Neonatal transitional support with intact umbilical cord in assisted vaginal deliveries: a quality-improvement cohort study

Midwifery and nursing: Considerations on cord management at birth

Mounting evidence overwhelmingly supports the practice of the return of an infant's placental blood volume at the time of birth. Waiting just a few minutes before clamping the umbilical cord can provide health benefits to infants of all gestational ages. Despite the robust evidence, uptake of delayed cord clamping (DCC) into mainstream obstetrical practice is moving slowly. The practice of DCC is influenced by various factors that include the setting in which the birth takes place, the use of evidence-informed guidelines and other influences that facilitate or hinder the practice of DCC. Through communication, collaboration, and unique disciplinary perspectives, midwives and nurses work with other members of their respective care team to develop strategies for best practice to improve an infant's well-being through optimal cord management. Midwifery has been practiced for centuries throughout the world and midwives have supported DCC since the beginning of recorded history. An important tenet of midwifery philosophy is watchful waiting and non-intervention in normal processes. Nurses are vital to care of birthing families in- and out-of-hospitals as well as in prenatal and postpartum ambulatory care. Nurses and midwives are positioned to be involved in the process of adapting to the mounting evidence for DCC. Strategies to increase better utilization of the practice of DCC have been proposed. For all, teamwork and collaboration among disciplines participating in maternity care are essential for adapting to the new evidence. Involving midwives and nurses as partners in an interdisciplinary approach to plan, implement and sustain DCC at birth increases success.

A hybrid type I, multi-center randomized controlled trial to study the implementation of a method for Sustained cord circulation And VEntilation (the SAVE-method) of late preterm and term neonates: a study protocol

BACKGROUND

An intact umbilical cord allows the physiological transfusion of blood from the placenta to the neonate, which reduces infant iron deficiency and is associated with improved development during early childhood. The implementation of delayed cord clamping practice varies depending on mode of delivery, as well as gestational age and neonatal compromise. Emerging evidence shows that infants requiring resuscitation would benefit if respiratory support were provided with the umbilical cord intact. Common barriers to providing intact cord resuscitation is the availability of neonatal resuscitation equipment close to the mother, organizational readiness for change as well as attitudes and beliefs about placental transfusion within the multidisciplinary team. Hence, clinical evaluations of cord clamping practice should include implementation outcomes in order to develop strategies for optimal cord management practice.

METHODS

The Sustained cord circulation And Ventilation (SAVE) study is a hybrid type I randomized controlled study combining the evaluation of clinical outcomes with implementation and health service outcomes. In phase I of the study, a method for providing in-bed intact cord resuscitation was developed, in phase II of the study the intervention was adapted to be used in multiple settings. In phase III of the study, a full-scale multicenter study will be initiated with concurrent evaluation of clinical, implementation and health service outcomes. Clinical data on neonatal outcomes will be recorded at the labor and neonatal units. Implementation outcomes will be collected from electronic surveys sent to parents as well as staff and managers within the birth and neonatal units. Descriptive and comparative statistics and regression modelling will be used for analysis. Quantitative data will be supplemented by qualitative methods using a thematic analysis with an inductive approach.

DISCUSSION

The SAVE study enables the safe development and evaluation of a method for intact cord resuscitation in a multicenter trial. The study identifies barriers and facilitators for intact cord resuscitation. The knowledge provided from the study will be of benefit for the development of cord clamping practice in different challenging clinical settings and provide evidence for development of clinical guidelines regarding optimal cord clamping.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04070560 . Registered 28 August 2019.

Toward greater nuance in delayed cord clamping

PURPOSE OF REVIEW

For over a decade, the International Liaison Committee on Resuscitation has recommended delayed cord clamping (DCC), but implementation has been variable due to lack of consensus on details of technique and concerns for risks in certain patient populations. This review summarizes recent literature on the benefits and risks of DCC in term and preterm infants and examines alternative approaches such as physiologic-based cord clamping or intact cord resuscitation (ICR) and umbilical cord milking (UCM).

RECENT FINDINGS

DCC improves hemoglobin/hematocrit among term infants and may promote improved neurodevelopment. In preterms, DCC improves survival compared to early cord clamping; however, UCM has been associated with severe intraventricular hemorrhage in extremely preterm infants. Infants of COVID-19 positive mothers, growth-restricted babies, multiples, and some infants with cardiopulmonary anomalies can also benefit from DCC. Large randomized trials of ICR will clarify safety and benefits in nonvigorous neonates. These have the potential to dramatically change the sequence of events during neonatal resuscitation.

SUMMARY

Umbilical cord management has moved beyond simple time-based comparisons to nuances of technique and application in vulnerable sub-populations. Ongoing research highlights the importance of an individualized approach that recognizes the physiologic equilibrium when ventilation is established before cord clamping.

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.

A review of different resuscitation platforms during delayed cord clamping

There is a large body of evidence demonstrating that delaying clamping of the umbilical cord provides benefits for term and preterm infants. These benefits include reductions in mortality in preterm infants and improved developmental scores at 4 years of age in term infants. However, non-breathing or non-vigorous infants at birth are excluded due to the perceived need for immediate resuscitation. Recent studies have demonstrated early physiological benefits in both human and animal models if resuscitation is performed with an intact cord, but this is still an active area of research. Given the large number of ongoing and planned trials, we have brought together an international group that have been intimately involved in the development or use of resuscitation equipment designed to be used while the cord is still intact. In this review, we will present the benefits and limitations of devices that have been developed or are in use. Published trials or ongoing studies using their respective devices will also be reviewed.