division of Neonatal Perinatal MedicineMedStar Georgetown University Hospital

Washington DC






(1989-2006)



doubly clampedrdquo



gt200 years ago






Erasmus Darwin

1801










stage





~16 mlkg

~ 10 mlkg






Umbilical cord

bull lt15 seconds

bull lt30 seconds

bull lt60 seconds


bull gt 3 minutes







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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih






(1989-2006)



doubly clampedrdquo



gt200 years ago






Erasmus Darwin

1801










stage





~16 mlkg

~ 10 mlkg






Umbilical cord

bull lt15 seconds

bull lt30 seconds

bull lt60 seconds


bull gt 3 minutes







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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih




(1989-2006)



doubly clampedrdquo



gt200 years ago






Erasmus Darwin

1801










stage





~16 mlkg

~ 10 mlkg






Umbilical cord

bull lt15 seconds

bull lt30 seconds

bull lt60 seconds


bull gt 3 minutes







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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih



gt200 years ago






Erasmus Darwin

1801










stage





~16 mlkg

~ 10 mlkg






Umbilical cord

bull lt15 seconds

bull lt30 seconds

bull lt60 seconds


bull gt 3 minutes







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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih










stage





~16 mlkg

~ 10 mlkg






Umbilical cord

bull lt15 seconds

bull lt30 seconds

bull lt60 seconds


bull gt 3 minutes







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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih





~16 mlkg

~ 10 mlkg






Umbilical cord

bull lt15 seconds

bull lt30 seconds

bull lt60 seconds


bull gt 3 minutes







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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih






Umbilical cord

bull lt15 seconds

bull lt30 seconds

bull lt60 seconds


bull gt 3 minutes







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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih




Umbilical cord

bull lt15 seconds

bull lt30 seconds

bull lt60 seconds


bull gt 3 minutes







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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih





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






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih






in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih




in term infants


clamping

time

Cord

HCT

24 hr

HCT


1 minute 50 59


5 minutes 48 63









Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih







Early 139 88 143 80 (15-180)

Delayed 141 99 116 105 (30-500)


plt0001 plt002





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih





Early

clamping

Delayed

clamping

RR ( 95CI) P

Delivery

(seconds)

16 94 lt00001


HCTgt70 8 13 06 (03 to 12) 015

6 months age

Hb gL 127 127 088









in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih






in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih




in infancy


J Pediatr 2012 Jun160(6)1027-33
















































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih



































red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih























red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih









red cell dilution

Delayed

clamp

Early clamp P value







in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih




in preterm infants


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


17 gt30 seconds 56


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)












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih












10319 (31) vs 17349 (49)










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih










(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih








(RR 042 95CI 023 -077 )


(RR 052 95 CI 024-111)


( MD 352 95 CI 06 to 645)










RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih









RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih







RR 062 95 CI 043-090






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih






RR 059 95 CI 041-085

















darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih













darroxygen days















Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih













Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih









Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih







Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih





Cord milking

n=36

Cord clamping

n=39

P value




IVH 25 513 002
















darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih













darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih











darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih







darr RV output



uarr LV afterload









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih









uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih







uarrRV output

No diff in


PDA rates





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih





ahead of time






least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih





least 30 seconds




possible)

European Consensus

Guidelines

ILCOR





Terima Kasih





Terima Kasih



Terima Kasih

Documents

Delayed Cord Clamping Sept 2013.pdf