 Chris or Linda first switching that on and I'm going to just go ahead and introduce Susanna Santos and she's a midwife from Portugal. It gives me great pleasure to tell you about Susanna. She started her education as a nurse practitioner and worked 10 years in an obstetric unit. Then in 2008 she became the mother of a beautiful baby girl who finished her education as a midwife. She's been a midwife for eight years now and works in a local labor ward for public maternity hospital and she chose this unit because the midwives there advocate normal and natural childbirth practices. In addition to the hospital she works independently helping couples during pregnancy to prepare for natural physiological and rewarding childbirth. She has experienced water birth and was the co-author of the first Portuguese study about water birth that she presented in ICM at Prague in 2014. She's been a guest assistant at Lisbon High School of Nursing and Midwifery departments and she's now doing her master's degree in midwifery and preparing her final thesis about the management of new course. So thank you Susanna and go ahead. Thank you very much Jane. Sorry for the sound and good afternoon to all of you. First I want to wish you all a happy International Day of the Midwife. Let me tell you that it's a pleasure and a great honor to participate in this conference. I ask you please to be patient with me. English it's not my first language. As Jane said I'm a midwife there are eight years old and work in obstetric units for 17 years. Over the years I've become more and more interested in all around normal and physiological birth. A few years ago I was with a midwifery student talking about a birth which we had attended and she told me Susanna cut a nuco cord is so difficult there is no other way. I smiled and said yes there is but we are going to have to read learn and discuss a lot. As we discussed in the last presentation we need to support our students their fears in their feelings. That time I decided I was going to do something to change clinical practice. Since then I have been looking for basis in scientific evidence and have been trying to spread the word here in Portugal. What I bring to you today is a presentation of a literature review entitled Nucle Corded Birth Evidence Based Practice. The aims of my presentation are identify scientific articles that lead to the best clinical practice of midwives around Nucle Corded Birth and improve knowledge about Cord Clampic Timing and different approaches to Nucle Cord Management. Also infer about indications advantages and disadvantages of the various clinical approaches and finally promote individual reflection about clinical practice. On scientific evidence the importance and the benefits of the late court clamping are already wildly improving. So why this study? Which is the better management for a Nucle Cord? This is what I need to know. I needed to know. Nucle cords are very common at birth but nevertheless very professionals continue to treat it as an obstetric complication. In addition to clinical practice seems to be based on personal experience and in what is routine in their workplaces. So we need to create here in Portugal we need to create guidelines for clinical practice. What did I know when I started this work? The principal aim of our assistance is a healthy mother and a healthy baby with the lowest interventional level. We need a valid reason for interfering in the natural and physiological process. By the other way we know Nucle Cord is defined as the presence of umbilical cord around baby's neck in one or more loops. Checking for a Nucle Cord is a common obstetric intervention. Nucle cords are usually associated to some kind of risk. However given their high incidence and low number of adverse effects reported it's difficult to define the concrete risk. In Portuguese education the guideline is pulling loose Nucle cords and clamping cut the tie ones. Although this practice continued to be described in books and guidelines the current scientific evidence contradicts this practice and put into questions that the theoretical contains in which they are based. The high incidence is referred by most of the authors that I consulted. It's more frequent in male babies and some authors related these facts with the longer length of the cord in these babies. Babybites. They may form during pregnancy or during labor. Some authors put this possibility because the incidence is smallest in elective c-sections. Nucle cords are in fact related to changes in baby's heart rate but in most situations this physiological, not pathological. For all of these I decided to study more deeply this subject. Then I conducted a review of the latest scientific articles on the subject. This script is used for Nucle cords, cord clamping and somersault maneuver as well as the Boolean operators and and arm. I used the beyond system from Lisbon High School of Nursing that includes the databases academic search complete, Sinal, PubMed, Medline, Scopus, Cielo, Up-to-date and Web of Science. In the Cochrane databases of systematic reviews has been used the descriptor cord clamping. Were eligible articles available in full text published in the last five years in Portuguese, English or Spanish? Electronic search was carried from October to November from last year. As the result we have 16 articles were identified that respond to the criteria and that are distributed as you can see in this slide. In the following in the following slides meet the summary of the selected article. The studies are mostly from UK and United States. We have five from UK and three from United States. And then we have other countries, Thailand, Iran, Pakistan. And I hope in a near future we may have a Portuguese one too. Sorry. These are the last ones. After analyzing the 16 articles what did I found? I found that time for cord clamping is contested. Different authors defense different timings. On the other hand, and despite these advantages, cord clamping remains the most widely used practice. Cut the cord is a reasonable need but clamping is controversial. Also the reasons behind this controversial practice are complex. Complex. The influence of the habit is hard to reverse and it's difficult to change behavior and it takes time. Lack of evidence based knowledge about the advantages of delayed cord clamping. They are no specific national guidelines and we need it. They are no perceived definitions about early cord clamping and physiological cord clamping. As I said, authors have different opinions. And then we have cryopreservation of the umbilical cord blood. Cryopreservation involves early cord clamping and also implies by professionals during pregnancy the transmission of correct and truly information to the parents. In this photo you can see a beautiful mom and her healthy baby who had the nucle cord at birth. If you see the cord is still uncut and white. And this slide is a resume of these advantages of early cord clamping and the advantages of delayed cord clamping according to the authors. This has disadvantages of early cord clamping. We have hypovolemia, bradycardia, epoxy in terms and preterm babies, increase of anemia in preterm and term newborns, increase of risk of interventricular hemorrhage, increase of respiratory complications. By the other hand has advantages of delayed cord clamping. We have that allows placenta transfusion in 30% increase of blood volume to the baby. It increases hemoglobin levels, increases iron reserves and ferritin levels up to six months, improves oxygen transport and decrease the need for blood transfusion in premature babies, decrease the days of oxygen therapy in premature infants and decrease also the need for assisted ventilation. Promote skin-to-skin contact and mother and child relationship. Many good reasons that justify changing the practice. Don't you agree? Delayed cord clamping is supported by many international organizations and they are referred by the authors. We have the WHO, FIGO, ICM, Royal College of Midwives and another international organization. Placental transfusion is protective for the baby, especially in stressful situations or fatal distress. Prevents hypopolymia and improves perfusion for all organs. I always, I found as well that there is a lack of level one evidence of how nucleic cords should be conducted, but there is enough evidence about how they should not be conducted. This is a great challenge for all of us. Cord clamping is not a physiological need, it's an obstetric intervention. The cord vessels will collapse. Remember the picture, the picture that I put and we saw, wait for white. Guidelines on the clinical practice need to be improved in order to prevent unnecessary interventions. So, and maybe this is the most important slide of my old presentation. It's about how should we act. Recommendations according to the authors and scientific evidence are to avoid early cord clamping, to avoid nucleic cords clamping. Many authors defend that pulling loose nucleic cords is the simpler solution. And many of them also defend that somersault maneuvers to tie warms or incases of multiple nucleic cords. In somersault maneuver, midwife gently supports the occipital of the baby's head, driving it to the inner side of mom's leg while the mother is pushing. No extraction maneuvers are needed, just a gentle support. The head and the neck of the baby remains near the perineum. It's a simple maneuver, gentle bending of the head which promotes flexing of the baby's body and his birth. At this time, nucleic cords comes off with ease. In water birds, babies do this alone, freeing itself from the cord. By doing this, we can have the possibility to delay cord clamping and the cord intact if reanimation is required. So, what can we do for change the practice? Literature reviews are very important. If you, we have knowledge based on scientific evidence, we will feel more secure to change the practice. We will have more inner resources to fight with our fears. Discussions about evidence like this one today, we have to share knowledge experiences, difficulties and success. And finally, we need education, simulated practice and training. And what were my conclusions? Delayed cord clamping is beneficial for the newborn and it's recommended. Recommended management of nucleic cords is the one that avoids compression of the umbilical cord associated to the clamping and cutting. Pulling nucleic cords is a simpler management. However, it's only safe in the presence of a wide-nucleic cord and involves manipulation of the cords. In the presence of a tie or multiple nucleic cords, the clinical decision must rest on the somersaults manufrim. These were my big conclusions. I am now ending my presentation. Thank you, Susana. But finally, I need to make a very special thanks to Amanda Burley, midwife of the year in 2014 in UK. I am very grateful for all your sharing knowledge, becoming an inspiration, but also for all support you have given me. Thanks, Amanda. And these are my references. Thank you very much for your attention. Here are my email contact if you need something. This photo behind is from my beautiful city, Si Tuval, very close to Lisbon, in the case you want to come here. Once again, thank you for this opportunity and sorry about my English and the sounds. Now I will be happy to hear your questions or comments. Thank you very much. Thank you, Susana. And I think your English is a hundred times better than my Portuguese. Okay, but you are not doing a presentation in Portuguese. So I'm going to relate to you some questions. Okay. Can you speak to, there's a question about giving oxytocin prior to when the cord is still intact and attached to the baby. Sorry? Oxytocin to the mother. When you give, when you have active management on the third stage and then you still have the baby attached, do you think the risk of exposure of oxytocin? Yes, I can understand the question and thank you. This is a commune question. Here in Portugal, we don't administrate oxytocin with the baby and the cord intact. But if you need an active management here in Portugal, we cut the cord. But if you are promoting delayed cord clamping, skin-to-skin contact, bonding from the mother, you will have breastfeeding earlier and oxytocin from the mother. Okay, and then there was another question. I think it was about taking cord gases. Yes, no. Here in my unit, we don't take, but it's possible. The needle is very, how can I say, a small one and we can, you can have gases. In a hospital near Situva, another hospital, this is practice. And in my next research, I want to include this data about gases to prove that this is safe. That's great. And Kerry is saying she took part in a study day about water birth. Yes. And they discussed taking blood for Rhesus analysis with the cord intact. And I'm guessing, she's guessing that blood gases would be the same. In my experience with water birth, as I told you, we, here, we don't take samples to gases. But I think it's possible. Yes. That's great. Does anyone want to put their hand up to us and ask a question? I wanted to ask Susanna whether it's normal practice to check for the cord before the baby is born, after the baby is born, before the body is born? Yes. Checking for the cord is, I think, it's an obstetric intervention also. It's not needed. We don't need it. I can tell you how I became more experienced with somersault maneuver. In the beginning, I need to read a lot. I saw movies about somersault maneuver. And one thing I did was trying to apply the maneuver in all Nucle cords, just not the Thai ones. So I became, how can I say, it's a habit. I don't check for Nucle cords. And then there's another question here from Charlotte saying that her tax on Germany changed, or sorry, Denmark, sorry, Denmark. She said three years ago they were able to change the procedure from taking blood while they're able to take them while the cord is still attached. Why? I think I cannot understand the question. Okay, so Charlotte was saying that her process changed three years ago. Yes. I cannot hear you. So that they are able to take cord gases and hello. I can't hear you. Right after. Can anyone hear me? Yes, I can hear you. Both. I can hear you both. Although something obviously happened because the screen has just gone blank. So maybe if we give it a minute, everything will suffer back down again. Can I speak? Yes, yes. Can I speak? Yes, you can. Yes, okay. I don't understand the question. Please speak. I don't understand the question because I can't hear. Can you read the question in the text box? It's in the text box, dear. Yeah. Oh, okay. I think I'm. So I think Charlotte's point, Susanna. Charlotte's point is. Yes, we can do, we can do gases. We don't, we don't do in my hospital because it's not a common practice here. But we can, I know that we can do in the other hospital near Lisbon. They are doing gases and in all babies, all ones. So I think there is there that I'm going to make my study. It's very exciting. We're very excited to hear that. And we look forward to hearing about it next year. Yes, maybe. Anyone in the audience interested in a multi-central study? Well, we actually in Florida and USA, we already do a lot of delayed cord clamping in the hospital. And what about clinical cords? Yeah, we usually leave them. We usually don't check for them or cut them. Yes, great. Here in Portugal, it's the common practice, cord clamping. And I have to fight for my position in my hospital and I have to lead with some questions like why are you doing it? Susanna, the baby is in a lower position than the mother or any any kind of questions. I don't know what is your... Well, I can send you. I actually published, Susanna. Sorry? I published a paper last year, 2014 on delayed cord clamping. Yes, yes. So I will send you that. Thank you. I don't know what... You can tell your obstetricians that actually cut the cord. Not just obstetricians, also pediatricians. I'm not hearing you, Jane. That's because you turned yourself off. Sorry, it's just with the echo. Sorry, it's just with the echo. So Susanna, if you give Jane a chance to finish your question, because there's a delay, you see, it's really quite strange. Okay. So what you need to tell your colleagues is that actually cutting the cord early... That is an intervention. It is not an intervention to leave the cord alone. It is an intervention. Yes. Yes, some of my colleagues are now doing somersault manoeuvres and not cutting the cord, but not all of them. And another aspect that I think it's very important is what women think about this. I don't know what is your experience, but here in Portugal, sometimes, many times indeed, we have birth plans when the women say that they want the light cord clamping, but also great preservation of the cord's blood. So I think we need here, it's improved information for the women. Katie, if you could go to the top of the toolbar and look at the speaker, and then to the right of that, there's a microphone, and you click on that, and you can click on that, it should go green, so you can hear you. Can you hear me? Yes. If you can hear me, my question is whether or not in her research she has discovered or seen any research on the connection between a decrease in maternal hemorrhage with delayed clamping until after the placental delivery, or whether that's even been studied. Jane, I think this question is for you. I'm not sure. I think it's for you. I'm not sure. Yeah. If you have an opinion. The research. If you have an opinion. No, in my, in the article that I reviewed, there are no, nothing about hemorrhage, no increase. Okay, thank you. I just wanted to note that I read the Royal College of Obstetrician and Gynecologist, and it was their opinion, but they claimed that there was research to demonstrate. That's not me. There was increased bleeding. If you, a delayed cord clamping. If you, a delayed cord clamping. Yes, I wrote that. I don't know. Maybe just their opinion because of the evidence. I don't see anything. Rachel, I'm asking if it's possible to create a preservation with delayed cord clamping. Some of the, what can I say, the cord banks, defense there it's possible, but the volume of blood to preserve, it's very, very, very, very lower. And we're just waiting for a few more questions here. So, Keri just wants to know if there's research about it. No, I have not found. I have no, I don't read, I don't have no founds, that is about this, but in my practice, it's a normal volume of blood. And it sounds like our colleagues have some interesting studies. Charlotte is saying that there's a Nordic study, which might give details. Okay. And Hallie, Hallie is saying that with, she's observed it with physiological third stage, that women have a heavier blood loss immediately, but less I'm, I think all of us have, have read something about the increase of blood loss. But what I think it's that maybe the position of the women can be influenced in this, in this fact because the volume of blood, of blood don't seems to me to be higher. It seems to be all, how can I say, when the women is in a vertical position, more blood at the same time, not more blood at all. I think I want to know if I can make me understandable. No, we understand, I believe, and I think that's concurring with what C.O. Jevitt just posted. Sorry, Jane. She says that in her unit, delayed cord clamping is the norm. Okay. In my unit, in my, the main blood loss for all women was 300. Okay. Okay. I agree. Good news. And, can you, I think we've all found this really stipulating. Yes. I want to ask if any of you have experiences like mine here with the resistance of professional, other professionals and colleagues. Okay. I would say that resistance is kind of normal, Susanna. Nobody likes change, do they? So you have to present a really good case and work slowly and eventually other people will be persuaded. And I think yes, the midwives, not just the obstetricians. Yes, with our colleagues too. But with the time, I think some of them think that it's a good practice. And some of them are also doing it. But the others, I don't, I think they don't recognize the importance. Sometimes it's difficult, but we can do it. Well, that's right. And I hope in 10 years we're not, we're just presenting that delayed cord clamping is not the norm. No checking for new cords. Thank you very much, Susanna. I'm sorry about the echoing sound there. I think we'll all be coming to visit you in your beautiful city. Okay. I'm waiting. Good. And I'll be sending you my publication as well. And I think. Sorry, Jane, I can't hear you. I think Charlotte can send hers. Okay, okay. It'll be great. And thank you very much for this opportunity. Thank you. And you did fantastic. It was a great presentation. Thank you so much. Okay. Thank you. Thank you. Thank you very much. Okay, so if somebody would like to turn off the record button for me, I really would appreciate that.