 Amanda yn ymwneud o'r cwrdd o'r ffordd yn ymddangos. Amanda ddweud yn ymddangos o'r 30 yma, ac mae'n ymddangos i'r pasiwn fel ychydig i'r ffordd i'r ffordd i'r newid ymddangos o'r ffordd yn ymddangos. Mae'n gweithio o enghraifft. Felly, dyma'n ymddangos i'r ffordd, ac mae'n gweithio i'r ffordd i'r ffordd mewn meddwl. Mae'n gweithio i'r ymddangos i'r ffordd i'r ffordd i'r ffordd. Felly, mae yw Amanda. I will I say good evening everybody I know that we're all in different time zones so I'll say hello and welcome. I'm going to talk about optimal core clamping. I do speak like that so hold on to your seat. Because everybody thinks it's a very small subject to talk about but it's actually not it's very comprehensive and I do try and cover everything. Either don't cover everything or there's any questions you can get back to me afterwards and I will answer your questions via social media. So we'll talk about optimal core clamping, whose blood is it anyway and hopefully by the end of this presentation there will be no doubt. So it's a not new thing. Aristotle spoke about optimal core clamping in 300 BC and he said frequently the child appears to be born dead or is feeble but before tying the cord a flux of blood occurs into the cord and adjacent parts. Nurses squeeze the blood back out into the core of the cord into the baby's body and at once the baby who has previous been have drained the blood comes to life again. Rasmus Darwin in 1796 said the same thing that another thing very injurious to the child is the tying of the cutting of the navel string too soon. We should always be left until the child has not only repeated degrees but until all pulsation in the cord ceases. Otherwise the child is much weaker than it also has been, a part of the blood being left in the placenta which also has been in the child. And at the same time the placenta does not so naturally collapse and withdraw itself from the side of the uterus and is not removed with so much safety and certainty. So where did immediate core clamping came in? It came in about 50 or 60 years ago when the advent of octatotic drugs were introduced to reduce postpartum hemorrhage which of course they did. But part of the active management was immediate core clamping which became routine practice. And at the time it came in routine practice there was no sort given to the effects of the immediate core clamping on the fetus even though it was documented and we knew that baby lost 30% of the blood volume. And there isn't any evidence to support immediate core clamping, there hasn't been then and there certainly isn't any more now either. Can everybody hear me? I think we've got a few signs saying that it's a bit muffled. I talk about a story, my story is I have two boys who you can see on these motorbikes, Sam and Max. Sam and Max, they both have ADHD which I'm not saying for one minute that immediate core clamping causes ADHD because it runs in the family. And some people have asked me when I was diagnosed and when I say that I wasn't, they're all quite surprised. But they've been dealing with schools, it took me into contact with teachers who were looking after children with special needs and they began asking questions. They were saying to me that we had lots of children with medical needs, behavioural needs and learning problems, particularly in boys and they wouldn't know where it was coming from. I also work with six job shares and we had 14 children between us. We had five girls and nine boys and seven of the boys have learning problems and only one could be diagnosed with a chromosomal problem. So it made me start looking at different things about whether, with no randomized control trials, but certainly was there any common denominator that we had which was where we have any smokers, any drinkers, anybody had too much sugar, was it caffeine, was it the hibiscus or the disinfectants we were using in theatre. And I kept looking at things until one night I had a light bulb known by our reflexive practitioners and we're supposed to do evidence-based practice. I've been a midwife for 16 years and I reflected on my practice and realised that immediate core clamping, which is what we were all taught to do in those days. And certainly I've had my hand slapped for not getting the clumps on quick enough, was not evidence-based. So I began some research to see if there was any evidence on the internet to do with this and I came across this guy called George Morley, who isn't a guy as an obstetrician from America, who did a very substantial piece of work where he was absolutely convinced that immediate core clamping injured the baby's brain and caused the laser autism. His article is really worth reading and he said that immediate core clamping caused his cerebral palsy, learning disorders and mental deficiency, respiratory disorder syndrome, intraventricular hemorrhage and necroticin and tachylytus. And the experiments that he did actually on monkeys with immediate core clamping quite often killed the monkeys or caused irreversible brain damage. I realised at that time and I thought because we were supposed to do evidence-based practice as midwives that it would be really easy to change practice and I was incredibly wrong. The anesthetist who told me that I might be right but it was a very big subject and to actually say that we were doing something wrong, it could be quite dangerous and be quiet. I spoke to a midwifery manager who always practised delayed core clamping and I informed a consultant obstetrician who avoided me. But there was a pediatrician who had a sit down chat with me and said that to change practice I had to gather evidence to say that what I was saying was right. I said to him on the contrary what we're doing is actually not bad by evidence and we should really stop what we're doing because we're depriving the baby of 30% of blood volume without knowing the short term and the long term effects. But it wasn't quite as easy as that. In 2010, I started campaigning in 2005 and in 2010 I was asked to be quiet because I went into community and I was telling the parents informed choice. They were coming into the hospitals and they were asking to delayed core clamping and I was actually asked to be quiet about it. But in response to being asked to be quiet about it I set up a Facebook page which is optimal core clamping. Wait for White had a big article in the paper and a set of a petition against NICE who were very reluctant to change the guidelines for four years. The guidelines at the time actually recommended immediate core clamping even though there was no evidence. But NICE are the guidelines which is the English guidelines because all women should get informed choice and of course they don't get informed choice because they're not told to talk about it. They rely on us to do the best for their babies. This photograph, it took about four years to get 6,000 people to follow the page and this page which shows a complete circuit. A lot of people don't understand the physiology that the percentage of the baby are one part and the mother is another part and the percentage of the baby are circulation. This picture shows it beautifully and our likers rose from 6,000 to 24,000 practically overnight. Go on to the evidence and this percentage is for a baby that was £10. But you can see by the amount of blood in the cord that the baby obviously had immediate core clamping and the baby should have been a lot bigger than £10. I said about changing practice who wants to change versus who wants to change versus who wants to change. And even though we're supposed to have evidence based practice and the evidence is there and we've got substantial amounts of evidence to support this. And also to remain any clamping and cutting of the cord before it stops pulsating is an actual intervention and all interventions should be discussed with the parents and consent should be obtained and we don't do this. So it has been a really interesting journey over the past 13 years but we're getting there slowly and we need to do this because we don't know the accumulative effects of immediate core clamping. The baby loses 30% of the blood volume. They also lose substantial amounts of stem cells and we're into second generation core clamping now. And we don't know what effect that's having on the population as a whole. Diane Farrah and her team are, we're a team in Bradford which is near my hometown and they did weighing babies to a suspicental function in 2010. This diagram shows that this baby was born at 3.4 kgs and after two or five minutes, the baby was four and a half minutes, the baby gained 200 grams which is blood that actually should be in the baby. It's not extra blood, it's a natural circulation and when the job is finished. We talk about the known benefits of delay core clamping and optimal core clamping. I actually don't mind whether it's called delay core clamping or optimal core clamping as long as immediate core clamping is stopped because it's dangerous. So delay core clamping is associated with increased neonatal ion stores in the neonatal period, increased organ perfusion and subsequent cardiopulmonary adjustment, increased duration of early breastfeeding, decreased risk of fetal maternal transfusion, decreased unbalycal infections because the cord is thin rather than being padded out with old blood, increased white cells and infection prevention, less blood splatter with HIV protection because if you've got a fat cord and you cut through the cord, there's blood splatter which so it protects caregivers. We know that it benefits neural developmental outcomes, particularly in males. We have that evidence now. White cell infection prevention also was important now, we heard in Africa because they all said that they did delay core clamping for three minutes because the increased white cells prevented malaria. I've never seen the evidence for that but it's not rocket science and it would make sense. I talk about Judith Mercer who is a midwife in America and she is my heroine. She realised very early on in the late 1990s, 2000 that immediate core clamping wasn't evidence based and needed to be changed. And as a midwife she knew that in a medical model in America that she needed to progress at the academic groups to change practice and she's now a professor and an artist and she is a midwife and she has a phenomenal amount. She's one of the women that has really really changed practice throughout the world and I had the pleasure of meeting Judith on a couple of occasions and she stayed with us last year after a conference in the UK and we were all very excited about staying at our house and my mum said what's the excitement and I said it's like having the lead singer of Metallica sitting in the new spare bedroom. And she's beautiful, she's a really humble woman and she said that midwifery is the most important job in the world. She's done a lot of information on delayed core clamping for premature babies and shows that it decreases the risk of intraintricular hemorrhage, necrotising into colitis, late onset sex, needs of blood transfusions for low blood pressure or anemia and needs of mechanical ventilation, increases hematoclobe hemoglobin, blood pressure, cerebral oxygenation and red blood flow, cell flow and also breastfeeding duration because babies are in more optimal condition. Olyr Andersson's pediatrician from Sweden and he did a randomised control trial in 2011. I showed in 382 full term infants that delayed core clamping resulted in a reduction of ion deficiency anemia with improved fertility levels at four months of age. There was no increase in phototherapy or respiratory symptoms and it showed that ion deficiency even without anemia has been associated with impaired development among infants. In 2015 he looked at 263 children from the initial study and it showed that boys in the delayed core clamping group had decreased fine motor and social skills which shows that boys, which is what I said right at the beginning, are affected more by anemia. The timing of core clamping may affect neurodevelopment in children born in a high income country. So that changed his guidelines throughout the world. In 2005 when I realised this that we weren't doing evidence based practices, the World Health Organisation recommended immediate core clamping but they've changed their guidance to recommend delayed core clamping should be performed during the position of essential neonatal care and particularly important in countries of endemic anemia. They started something last year called the first embrace that recommends that the course should be shut up after the course has stopped pulsating in all babies, particularly in underdeveloped countries. Royal College of Obstetricians and Gynaecologists in the UK changed their guidance in 2009 to say the course should be not clamped earlier than is necessary based on a clinical assessment. More importantly along with that is that the timing of clamping and cutting the core should be documented so that we have some retrospective studies. Royal College of Midwires which is in the UK in 2012 recommended that women in midwires should be competent in both active management and physiological management. When women are offered physiological third stage in low risk women as a reasonable option many will choose it but normally we don't quite often give women that, we always do active management. But if somebody has got a low risk pregnancy, low risk delay labour and the baby is a normal delivery, why do we always go for active management because it does have certified effects? Nice guidelines in 2014 I say hallelujah because it was a struggle to get them to change. They do not clamp the cord earlier than one minute from the birth of the baby unless the cord or the baby has a heart beat below 60% of the beats in minutes that's not getting faster which is a very rare case. And they say that the cord should be left to fall asleep between one and five minutes. Many hospitals just do the one minute and again we need to be giving parents this information so that they can make the decisions. We've got a new campaign called Wait for White because we think that in all babies that are uncomplicated they should have a natural transition so the baby is delivered and the cord goes through the process of shutting down on its own so that the baby has a gentle transition to the outside and they get the blood that they require from the presenter. This is a diagram. Another baby with a knife white cord, the cord is empty there you can see that the baby has got the full transition in the jublion pink and they are very calm with these babies as well. They don't have to struggle. If the cord is clamped and cut the baby has to take a deep breath intake of breath and it upsets the whole transition. Gold an hour after delivery we say the best start in life is an hour that this baby will never get back. A safe environment with a warmth, privacy, dignity, respect, quiet and undisturbed and you have slow, gentle and peaceful. That results in raised doctor's hoping, decreased adrenaline and therefore quite often a less problematic third stage. Baby gets optimal cord clamping and we wait for white, immediate skin to skin and breastfeeding and time alone to bond with the parents. Pitch of a baby there, what's the rush so there's no recess, no bleeding, there's no rush. We just think that we have to dive in there and separate the presenter from the baby when actually in the majority of cases there's no rush whatsoever. Talk again about informed choice involving the parents in making the decisions and it's a given that the parent should be involved. The physiological third stage could be considered as default management in the absence of pregnancy complications. Delayed cord clamping is part of active or physiological management because some people think that if you have active management you can't have delayed cord clamping. You can and in my practice I tend to do delayed active management so when the baby is born I check the baby, make sure the baby is absolutely fine. The majority in nearly all cases of no bleeding because if the placenta is attached, the bleeding only happens when the placenta comes away and the bleeding starts then. With a neonatal reclutitation with the umbilical cord intact wherever possible and I do go on to discuss that. For active management we know that oxytocic, following the delivery of the baby, nice in the UK recommend the media, in fact they recommend with the anterior shoulder, which really if we think about doing the oxytocic with the anterior shoulder we've actually made a decision to shut that placenta down before the baby is even born, which is a bit bonkers really. Many midwives delay administration and we call it delayed active management. Nice say allow, call to pull say unclamp for one to five minutes or longer to parents request and this is really important if parents request this we support them in that because some hospitals are saying that because nice say one to five that that's a given. New controls call traction. In 2010 coquem review showed that timing of oxytocic made no significant difference to the risk of PPH so we don't have to rush and the New Zealand guidance said that there's no oxytocic before clumping because very rightly so we don't have the evidence, we don't actually have the evidence to say that they are giving the oxytocic before the call to pull say thing or before clumping is a problem and can cause a problem. So are we falling into the same mistake of doing something without the evidence, which is what we did with immediate call to clumping. It is very important to assess and manage the risk of PPH because if you've got somebody that's higher risk of PPH, post-calc and hemorrhage, of course we give the oxytocic sooner rather than later. One birth centre found that they were they have increased rates of PPH but women were be given, they were all being given physiological third stage rather than assessing the woman in holistic manner. When they did the re-education they got their PPH rates down to less than the average. Physiological third stage we know is no oxytocic, no clamping and cutting and hands off completely because I've seen this weather to physiological and people pulling and that's what can cause the post-calc and hemorrhage. As I said before if the call is pulsating the potential is still functioning. In the UK if the post-calc and hemorrhage are a delay of an hour of more than an hour administer the oxytocic and clamp and cut the call. Show this, it's the same cord of a baby and the mum actually had her second baby had a new cord which was cut and then a difficulty delivering the shoulders and that child was actually autistic and she did this to show that this was between the transition and the same cord. Waiting for bite, we've got some pictures to show baby's way. I think those presentations are very boring if they haven't got any pictures. The evidence you can see here with two twins. It looks like a twin-to-twin transfusion but it's not twin-to-twin transfusion and you can see very very clearly which baby has had immediate call clamping and which one hasn't. South Africa and optimal call clamping because the UK imported what they exported by practice to all the colonies and South Africa and not all the places are doing immediate call clamping. There's a big bunch of midwives down there that are working very very hard on birth workers to turn this on and quite often we see pictures on social media where the baby's actually been delivered with a cord intact and this baby looks lovely and pink and has got its pretender attached. I went to Tunisia, I had the pleasure of going to Tunisia in February where they asked me to invite me to go over and speak and they're trying to bring optimal call clamping into their hospitals and this is a friend Saida Freo who works very very hard to change practices in Tunisia and when I visited Tunisia they had a car park full of men who were still outside the hospital who don't go into the delivery rooms with their wives. The practice is very different to what we do in the UK, a popular set of midwives. Lotus birth is something that's not my specialty but Sarah Buckley in Australia writes about Lotus birth where the pretender is actually left attached to the baby until it shovels up and drops off. There's lots of information out there that people want to have a look at it. Nucl core cuttings, and the nucl core should never ever be cut before the baby's delivered and you can see why with this baby. I mean it's a little bit prim but it says the problem with those shoulders is that baby is in really deep doo doo and usually well not usually baby will deliver through a nucl cord. So we say with a nucl cord and the same with shoulder dystociae. If the core tightens around the neck, the soft wall veins more easily compressed, blood backs up in the pretender and the baby gets hypoxic as well as hyperbolemic. Same with shoulder dystociae. If you have a baby that's stuck in the vagina, the blood is backing up in the pretender and babies are delivered in their wives. Quite often the babies have an idiot core content to be rushed to the respiratory. The baby's white because more than 30% of the blood volume is actually in the pretender so that baby is hypoxic as well as hyperbolemia. Nucl cord literature review, it shows that evidence that cutting the cut of the nucl cord before the birth does cause harm. It causes a birth rate reduction, hypovolemia, hypertension and shock, anemia, hypoxic, encephlopathy, cerebral palsy and neurodevelopmental delay. Nucl cord and shoulder dystociae occurs in 1.7 of all births. Case review of 9 births shows that nucl cord was cut before the birth of the shoulders. Three to seven minutes before the shoulders were born, all babies had low apgas and signs of HIE. Several with cerebral palsy and the authors recommend no cutting of the nucl cord before birth as a method to protect the baby's health and prevent the provider from medical legal action. Show a picture of the sum of salt manoeuvre which really this diagram should be turned on its end because we will get a lot better results with gravity where the baby will actually deliver with it through the cord. Another reason people use to do immediate cord clamping is that the baby needs blood gasses or cry-hauer. In the UK some hospitals have started blood gasses from all babies including physiological third stages and demanding that the cord is cut immediately to do this which is absolutely bonkers. Babies come out and they are in good condition but depriving the baby of 30% will definitely have a bad effect on the baby's condition. And cord blood samples can still be taken from a full-facing cord. There is no need to clamp on the cord whatsoever. After taking the samples you apply gentle but firm pressure to the needle's entry side as it would if you were taking venous blood from an adult. Certainly we put gentle pressure on a taking blood from an adult. We do the same with the cord. Let's talk about a hospital in Newcastle because they went to a conference run by David Hutchins who is a retired obstetrician in the north of England. And he has been campaigning for delay cord clamping for a long time and he's like the king of delay cord clamping. He's done lots and lots of work. They went to one of his conferences and there was a midwife, an obstetrician and a neonatologist. And they came back and they changed practice over 2009. And at 4 o'clock in the afternoon they got back and they implemented delay cord clamping in all their babies. George, who was the advanced neonatal nurse practitioner and midwife, took home 1,973 notes and did a retrospective study which showed that delay cord clamping in the hospital reduced. Babies gone to the wist of the pair from 15% to 4.08% and their admissions to Scaboo neonatal unit were 4.5 reduced to 2.5. Talk about jaundice because that's one of the obstacles as well that people say that babies get too much jaundice if they get this blood. And this isn't true. 8 studies showing involving over 1,000 neonates there was no significant difference in risk of jaundice between 24 to 48 hours. And the most recent meta-analysis of 18,000, well, 1,828 infants in five studies, there were no significant differences in the clinical jaundice. Serian sections as well. Lots and lots of doctors now are doing delay cord clamping in general serian sections. There has been resistance but I found on the whole most doctors are very receptive to changing practice because the evidence is there. First section was a gentle section. This is not such a gentle section. You can see that this baby is a little bit prem. Looks completely stunned and looks like it could have done with a minute or two to come round and have that transition. And it's losing all that blood that's in the placenta. Talk about gentle sections. So you've got delay cord clamping or milking of the cord which I'll talk about in a minute. A warm towel, bedside recalculation which I'll also talk about. I'm waiting to clamp the cord, the unpolical cord, for 30 seconds after analysis section. Results in higher iron stores at four months of age compared with early cord clamping after vaginal birth. And seems to ensure iron status comparable with those achieved after 180 seconds delay cord clamping after vaginal birth. Which makes me wonder that if the baby's coming through the vagina, whether the blood that's squeezed as the baby's going through the vagina backs up in the placenta, but that of course doesn't happen in analysis for their infection. Talks about cord milking, which cord milking or cord stripping, two to four times gave the same benefits of delay cord clamping. So if anybody's in a rush and the baby's delivered, holding the cord and stripping the blood through to the baby and then releasing let the cord fill up again and doing the same two to four times have the same benefits of delay cord clamping. But of course it's a lot quicker. No harm with milking. There's no increase in joint assault polycythemia. And percentile transfusion should be considered at every delivery as it can have a marked impact on the outcome of newborns. Annab Cathera in San Diego has done extensive research into cord milking. So if anybody wants to have a look at that, he's the guy to look at. Talk about neurological development with delay cord clamping. And refill animal and human studies suggest that early cord clamping, before the onset of certain operations, appears to adversely affect several presusions during fetal to neonatal transition. Judith Mercer again has demonstrated improved motor function at 18 to 22 months, corrected age, with delayed cord clamping, combined with one time umbilical cord milking, compared with immediate cord clamping. Icarabie in the UK as well has demonstrated similar outcomes with umbilical cord milking, compared with delay cord clamping at two and 3.5 years of age. And all around us and we've already discussed his results. We talk about loathers sections where the baby can be delivered with a section, which is really easy to do. Resuscitation is really important. The first minute of baby being born, we do 30 seconds of setting and 30 seconds of rescue breath, and this can all be done with a cord intact. Baby that has a cord intact is far likely to be resuscitated more successfully if it's got that blood volume. We say to the ambulance people if you had a road traffic accident of somebody that had needed resuscitation but no blood loss, compared to a road traffic accident where somebody needed resuscitation but they'd lost 30% of their blood volume. Who would you be more successful? At the moment we clump and then we look at the breathing in the airway. It should be the other way round. We should look at the airway breathing and then clump. Resuscitation guidelines are looking at that and they're actually recommending in their training that we try and keep the cord intact for the first 60 seconds. As I said, dry baby, SS for 30 seconds and then 5 inflation breath. Obviously, resuscitation is really, really important for that reason that we actually developed a resource trolley called the Liestart trolley and I'll just flick on to that because we're running out of time. It's called the Babeside assessment stabilisation and initial cardiorespiratory support system trolley. It was a group of consultants on myself and we realised that the babies that benefitted more from delay cord clumping were the premature babies and the compromised babies. But they, at the moment, are the babies that are more likely to get immediate cord clumping and we realise that this has to stop because the benefits are widely researched and immediate cord clumping on these babies does cause harm. This is the Liestart trolley and it can be used in four sex deliveries and cesarean sections and it's very easy to use and can give that baby a few minutes extra to start. Did a case study, there was a case study where one twin was born and it was completely normal. Everything was fine. The second baby had a cardiac malformation and the baby was resuscitated with the cord intact. Mum and dad held the baby whilst the baby was being resuscitated and after three minutes, to five minutes, the baby was transferred to the neonatal unit and the baby actually died but the parents said the positive aspects of actually having that baby for three minutes at their bedside whilst they were holding the baby's hand the alternative would have been the baby was whisked away to the resuscitator and they would not have had that baby, they would have seen a fear back. We did win an award, which was really good fun. You can go into that cord resuscitation if possible and bedside resuscitation is acceptable and we need to bring that in. Hanup Cathera in San Diego has been doing lots of research and there is research out there for people to have a look. Talk about the cord blood donations because parents are quite often coerced into signing up to donate their baby's cord blood or store their baby's cord blood without being given the benefits of delay core clomping. We can do both, we can do delay core clomping as a source of storage but parents are signing up to this and going for the one minute delay core clomping without realising that they could be risking their baby having anemia and certainly in countries where they haven't got guidelines for delay core clomping babies have immediate core clomping with the hope of getting the biggest volume possible. There are also parents signing up to altruisticly to give this to people who need it for their other children but they are not realising and they are not giving the information about the disbenefits for their own baby. It is really important that as caregivers we give them both sides of the story so that they can inform choice on what is best for their baby. It is our blood, don't do this away. Hannah Tisard is a student or she's qualified midwife and she does resources all over the world. She has a website called www.lustababy.com You can get free resources which can be shipped out to any country by going to this website. She's also building on the website so there's lots of information about optimal core clomping so if anybody wants to go there. But global network, everybody in the world is working towards optimal core clomping and waiting for white because it's the benefits or the disbenefits of immediate core clomping which is an intervention that we haven't got the evidence that we've no evidence to say that that is the right thing to do. We should be letting these babies have a gentle transition into the world which gives them benefits for life. Any child that's anemic that has neurological development problems or learning problems, their mental health is affected for the rest of life which is a public health problem as well. Ted Talk by Alan Green, he's a Ted Talk, it's 90 seconds to change the world. It's an 18 minute trip, really really good because lots of information on there. Did win an award because I didn't particularly change the guidance for nice but I nagged them so much that they did change and it just shows that you can chip away, you can get there in the end but there's lots more work to do. And there are my contact details. We did do a survey this year, we looked at 3,500, well the positive birth movement with Millie Hill did a survey for 3,500 women or parents and it shows that 20% of babies in the UK are still getting immediate core clomping and 40% of parents report that the cause has been cut earlier than they want because people just do not understand the physiology or the evidence or the benefits behind delayed core clomping and we need to do. The research that does the cause melting is ANUP, A-N-U-P, CAFERA, K-A-T-H-E-R-I-A, I will spell it. That is the end of the presentation. Thank you Amanda. Thank you Amanda. Sorry, it's a whistle stop tour but lots to say. Yes but you did it fine and it wasn't too fast and it is fascinating to understand the background to all of this and I certainly can relate to the fact that when I first practised as a midwife active birth or active management really was coming in and I was taught to cut and clamp the cord quite quickly and that if you didn't there would be jaundice and there certainly was a lot of jaundice, physiological jaundice and to this day we still don't really know why that was perhaps nowadays babies are more healthy, I don't know. But anyway so this is fascinating. Any comments from anybody? Sorry, go on Amanda. We're saying about the jaundice, we do give the orthothothic and there isn't evidence around this but if you think that you give the orthothothic and it clamps down the potential the research says there isn't any jaundice but you will say that community midwives say there is more but if you give an orthothothic and the uterus clamps down you interfere in that fine transition between mum and baby and I do wonder, we obviously need lots more research whether that does the interference may cause but we have to be really good at picking upon the jaundice. A little bit of increased jaundice is not a good enough reason to be doing immediate call clamping or early call clamping. I totally agree. Vicky is saying that she's getting women coming to her with this is an idea now. Vicky where do you work, live in New Zealand? Now I thought New Zealand were usually leading the way so optimal call clamping is not normal practice in New Zealand? Well Christchurch has fantastic guidelines. You've got Sarah, she's got some fantastic guidelines down in Christchurch so it might be worth getting in touch with Christchurch. I've got a name Sarah, it's gone, it's gone. They've got some fantastic guidelines in fact if you get in touch with me I can send the guidelines out or put you in touch. Better take a picture of this page everybody so you can contact Amanda. I think it's the same with everything. It's the same in the UK. You've got pockets of people that are doing optimal call clamping and they're doing fantastic and the hospital in the next town might be doing immediate call clamping and I would say it's probably the same all over. Practice is really patchy. Is there a pallet? Is there a pallet? She's actually on our page. I started the page and there was just me and then it's such a good platform that we've got lots and lots of people on there now to use this platform to change practices throughout the world and Sarah pallet's done great work in New Zealand. Thank you, Nicky. It is. People don't understand. I don't know how we change it and I also think midwives, we have to impart so much information that is squeezing another bit in and in the survey that Millie Hill did it shows that a lot of the information that parents are getting are coming from outside antenatal courses, NCT, positive birth movement, Katherine Graves, hypnobirthing, the Daisy Foundation, lots of people are doing the information. That's in the UK but we just need to keep chipping away and the more people that jump on it's a really good ban to be in really because there's no competition which is unusual in the medical profession but everybody wants the same outcome really so the more people that get on there you can use my presentation for your own needs or just get in touch with me and join the snowball rolling. All around us and said it's like rolling a snowball it's getting bigger and bigger and it doesn't matter who pushes it whether it's a parent or a top researcher but the more that we push and the bigger it gets and then hopefully immediate call-clamping will become practice in the past. Kerry in Northampton is saying that she's going to take it back to her fellow students and I was about to type in and ask if you taught this. Hi Paula. Okay. Fair enough. But you're not taught wait for white. Okay. That's fair enough. I think it's very descriptive isn't it? Did we have any other questions at the top of the time missed? Yes this whole thing about called gases why do we need to worry about called gases? This is like patho physiologically labelling all babies at birth isn't it? It's medical legal. It's medical legal but what they're actually doing is the babies come out and they're probably absolutely fine and then we deprived the baby of 30% of the blood volume. We have a K2 training package in the UK that actually says cut the cord immediately to do this but I have to say that I got in touch with them and they have changed their they've changed it. They've changed their K2 training and they're going to look into advertising on the cord intact. It can be done. Nana Waiburg in Sweden have done studies and Ulur Andersson have done studies where they looked at PHS which were done with the cord intact. It can be done. So why we have to go in and it's awful to see a baby that's been born and then you look at all the blood that's in the cord. And you know we expect the baby to but we expect the placenta to resuscitate the baby with its inside as there's a deceleration we don't go in and clamp and cut the cord. So all this was to take that baby you know it's just having the confidence to sort of stand back. I worked at a hospital last year where we did birth centre and we did no cord management. Baby was delivered skin to skin, no cord management. On the labour ward they did do one minute which isn't long enough but you know you get the pediatricians coming into the room and they would stand back everybody would stand back for a minute and watch this baby and 99 times out of 100 and they just walk away because the placenta does its job. You know? You kind of think that the medical thing would apply in the light of the evidence if you did not allow it to stop clamping because you are actually intervening aren't you? I agree completely and that's again it's the not understanding of the physiology of the placental transfector's fusion. Judith Mercer does a fantastic paper that's called Re-Thinking for Central Transfusion and I'd recommend everybody read it. It covers everything from stem cells to anemia to resuscitation to the transition so I would recommend everybody that. That's Judith Mercer, I'll write it down. Judith Mercer and it's Re-Thinking Central. I'm not doing capital fusion. It's online, you can get it quite easily on Google. OK. We've got time for one more question so I'm going to really put you in the spot because Susanna has asked quite a humdinger of a question which has just disappeared from my screen anyway. In your experience what kind of advocacy has worked when presenting this information to physicians and pediatricians? Lack of that with Northumbria they were really really good and you have to do it as a team approach. You have to get everybody on board. Midwives can find it quite difficult I did find it quite difficult and if you don't succeed with consultants find a consultant that will back you. Pediatricians you can't say that one group is worse than another really but sometimes you'll get pediatricians. We did find the hospital that I worked in 2012 I won an award for this and we were doing really really well and I came back to work and they called clamping for 14 months because the pediatricians have said that it calls polycythinia. They had no evidence to support that but that was absolutely devastating. So it's about doing a joint approach I know Aberdeen in the UK are all working together because they did a talk up there and it was attended by if you attend a conference like this or a conference you get all the information it's not rocket science and if you've got people from different nominations in that conference you can change practice really quite quickly like they did in Northumbria. So it's about I don't know get a copy of Judith Merse as we think in Percentral Transfusion and wave it under their nose and it's about chipping away and if you find that some visit try and find some visits not because eventually at the trust that I work we did get it through and it was a consultant that did it it was a consultant who saw the benefits who managed to change it and it's about chipping away it's about chipping away and parents are incredibly important because parents are the people that are asking for this now they're coming and they're demanding delay called clamping because they know the benefits they shouldn't have to we should be doing this and it's parents that are being the biggest change up to this as they often are well I have to say thank you very much Amanda for a fabulous presentation I'm very pleased to have heard it at last and obviously it's getting out there and it's nice to see that the midwives around the world are are involved in this I've always felt that the whole childbirth thing was far too rushed and probably we accidentally left the cord for quite a while in the past because you were never in a rush to get the whole thing completed you were too busy admiring the baby and dealing with the husband and other children who came running and all that kind of stuff so there you go anyway