In the potentially fatal event below, a cord blood infusion really put into practice everything we already know about delaying cord blood clamping – the increased provision to the neonate of oxygen, red blood cells, stem cells, immune cells, iron reserves, and blood volume.

It was wonderful was seeing this baby go home with no apparent sequellae after a complete abruption at birth.

The mom was 17 years old and 27+5 weeks gestation when she arrived at our hospital for GBS bacteriuria, lower back pain and abdominal cramping. She stayed on our antepartum unit for five days due to cervical dilation 1-2 cm and received antibiotics and Betamethasone.

On day six, the mom complained of contractions around 0800. The resident checked her, she was 5 cm/80% and uncomfortable. We started her on Magnesium for neuroprotection, as ACOG recommends. We started her on a Magnesium Sulfate 6 gram loading dose and continued the Magnesium at 2 grams/hr.

At 1600 she was found to be 7 cm dilated and requesting an epidural. Four hours later, as she began to push, the baby began having prolonged decelerations. She brought the baby down quickly while experiencing tachysystole. With the last few contractions, the fetal heart rate plummeted as she pushed out her 1120 gm infant along with an abrupted placenta.

The baby’s pale, lifeless body was received by the NICU team. The physician carried both the baby and placenta to the warmer. For seven minutes, the pulsating placenta infused blood into the baby while the NICU team began to resuscitate the baby. Within the first minute, the baby gasped and cried while we watched in awe as this hypovolemic baby began to cry and turn pink as the doctor continued to hold the placenta above the baby. Baby’s APGAR scores were 7 at one minute and 8 at five minutes. CPAP and Neopuff was all the NICU team used to stabilize this neonate. Baby’s initial CBC: 10.1>15.8/46.3<272

Had we done what was “usual” and clamped the cord, would there have been enough blood cells for a successful resuscitation?

The time that it would’ve taken for them to crossmatch a sample then give adult blood with no stem cells would have been enough time for hypoxemia to occur. The baby received no blood transfusions during her hospital course of care and went home after about seven weeks of care.

Studies have also shown a reduction in newborn anemia; need for transfusion, intraventricular hemorrhage and necrotizing entercolitis. Other studies have found an increased risk for polycythemia and jaundice. In the event that hypovolemia be suspect, a cord blood infusion would be preferred and beneficial with the later treatments for possible polycythemia and jaundice provided if necessary. Based on new data and the current literature that profoundly encourages a delay in cord blood clamping, in the rare instance of a complete placental abruption this event could be modeled to save an infant’s life. This really impacted our hospital and we have since been able to do this in another case. My hope is that you’ll be able to glean wisdom from our experience.

Lisa-Marie Cook is a Labor and Delivery Nursing Preceptor in Washington, DC and teaches AWHONN Intermediate Fetal Monitoring. She is also the CEO of Birthing Basics, LLC where she teaches evidence-based birthing classes.

Resources

“Perspectives on Implementing Delayed Cord Clamping,” Nursing for Women’s Health, 19(2), 164–176.

ACOG Committee Opinion Number 543 (2012) Timing of Umbilical Cord Clamping.

Hutton, E.K., Hassan, E.S. (2007). “Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials”. Journal of the American Medical Association, 297(11): 1241-52.

McDonald, S.J. et al. (2013) Effect of timing of umbilical cord clamping of term infants on mother and baby outcomes. Cochrane Database Systematic Review, July 11. McDonald, S.J. et al. (2013) Effect of timing of umbilical cord clamping of term infants on mother and baby outcomes. Cochrane Database Systematic Review, July 11.

Rabe, H. et all. (2012) Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Systematic Review, Aug 15.