Conversely, a higher hemoglobin concentration increases risks for hyperbilirubinemia and extended hospitalization for neonatal phototherapy (McDonald, 2013). Delayed cord clamping may also hinder timely and needed neonatal resuscitation. That said, early pilot studies are assessing the value of resuscitating newborns at the bedside to permit delayed clamping (Katheria, 2017; Winter 2017). Fortunately, in general, delayed umbilical cord clamping compared with early clamping does not worsen Apgar scores, umbilical cord pH, or respiratory distress caused by polycythemia. Regarding maternal outcomes, rates of postpartum hemorrhage are similar between early and delayed clamping groups (Andersson, 2013). Fewer data are available regarding cord "milking," in which the opera tor pushes blood through the cord toward the newborn. his clamping is clinically indicated (Upadhyay, 2013).
For the preterm neonate, delayed cord clamping has sev eral benefits. hese include higher red cell volume, decreased need for blood transfusion, and lower rates of intraventricu lar hemorrhage and of necrotizing enterocolitis (Backes, 2014;
Rabe, 2012). For neonates who require expedited resuscitation, cord milking may have beneits to quickly transfer volume (Al-Wassia, 2015; Katheria, 2015; Patel, 2014). Still, because of rapid blood volume changes, the American Heart Associa tion currently suggests against the routine use of cord milking for neonates born <29 weeks' gestation (Wyckof, 2015).
The American College of Obstetricians and Gynecologists (2017a) notes suicient evidence to support delayed umbili 30 to 60 seconds after birth. This opinion is also endorsed by the American Academy of Pediatrics (2017 a). The American
Heart Association guidelines advise that the practice may have resuscitation at birth (Wyckof, 2015).
In the absence of a pelvic architecture abnormalit) or asynclitism, the occiput transverse (OT) position is usually transitoly. Thus, unless contractions are hypotonic, the head usually spontaneously rotates to an OA posItion. If rotation ceases because of poor expulsive forces, vaginal deliveY usually can be accomplished readily in several ways. he easiest is manual rotation of the occiput either anteriorly to OA or less commonly, posteriorly to occiput posterior. If either is successful, Le Ray and coworkers (2007) reported a 4-percent cesarean delivery rate compared with a 60-percent rate in women in whom manual rotation was not successful. Some recommend rotation with Kielland forceps for the persistent OT position as outlined in Chapter 29 (p. 561). These forceps are used to rotate the occiput to the anterior position, and delivery is accomplished with the same forceps or by substitution with Simpson, Tucker-McLane, or similar forceps.
In some cases, pelvic shape leads to a persistent OT position that is not easily overcome. For example, a platypelloid pelvis is lattened anteroposteriorly and an android pelvis is heart shaped. With these, space may be inadequate for occipital rotation to either an anterior or posterior position (Fig. 2-17, p. 31). Because of these concerns, undue force is avoided if forceps delivery is attempted.