Transition at birth and delayed cord clamping — structured clinical encounter

Station brief (candidate)

You are the neonatal registrar. A 27-week gestation infant is about to be delivered to a mother in preterm labour who received antenatal steroids. The obstetric team asks for your cord-management plan. A colleague on the team suggests cord milking to deliver the placental transfusion faster. You have 12 minutes with the team and 5 minutes for examiner discussion. [2]

Information available on request

• Gestation 27 weeks, singleton, anticipated vaginal delivery, antenatal steroids complete, no chorioamnionitis. [2]
• A bedside trolley for intact-cord stabilisation and a trained neonatal team are available. [13]
• The colleague's rationale for milking is that a full deferral may be impractical in a very preterm infant. [3]

Tasks

1. State the cord-management plan for this infant, including timing and thermoregulation. [2]
2. Address the colleague's suggestion of cord milking, with the evidence. [3]
3. Describe how you would deliver intact-cord resuscitation if the infant is non-vigorous. [13]
4. Explain the preterm-specific benefits of the placental transfusion to the team. [2]

Marking anchors

Must-hit

• Plans deferred cord clamping for at least 30 to 60 seconds with intact-cord stabilisation and aggressive warming (plastic wrap, thermal mattress, hat, raised ambient temperature). [2]
• States clearly that cord milking is contraindicated under 28 weeks, citing the Katheria 2019 JAMA trial and the excess of severe intraventricular haemorrhage. [3]
• Names the preterm benefits: fewer blood transfusions, less intraventricular haemorrhage, better circulatory stability. [2]

Merit

• Describes the bedside trolley technique for intact-cord resuscitation: warmth, assessment of tone, breathing and heart rate, and positive-pressure ventilation with the cord attached. [13]
• Acknowledges that if the infant cannot be stabilised on the cord, the team clamps and moves for advanced resuscitation. [12]
• Cites the Mercer 18-month outcome data suggesting developmental benefit from placental transfusion in the preterm. [8]

Fail

• Agrees to cord milking for the 27-week infant. [3]
• Plans deferred clamping without any thermoregulation measures. [2]
• Leaves a non-vigorous infant on the cord instead of ventilating. [12]