Current practice of cord clamping in the Netherlands: a questionnaire study

Delayed cord clamping vs cord milking in elective cesarean delivery at term: a randomized controlled trial

BACKGROUND

Delayed cord clamping has significant beneficial effects on the neonate and its transition to extrauterine life and, therefore, is common practice at vaginal births in the Netherlands. In 2015, 16% of neonates were born via cesarean delivery; moreover, in 81% of these cases, the umbilical cord was clamped and cut immediately. Neonatal benefits of delayed cord clamping are an increased circulating volume of 25 to 30 mL/kg, leading to a higher preload of both the right and left ventricles during the transition from umbilical circulation to pulmonary circulation, thus maintaining a stable left ventricle output, and to higher neonatal hemoglobin and hematocrit levels 24 to 48 hours after birth. Currently, little is known about whether the abovementioned neonatal benefits of delayed cord clamping could apply to neonates delivered by cesarean delivery. In these cases, possible negative effects on neonatal outcomes (ie, neonatal hypothermia, lower Apgar scores, and hyperbilirubinemia) and maternal outcomes (ie, increased maternal blood loss and higher postoperative infection rate) should also be taken into consideration.

OBJECTIVE

This study aimed to determine whether clamping the umbilical cord after 2 minutes is superior to cord milking during elective cesarean deliveries at term, taking both short- and long-term neonatal and maternal outcomes into consideration, and to determine whether cord milking could be an appropriate alternative to delayed cord clamping.

STUDY DESIGN

A randomized controlled trial was conducted in a large secondary care center in the Netherlands (Amphia Hospital in Breda) from October 2020 to April 2022. A total of 115 patients who underwent an elective cesarean delivery between 37 0/7 and 41 6/7 weeks of gestation were included. The primary outcomes were neonatal hemoglobin and hematocrit levels at 48 hours after birth. The secondary outcomes were divided into neonatal and maternal outcomes.

RESULTS

After randomization, 58 participants were treated with cord milking, and 57 participants were treated with delayed cord clamping. There was no significant difference in demographic characteristics between both groups. There was no significant difference in the primary outcomes, with a mean hemoglobin level 48 hours after birth of 12.1 mmol/L in the delayed cord clamping group and 12.2 mmol/L in the cord milking group (P=.80). Regarding our secondary outcomes, there was no significant difference regarding Apgar score, neonatal body temperature, maternal blood loss, and postoperative infection rate between our intervention groups.

CONCLUSION

Hemoglobin and hematocrit levels at 48 hours after birth showed no significant difference when comparing delayed cord clamping with cord milking. Delayed cord clamping did not lead to increased maternal blood loss or postoperative infections compared with a method with a much shorter timeframe between delivery and clamping of the umbilical cord, namely, cord milking. In addition, delayed cord clamping did not lead to a lower Apgar score or neonatal temperature compared with cord milking. Our research suggests that delayed cord clamping can be safely performed during elective cesarean deliveries at term. If intraoperative circumstances do not allow for delayed cord clamping, cord milking can be an appropriate alternative for the neonate at term.

Knowledge gaps in optimal umbilical cord management at birth

In 2014 the World Health Organisation recommended providing placental blood to all newborn infants by waiting for at least one minute before clamping the umbilical cord. Mounting evidence supports providing a placental transfusion at the time of birth for all infants. The optimal time before clamping and cutting the umbilical cord is still not yet known, and debate exists around other cord management issues. The newborn's transition phase from intra- to extra-uterine life and the effects of blood volume on the many necessary adaptations are understudied. How best to support these adaptations guides our suggested research questions. Parents' perceptions of enrolling their unborn infant into a study play important parts in the conduct of such trials. This article aims to address these topics and suggest research questions for further studies.

Integrated review of the knowledge, attitudes, and practices of maternity health care professionals concerning umbilical cord clamping

BACKGROUND

Umbilical cord clamp timing has implications for newborn health, which include increased iron stores up to 6 months of age. National and International cord clamping guidelines differ as do health professionals' practices. The rationale for differences in cord clamping practice is unclear.

AIMS AND OBJECTIVE

Studies on the knowledge, attitudes, and practices of maternity health care professionals about cord clamp timing were synthesized. Similarities and differences between professional groups and understanding of the optimal timing of cord clamp timing for term newborns were compared.

METHODS

An integrative review was undertaken. PubMed, Scopus, MIDIRS, CINAHL, and Google Scholar were searched. Publication date limits were set between January 2007 and December 2020. Quality appraisal was undertaken using the Critical Appraisal Skills Program (CASP) tools.

RESULTS

Eighteen studies met inclusion criteria, as they included primary research studies that investigated maternity health care professionals' knowledge, attitudes, and practices about umbilical cord clamping, and were written in English. Four main subject areas were identified: a) knowledge of optimal cord clamp timing; b) attitudes and perceptions of early vs deferred cord clamping; c) cord clamping practice; and d) rationale for cord clamping practice.

CONCLUSIONS

Different attitudes and practices were identified between midwifery and medical professionals in relation to cord clamp timing together with health professional knowledge and practice gaps pertaining to optimal cord clamp timing. Contemporary evidence should inform guidelines for clinical practice and be embedded into maternity health professional curricula and professional development programs.

Cord clamping beyond 3 minutes: Neonatal short-term outcomes and maternal postpartum hemorrhage

BACKGROUND

Delaying cord clamping (CC) for 3-5 minutes reduces iron deficiency and improves neurodevelopment. Data on the effects of CC beyond 3 minutes in relation to short-term neonatal outcomes and maternal risk of postpartum hemorrhage are scarce.

METHODS

This was a prospective observational study performed in two delivery departments. Pregnant women with vaginal deliveries were included. Time to CC, estimated postpartum blood loss, and perinatal data were recorded. Spearman's correlation analysis and comparisons between newborns clamped before and after 3 minutes were performed.

RESULTS

In total, 904 dyads were included. The mean gestational age ± standard deviation was 40.1 ± 1.2 weeks. CC was performed at a median time of 6 minutes (range 0-23.5). Apgar scores at 5 and 10 minutes were positively correlated with time to CC (correlation coefficient .140, P < .001 and .161, < .001). There was no correlation between CC time and bilirubin level (correlation coefficient .021, P = .54). The median postpartum blood loss was 300 mL (70-2550 mL), with a negative correlation between CC time and postpartum blood loss (-0.115, P = .001). The postpartum blood loss was larger in the group clamped at ≤3 minutes (median [interquartile range] 400 mL [300-600] vs 300 mL [250-450], [P = .003]].

CONCLUSIONS

Umbilical CC times beyond 3 minutes in vaginal deliveries were not associated with negative short-term outcomes in newborns and were associated with a smaller maternal postpartum blood loss. Although CC time as long as 6 minutes could be considered as safe, further research is needed to decide the optimal timing.

Delayed cord clamping practice at birth: A narrative review of literature

BACKGROUND

Anaemia in infants is a major public health concern particularly in low and middle-income countries. Delayed cord clamping (DCC) has been advocated as a strategy to decrease iron deficiency anaemia in infants because of the benefits that come with placental transfusion. Despite the documented benefits of delayed cord clamping in preventing anaemia the current practices of delayed cord clamping by midwives and obstetricians across countries and in different contexts is unclear. This narrative review assesses the literature on delayed cord clamping practices published from 2013 to February 2022, in order to examine current practice in birth units globally, and with a focus in low and middle-income countries (LMICs).

METHOD

A search of four bibliographic databases Medline, Scopus (Elsevier), ProQuest, CINAHL and two network and search engines, Wiley and Google Scholar, was undertaken from 2013 to February 2022 using key terms related to delayed cord clamping and immediate cord clamping. A snowball method as well as backward and forward reference checking was also undertaken.

RESULTS

The search strategy identified 10 studies on umbilical cord clamping practices by midwives and obstetricians. Only two studies were conducted in low and middle-income countries.

CONCLUSION

Despite the potential benefits of DCC in reducing anaemia, particularly in low and middle-income countries where the burden of anaemia is a public health concern, there is a paucity of literature on current DCC practices by obstetricians and midwives. Research to establish current DCC practices in these countries is needed to address this gap in the literature.

A Survey on Current Practices of Umbilical Cord Clamping in Malaysia

Background

Delayed cord clamping (DCC) has been demonstrated to have significant benefits in reducing the incidence of intraventricular hemorrhage, blood transfusion and neonatal mortality in preterm neonates and improving hemodynamic and long-term neurodevelopment among term infants. There is no clear guideline on umbilical cord clamping (UCC) practices in Malaysia.

Objective

The aim of this survey was to assess the knowledge and practice of DCC among obstetric doctors and midwives in Malaysia, and pediatric colleagues who witness the delivery.

Method

This is a cross-sectional survey conducted in childbirth facilities in Malaysia from October 2020 to January 2021. A convenient snowball sampling was adopted. A validated questionnaire was disseminated to practicing obstetric and pediatric doctors and midwives electronically via email and WhatsApp using Google Form. The data were analyzed using descriptive and analytical statistics.

Results

A total of 327 respondents completed the questionnaires, comprising 206 obstetric doctors, 72 pediatric doctors and 49 midwives. The majority of respondents were specialists or higher in rank (53.2%). Only 29% reported the existence of guidelines on UCC in their place of work. Midwives (P = 0.003) and staff of lower ranks and level of education (P < 0.001) appeared to be more aware of the existence of a UCC guideline. Most respondents had positive knowledge of DCC for both term and preterm neonates. A large proportion (82%) of respondents agreed that DCC helped increase neonatal iron stores, and was good for both preterm (70.7%) and term (76.2%) neonates not requiring positive pressure ventilation. Doctors, specialists, those who are 40 years old and above, and those who have been in service for at least 10 years were found to have better knowledge regarding DCC (P < 0.05).

Conclusion

The awareness and practice of obstetric, pediatric and midwifery staff of guidelines on UCC were less than satisfactory. Even though most respondents have good knowledge and positive perception regarding benefits of DCC, these were not translated into their routine practice. Hence, a national guideline emphasizing the benefits of DCC should be made available in all childbirth facilities.

Behaviors and Attitudes of Obstetricians in Turkey Related to Cord Clamping, Cord Milking, and Skin-To-Skin Contact

Objective This study was planned to evaluate obstetricians' practices of umbilical cord clamping, milking, and skin-to-skin contact applications and to determine the related variables. Material and methods A total of 522 obstetricians participated in the study. Participants were reached via the internet and a 15-item questionnaire was applied about umbilical cord clamping, cord milking, and skin-to-skin contact. Mann-Whitney U test and Student's t-test were used for continuous data and Chi-square test or Fisher's exact test for categorical data in determining the difference between groups. For the multivariate analysis, the possible factors identified with univariate analyses were entered into the logistic regression analysis to determine further independent predictors of delayed clamping. Statistical analysis was performed using the SPSS software (version 20, IBM Corp, Armonk, USA). Results It was determined that 234 (44.8%) of the participants clamped the umbilical cord early whereas 288 (55.2%) clamped it late. It was found that the delayed clamping rates of physicians working in public hospitals were significantly lower than those working in private (p<0.001). It was observed that 132 of the participants (25.3%) did not milk the cord and 180 (34.5%) of them applied it continuously, and no significant difference was found between physicians working in the public and private sectors (p=0.130). It was observed that 384 (73.6%) physicians applied skin-to-skin contact. In the multivariate regression analysis, it was determined that working status in a private hospital with a 3.6 odds ratio (OR) (95% CI = 2.0-6.3) and a low number of patients examined daily with a 1.2 OR (95%CI= 1.0-1.4) were the most important independent factors affecting the choice of delayed clamping. Conclusion It is seen that the most important parameter affecting the birth practices of physicians in our country is the employment status in public or private institutions. The age and professional experience of the physicians who clamp the umbilical cord late were found to be higher. Obstetricians are at the key point in obstetrics practice, and the experience of physicians and the type of institution they work with affect these practices.

Cord Management of the Term Newborn

Keeping the umbilical cord intact after delivery facilitates transition from fetal to neonatal circulation and allows a placental transfusion of a considerable amount of blood. A delay of at least 3 minutes improves neurodevelopmental outcomes in term infants. Although regarded as common sense and practiced by many midwives, implementation of delayed cord clamping into practice has been unduly slow, partly because of beliefs regarding theoretic risks of jaundice and lack of understanding regarding the long-term benefits. This article provides arguments for delaying cord clamping for a minimum of 3 minutes.

The Association Between Placental Residual Blood Volume and Two Placental Transfusion Methods After Delivery at Term

Background: Despite reports of the beneficial effects, such as increasing hemoglobin level and iron store in the neonatal period, of delayed cord clamping, or umbilical cord milking after delivery in healthy term-born infants, the duration of delayed clamping or rounds of milking in most previous reports were determined arbitrarily and varied widely across different studies. Methods: We prospectively recruited 80 women with normal singleton pregnancies at 38-40 weeks' gestation. Participants were classified according to the mode of delivery and randomly assigned to either collecting blood from the placenta by umbilical cord drainage (CD) or cord milking (CM), with the placenta left in the uterus. The volume of blood collected, the duration of CD, and the number of rounds of CM were recorded. Results: Collected placental residual blood volume positively correlated with birth weight, placental weight, and length of the cord. When 80% of the total placental residual blood volume collected was set as the threshold, more than 80% of women who delivered vaginally reached this level within 60 s of CD or seven repetitions of CM. This amount of blood could be obtained within 120 s of CD or after seven repetitions of CM in more than 80% of women who underwent cesarean delivery. Conclusion: In most women, regardless of birth weight and placental weight, more than 80% of placental residual blood volume could be collected by CD within 60 s after vaginal delivery, 120 s after cesarean delivery, and seven repetitions of CM in both vaginal and cesarean deliveries.

Australian maternity healthcare professionals' knowledge, attitudes and practices relevant to cord blood banking, donation and clamp timing: A cross-sectional survey

PROBLEM

Australian health professionals' knowledge and attitudes towards third stage labour options of cord clamp timing, cord blood banking and donation and their practice of informing parents of these options is unknown.

BACKGROUND

Parents have several options for the management of their infant' cord blood during the third stage of labour. Early or deferred cord clamping practices may affect parent choices about physiological transfusion to the neonate and/or cord blood collection for private or public banking or donation.

AIM

To identify health professionals' knowledge and attitudes towards third stage labour options of cord clamp timing, cord blood banking and donation and their practice of informing parents of these options.

METHODS

A total of 129 Australian maternity healthcare professionals responded to the self-administered survey between December 2017 and June 2018.

FINDINGS

Occupational differences were revealed in regard to cord clamp timing, cord blood banking and donation knowledge, attitudes and practices. Midwives were more likely to discuss cord clamp timing with parents and to clamp the cord later than obstetricians. Obstetricians were more knowledgeable of cord blood banking and donation options than midwives. Cord blood banking and donation options were discussed by both groups if parents asked.

DISCUSSION

Identification of gaps in knowledge should guide future maternity health professional education that is inclusive of all third stage labour options to ensure that open discussion and informing parents of options is consistent, contemporary and evidence-based.

CONCLUSION

To make informed decisions, parents need evidence-based information on all third stage labour options.

Knowledge and barriers on correct use of modified guidelines for active management of third stage of labour: a cross sectional survey of nurse-midwives at three referral hospitals in Dar es Salaam, Tanzania

Background

Despite the fact that it is possibly preventable, postpartum haemorrhage (PPH) is the global most deadly form of obstetric bleeding, mainly sub-Saharan Africa with at least one-fourth of maternal deaths in East African regions. Active management of third stage of labour (AMTSL) is recommended to prevent PPH. However, AMTSL guidelines have been revised since 2006.

Objectives

To examine the current status of nurse-midwives' knowledge on modified AMTSL guidelines and highlight barriers to AMTSL correct use.

Method

Descriptive cross sectional survey was conducted to 160 nurse-midwives at three referral hospitals in Dar es Salaam, Tanzania. One-way, interactive modes ANOVA and Chi square (χ2) test were run in SPSS 21 version to compare the association of independent and dependent variables.

Results

Virtually all nurse-midwives knew the first recommended uterotonic (99.4%) and delayed cord clamping (98.8%) protocols as modified. Knowledge was significantly contributed by multiple factors; p=0.001. Reported correct AMTSL use was 46.8% which was significantly affected by AMTSL training (χ2 = 6.732, p = 0.009) and prioritizing atteding an asphyxiated baby (χ2 = 5.647, p = 0.017).

Conclusion

Regardless of high nurse-midwives' AMTSL knowledge; it is imperative that responsible authorities plan appropriate strategies to solve reported barriers affecting correct AMTSL use.

Variations in umbilical cord clamping practices in the United States: a national survey of neonatologists

OBJECTIVE

Since the first publication of the American College of Obstetricians and Gynecologists committee opinion in 2012, and following the update in 2017, multiple institutions in the United States (US) adopted the practice of delayed cord clamping (DCC) and/or umbilical cord milking (UCM) in preterm and term infants. However, there have been variations reported in practices with regard to method of placental transfusion, timing of cord clamping and gestational age thresholds. Furthermore, the optimal cord clamping practice in situations of depressed infants needing resuscitation or in higher-risk delivery situations, such as placental abruption, intrauterine growth restriction, multiple gestation, chorioamnionitis, maternal human immunodeficiency virus syndrome/hepatitis or maternal general anesthesia is often debated. An evaluation of these variations and exploration of associated factors was needed to optimally target opportunities for improvement and streamline research activities. The objective of this survey, specifically aimed at neonatologists working in the US was to identify and describe current cord clamping practices and evaluate factors associated with variations.

STUDY DESIGN

The survey was distributed electronically to the US neonatologists in August 2019 with a reminder email sent in October 2019. Clinicians were primarily identified from Perinatal Section of AAP, with reminders also sent through various organizations including California Association of Neonatologists, Pediatrix and Envision national groups. Descriptive variables of interest included years of experience practicing neonatology, affiliation with a teaching institution, level of the neonatal intensive care unit (NICU) and practicing region of the US. Questions on variations in cord management practices included information about center specific guideline/protocol, cord clamping practices, gestational age threshold of placental transfusion, performance of UCM and practice in higher-risk delivery situations.

RESULTS

The response rate was 14.8%. Among 517 neonatologists whom responded, majority (85.5%) of the practices had a guideline and performed (81.7%) DCC in all gestational ages. The cord clamping practice was predominantly DCC and it was categorized as reporting clamping times <60 s in 46.6% and ≥60 s in 48.7% of responses. A significant association was detected between time of delay in cord clamping and region of practice. The Northeast region was more likely to clamp the cord in <60 s than other regions in the US. More than half of the providers responded not performing any UCM (57.3%) in their practice. Significant associations were detected between performance of UCM and all queried demographic variables independently. Clinicians with >20 years of experience were more likely from institutions performing UCM compared to the providers with fewer years of experience. However, teaching hospitals were less likely to perform UCM compared to non-teaching hospitals. Similarly, practices with level IV NICUs were less likely to perform UCM compared to practices with level III units. Hospitals in the Midwest region of US were less likely to perform UCM compared to hospitals in the Western region. Significant variations were also noticed for not providing placental transfusion in higher-risk deliveries. Demographic and professional factors were noted to be associated with these differences.

CONCLUSION

Although the majority of practices have a guideline/protocol and are performing DCC in all gestational ages, there are variations noted with regard to timing, method, and performance in higher-risk deliveries. Demographic and professional factors play an important role in these variations. Future research needs to focus on the modifiable factors to optimize the procedure and impact of DCC.

A Comparison of Strategies for Managing the Umbilical Cord at Birth in Preterm Infants

OBJECTIVE

To evaluate the rates of practice, and the associations between different cord management strategies at birth (delayed cord clamping [DCC], umbilical cord milking [UCM], and early cord clamping [ECC]) and mortality or major morbidity, rates of blood transfusion, and peak serum bilirubin in a large national cohort of very preterm infants.

STUDY DESIGN

We retrospectively studied preterm infants <33 weeks of gestation admitted to the Canadian Neonatal Network between January 2015 and December 2017. Patients who received ECC (<30 seconds), UCM, or DCC (≥30 seconds) were compared. Multiple generalized linear/quantile logistic regression models were used.

RESULTS

Of 12 749 admitted infants, 9729 were included; 4916 (50.5%) received ECC, 394 (4.1%) UCM, and 4419 (45.4%) DCC. After adjustment for potential confounders identified between groups in univariate analyses, the odds of mortality or major morbidity were higher in the ECC group when compared with UCM group (aOR, 1.18; 95% CI, 1.03-1.35). Mortality and intraventricular hemorrhage were associated with ECC as compared with DCC (aOR, 1.6 [95% CI, 1.22-2.1] and aOR, 1.29 [95% CI, 1.19-1.41], respectively). The odds of severe intraventricular hemorrhage were higher with UCM compared with DCC (aOR, 1.38; 95% CI, 1.05-1.81). Rates of blood transfusion were higher with ECC compared with UCM and DCC (aOR, 1.67 [95% CI, 1.31-2.14] and aOR, 1.68 [95% CI, 1.35-2.09], respectively), although peak serum bilirubin levels were not significantly different.

CONCLUSIONS

Both DCC and UCM were associated with better short-term outcomes than ECC; however, the odds of severe intraventricular hemorrhage were higher with UCM compared with DCC.

Early or delayed umbilical cord clamping? Experiences and perceptions of nurse-midwives and obstetricians at a regional referral hospital in Tanzania

Background

Umbilical cord clamping is a crucial step during the third stage of labour that separates the newborn from the placenta. Despite the available evidence that delayed umbilical cord clamping is more beneficial to infants, as well as the existence of 2014 WHO recommendation that the umbilical cord should be clamped between 1 and 3 minutes, its implementation is still low in many countries including Tanzania.

Objective

This study describes the experiences and perceptions of nurse-midwives`and obstetricians`about the timing of umbilical cord clamping at a regional referral hospital in Tanzania.

Methods

A descriptive qualitative study design that adopted a purposeful sampling strategy to recruit 19 participants was used. Nine semi-structured interviews with six nurse-midwives`and three obstetricians`, as well as one focus group discussion with ten nurse-midwives`were conducted. Thematic analysis guided the analysis of data.

Results

Three main themes generated from the data, each having 2 to 5 subthemes. 1. Experiences about the timing of umbilical cord clamping. 2. Perceptions about the umbilical cord clamping. 3. Factors influencing the practice of delayed umbilical cord clamping to improve newborn health outcomes.

Conclusion

Although the nurse-midwives`and obstetricians`commonly practiced clamping the umbilical cord immediately after delivery, they understood that delayed cord clamping has a potential benefit of oxygenation to the newborn in the event of the need for resuscitation. To move forward with the good practice in maternal and newborn care, proper pre-service and providers training on matters underlying childbirth is essential to address the gap of knowledge. Delayed cord clamping should be practiced widely to improve the health outcomes of the newborn.

Umbilical Cord Practices of Members of the American College of Nurse-Midwives

INTRODUCTION

Mercer et al surveyed members of the American College of Nurse-Midwives (ACNM) about their umbilical cord clamping practices in 2000. Over the last 20 years, a significant body of research supporting delayed cord clamping (DCC) has been published. The purpose of this study was to learn how midwives today manage the umbilical cord at birth.

METHODS

To better understand the current practices of midwives, in 2017, a national online survey of ACNM members was conducted. A total of 24 questions were asked about DCC, cord milking, specific clinical circumstances, and the presence of policies or guidelines.

RESULTS

A total of 5306 surveys were sent with 1106 responses. After applying inclusion criteria, 1050 were available for analysis. Respondents practiced in all settings: home, birth centers, and hospitals. Compared with 2000, a 46% increase in the practice of DCC was identified. In this study, 98% of the participants reported facilitating DCC for full-term vaginal births as compared with 67% in 2000. In addition, 25% practiced DCC for near-term and 65% for preterm neonates. Cord milking was practiced by 37% of participants. When asked about barriers to practicing DCC, 54% of participants identified time pressures to hand off the newborn as the greatest detriment. It was challenging to practice DCC in situations wherein the newborn needed resuscitation or in breech births. Far fewer midwives practice cord milking compared with DCC.

DISCUSSION

The survey results suggest there has been an increase in the practice of DCC over the last 20 years. Cord milking is not as widely practiced as DCC, and respondents were less likely to be convinced by the evidence for cord milking. This speaks to the opportunity for more education for midwives. There is also a need for clinical guidelines that address umbilical cord management when challenging circumstances arise such as breech birth, shoulder dystocia, and the need for resuscitation.

Variability and associated factors in the management of cord clamping and the milking practice among Spanish obstetric professionals

Clinical practice guides recommend delayed clamping of the umbilical cord. If this is not possible, some authors suggest milking as an alternative. The objective of this study was to determine the variability in professional practice in the management of umbilical cord clamping and milking and to identify factors or circumstances associated with the different methods. An observational cross-sectional study done on 1,045 obstetrics professionals in Spain in 2018. A self-designed questionnaire was administered online. The main variables studied were type of clamping and use of milking. Crude odds ratios (OR) and adjusted odds ratios (ORa) were estimated using binary logistic regression. 92.2% (964) performed delayed clamping. 69.3% (724) clamped the cord when it stopped beating. 83.8% (876) had heard of milking, and 55.9% (584) had never performed it. Professionals over 50 were less likely to perform delayed clamping, with an ORa of 0.24 (95% CI: 0.11–0.52), while midwives were more likely to perform delayed clamping than obstetricians, with an ORa of 14.05 (95% CI: 8.41–23.49). There is clinical variability in the management of umbilical cord clamping and the use of milking in normal births. Part of this variability can be attributed to professional and work environment factors.

Strategies for implementing placental transfusion at birth: A systematic review

BACKGROUND

Enhanced placental transfusion reduces adverse neonatal outcomes, including death. Despite being endorsed by the World Health Organization in 2012, the method has not been adopted widely in practice.

METHODS

We performed a systematic literature search and included quality improvement projects on placental transfusion at birth and studies on barriers to implementation. We extracted information on population, methods of implementation, obstacles to implementation, and strategies to overcome them.

RESULTS

We screened 99 studies out of which 18 were included in the review. The preferred methods of implementation were protocol development (86% of studies) reinforced by targeted education (64% of studies) and multidisciplinary team involvement (43% of studies). Barriers to implementation were mentioned in 12 studies and divided into four categories: general factors such as lack of staff awareness (5 studies) and professional resistance to change (5 studies); obstetrician-specific concerns, including the impact during cesarean (3 studies) and the risk of postpartum hemorrhage (3 studies); pediatrician-specific concerns, including the need for resuscitation (5 studies), risk of jaundice (3 studies), and polycythemia (2 studies); and logistical difficulties. The main strategies to facilitate placental transfusion at birth included effective multidisciplinary team collaboration, protocol development, targeted education, and constructive feedback sessions.

CONCLUSIONS

Placental transfusion implementation requires a multidisciplinary approach, with obstetricians, midwives, nurses, and pediatricians central to adoption of the practice. Understanding the obstacles to implementation informs strategies to increase placental transfusion adoption of practice worldwide. We suggest a stepwise approach to implementation and enhancement of placental transfusion into practice.

Umbilical cord clamping practices of U.S. obstetricians

BACKGROUND

Delayed umbilical cord clamping is associated with significant benefits to preterm and term newborns and is recommended for all infants by the World Health Organization and the American College of Obstetricians and Gynecologists (ACOG). Little is known about the cord management practices of U.S. obstetricians.

OBJECTIVE

The objective of this study was to describe current cord clamping practices by U.S. obstetricians and investigate factors associated with delayed cord clamping.

STUDY DESIGN

A cross-sectional survey was sent to 500 members of the American College of Obstetricians and Gynecologists. Umbilical cord practices were assessed, and factors related to delaying cord clamping were examined using Chi-square tests and multivariate logistic regression models.

RESULTS

The overall response rate was 37% with 74% of those opening the email responding. Sixty-seven percent of respondents reported DCC by one minute or more after vaginal births at term. After preterm and near-term vaginal births, 73% and 79% said they waited at least 30 seconds before clamping. The factor most consistently and strongly related to delaying cord clamping in both bivariate and multivariate analyses was having the belief that the timing of clamping was important. Additional analysis revealed that believing the timing was important was positively associated with the physician's institution having a written policy on the cord clamping.

CONCLUSIONS

In this study, a majority of respondents reported delaying cord clamping and indicated that employing strategies to implement the full uptake of this practice could be valuable. Findings suggest that institutional policies may influence attitudes on cord clamping.

Delayed Cord Clamping in Term Neonates: Attitudes and Practices of Midwives in Irish Hospitals

Background:

At the time of birth, the baby is attached to its mother’s placenta via the umbilical cord. A delay in cord clamping is physiologically beneficial to the neonate as they receive an increase in blood volume (30%–40%), increased iron stores (20–30mg/kg), and an easier transition to extrauterine life. Active management of the third stage of labor, in order to prevent maternal postpartum hemorrhage, may contribute to early cord clamping practices in Ireland.

Objective:

To describe the current practices and attitudes of midwives in Irish hospitals toward delayed cord clamping in term neonates.

Methods:

A cross-sectional descriptive survey was distributed to three maternity hospitals and two Irish online midwifery groups.

Results:

One hundred and fifty-three valid responses were received. One hundred and eleven midwives (72.4%) defined delayed cord clamping as “clamping after the cord ceases to pulsate.” One hundred and forty (91.5%) respondents practiced delayed cord clamping. Moreover, 62.7 % (98/153) of participants routinely clamp the umbilical cord >1 minute when practicing active management of the third stage, with 49.1% (48/98) of those waiting until cord pulsations have ceased. Awareness of research, practice guidelines advising delayed cord clamping, and experience of practicing physiological third stage are associated with increased delayed cord clamping practices. Early cord clamping is influenced by a deteriorating neonatal or maternal condition and the cultural context within clinical sites. Delayed cord clamping times during active management of the third stage differ significantly between clinical sites and maternity care pathways.

Conclusion:

A variety of midwifery practices were identified with differing attitudes toward cord clamping practices. Diverse influences included the practice environment, awareness of research, and availability of adjunct resuscitation supports. Recommendations for future practice include a synchronized approach to delayed cord clamping in the third stage of labor, including the provision of a national guideline.

Current umbilical cord clamping practices and attitudes of obstetricians and midwives toward delayed cord clamping in Saudi Arabia

BACKGROUND

In Saudi Arabia, as in many countries, there is usually no clear definition of the timing of umbilical cord clamping (UCC) in the policies and procedures used by hospitals. The World Health Organization (WHO) recommends delayed cord clamping (DCC) ( > 1 minute after birth) as it can significantly improve hemodynamics and long-term neurodevelopment.

OBJECTIVE

To investigate current practices of healthcare professionals on the timing of UCC in Saudi Arabia.

DESIGN

Cross-sectional survey.

SETTING

Five tertiary hospitals in Riyadh, Saudi Arabia, during May to October 2016.

SUBJECTS AND METHODS

Obstetricians and midwives completed a widely-used questionnaire on UCC practices.

MAIN OUTCOME MEASURE(S)

Current UCC practices and attitudes of obstetricians and midwives toward DCC.

RESULTS

Eighty-two obstetricians and 75 midwives completed the questionnaire for a response rate of 80%. The majority of respondents were aged 30 years or older (81%) and 84% were females. Most respondents were non-Saudi (66%) and had an educational level of bachelor's degree or higher (72%). Only 42% of respondents reported the existence of UCC guidelines in their practice; 38% reported the existence of a set time for UCC when the neonate was term and healthy, and only 32% had a set time for UCC in preterm neonates. While lower levels of agreement were reported among obstetricians and midwives on the benefits of DCC for babies requiring positive pressure ventilation, the majority of respondents (69-71%) thought that DCC was generally good for both term and preterm babies and that its benefits extend beyond the neonatal period.

CONCLUSIONS

While the majority of obstetricians and midwives that participated in this study had a positive perception toward DCC, this did not translate to their daily practice as most of these professionals reported a lack of existing UCC guidelines in their institutions. Further studies are warranted to confirm these findings.

LIMITATIONS

Participant selection by convenience sampling.

Neurodevelopmental Outcomes at 2 and 3.5 Years for Very Preterm Babies Enrolled in a Randomized Trial of Milking the Umbilical Cord versus Delayed Cord Clamping

BACKGROUND

Guidelines published by the International Liaison Committee for Resuscitation and by the World Health Organization recommend delaying cord clamping at birth as part of routine care for infants.

OBJECTIVE

To study the use of milking of the cord 4 times as an alternative to enhance the redistribution of placental blood into the baby.

METHODS

This is a prospective cohort study of neurodevelopmental assessment by the Bayley III method of very preterm infants who had participated in a trial of delayed cord clamping versus cord milking at birth that was conducted in a neonatal tertiary care hospital. The primary outcomes were differences in cognitive, motor and language development at 2 and 3.5 years. Two-tailed analyses were performed with the x03C7;2 test, Fisher's exact test, t test, Mann-Whitney U test and ANCOVA.

RESULTS

Out of the 58 infants enrolled in the original study, 39 infants (67%) were assessed at 2 years and 29 (50%) at 3.5 years of age. Neurodevelopmental outcomes at 2 and 3.5 years did not significantly differ between the two groups for the three Bayley III composite scores. At 3.5 years there was a trend towards higher scores for girls in the language composite scores (girls: mean = 121.6, SD = 15.22; boys: mean = 101.07, SD = 19.84) and on the motor scale (girls: mean = 124.60, SD = 18.15; boys: mean = 97.86, SD = 17.23).

CONCLUSIONS

In this small number of participants followed up at 2 and 3.5 years of age, milking of the cord 4 times did not have any long-term adverse effect on neurodevelopmental outcome, suggesting that cord milking could be used as an alternative to delayed cord clamping.

Umbilical Cord Blood-An Untapped Resource: Strategies to Decrease Early Red Blood Cell Transfusions and Improve Neonatal Outcomes

Umbilical cord blood is a resource that is available to all neonates. Immediately after delivery of the fetus, cord blood can be used for the direct benefit of the premature infant. Delayed cord clamping and milking of the umbilical cord are 2 methods of transfusing additional fetal blood into the neonate after vaginal or cesarean delivery. Additionally, umbilical cord blood can be utilized for neonatal admission laboratory testing rather than direct neonatal phlebotomy. Together these strategies both increase initial neonatal total blood volume and limit immediate loss through phlebotomy.