Factors associated with timing of umbilical cord clamping in tertiary hospital of Nepal

Impact of the Timing of Umbilical Cord Clamping on Maternal and Neonatal Outcomes in Saudi Arabia

INTRODUCTION

The optimal time for umbilical cord clamping after delivery has been under debate for several decades. This study aimed to assess the time-dependent effects of umbilical cord clamping on maternal and neonatal outcomes.

METHODS

An observational correlational design was used to recruit 161 pregnant women conveniently. Outcomes were observed and recorded using a structured checklist developed by the authors. Pregnant females aged ≥18 years, with uncomplicated delivery, and who were willing to participate were recruited. Exclusion criteria included stillbirths, newborns with congenital anomalies, newborns too small for their gestational age, intra-uterine growth restriction, nuchal cord, and meconium-stained liquor.

RESULTS

The mean age of the participants was 29.93 ± 6 years. Early clamping (<1 minute) was performed for 93.8% of the participants with a mean of 29.58 ± 18 seconds. Delayed clamping was associated with a decrease in blood loss and the length of hospital stay in addition to an increase in first-minute APGAR score and neonatal temperature (P < 0.05).

CONCLUSIONS

Delayed cord clamping was associated with improved maternal and neonatal outcomes.

An assessment of immediate newborn care readiness and availability in Nepal

BACKGROUND

Global neonatal mortality necessitates access to immediate newborn care interventions. In Nepal, disparities persist in the readiness and availability of newborn care services within health facilities.

OBJECTIVE

This study aimed to assess this status and compare facilities that had implemented an intensive newborn resuscitation capacity building and retention programme in the past five years with those that had not.

METHODS

Our observational cross-sectional study involved 154 health facilities across Nepal. Through on-site inspections and maternal log reviews, we evaluated the immediate newborn care readiness and availability.

RESULTS

The mean immediate newborn care intervention availability score of 52.8% (SE = 21.5) and the readiness score averaged 79.6% (SE = 12.3). Encouragingly, 96% of facilities ensured newborns were dried and wrapped for warmth, and 69.9% provided newborn resuscitation. Practices such as delayed cord clamping (42.0%), skin-to-skin contact (28.6%), and early breastfeeding (63.5%) showed room for improvement. Only 16.1% of health facilities administered Vitamin K1 prophylaxis.Domain-specific scores demonstrated a high level of facility readiness in infrastructure (97.5%), medicine, equipment, and supplies (90.6%), and staff training (90.9%), but a lower score for neonatal resuscitation aids (28.8%). Disparities in readiness and availability were evident, with rural areas and the Madhesh province reporting lower scores. Variations among health facility types revealed provincial and private hospitals outperforming local-level facilities. A positive association was observed between the LDSC/SSN mentoring programme and both the readiness and availability of immediate newborn care services.

CONCLUSION

This study highlights the gap between healthcare facility readiness and the actual availability of immediate newborn care interventions in Nepal. Addressing disparities and barriers, particularly in rural areas and local-level facilities, is crucial for improving neonatal survival. The positive link between the LDSC/SSN programme and service availability and facility readiness emphasises the significance of targeted training and mentorship programmes in enhancing newborn care across Nepal.

Prevalence of anaemia and associated factors among infants under 6 months in rural China

OBJECTIVE

To examine Hb level and anaemia status among infants under 6 months of age in rural China.

DESIGN

A cross-sectional survey collected data among infants under 6 months and their primary caregivers in Sichuan, China. Anaemia was defined using both the WHO and China Pediatrics Association thresholds. Multivariable linear regression was used to identify relevant factors among two age groups (<4 months; 4-5 months).

SETTING

Eighty townships were selected in Sichuan, China from November to December 2019.

PARTICIPANTS

Nine hundred and forty-two infants under 6 months, while Hb level was tested for 577 infants.

RESULTS

The overall mean (±sd) Hb level was 106·03 (± 12·04) g/l. About 62·6 % (95 % CI 58·5, 66·6) of sample infants were anaemic using the WHO threshold, and 20·5 % (95 % CI 17·3, 24·1) were anaemic using the China Pediatrics Association thresholds. Anaemia rates rose with increasing age in months. Multivariable linear regressions revealed that lower Hb levels were significantly associated with lower birth weight (<4 months: β = 4·14, 95 % CI 0·19, 8·08; 4-5 months: β = 6·60, 95 % CI 2·94, 10·27) and delivery by caesarean section (<4 months: β = -4·64, 95 % CI -7·79, -1·49; 4-5 months: β = -4·58, 95 % CI -7·45, -1·71).

CONCLUSION

A large share of infants under 6 months in rural western China are anaemic. Infants with low birth weight and caesarean delivered should be prioritised for anaemia testing. Future studies should move the point of focus forward to at least 4 months of age and examine the link between caesarean section and anaemia to promote health and development in infancy.

Implementation of Delayed Cord Clamping in public health facilities: a case study from India

BACKGROUND

Global and country specific recommendations on Delayed umbilical cord clamping (DCC) are available, though guidance on their implementation in program settings is lacking. In India, DCC (clamping not earlier than 1 min after birth) is a component in the package of services delivered as part of the India Newborn Action Plan (INAP) supported by Nutrition International (NI) in two states. The objective of this case study was to document the learnings from implementation of DCC in these two states and to understand the health system factors that affected its operationalization.

METHODS

Mixed methods were followed. Using the World Health Organization (WHO) Health Systems building blocks as a framework, 20 Key-Informant Interviews were conducted to explore facilitators and barriers to routine implementation of DCC in public health settings. Existing quantitative program data and secondary data from labour-room registers from eight NI- supported districts were analysed to assess the prevalence of DCC implementation in public health systems settings.

RESULTS

A demonstrated commitment from the government to implement DCC at all delivery points in NI supported districts was observed. Funds were sufficient, trainings were optimal, knowledge of the health workforce was adequate and a recording mechanism was in place. According to record reviews, DCC was more likely to happen in facilities that provide Basic Emergency Obstetric services and among normal deliveries. It was less likely to be followed in babies delivered by Caesarean section (OR 0.03; 95%CI 0.02,0.05), birthweight < 2000 g (OR 0.22; 95%CI 0.12,0.47), multiple pregnancies (OR 0.17, 95%CI 0.05,0.63), birth asphyxia requiring resuscitation (0.37; 95%CI 0.26,0.52), and those delivered during day shift (OR 0.59, 95%CI 0.40, 0.83).

CONCLUSIONS

Wide coverage of DCC in public health settings in the two states was observed. Good governance, adequate funding, commitment of health workforce has likely contributed to its success in these contexts. These are critical elements to guide DCC implementation in India and for consideration in other settings.

Factors associated with umbilical cord clamping in term newborns

OBJECTIVE

To identify factors associated with umbilical cord clamping in term newborns and to compare the recording of clamping time in the medical record with what was observed.

METHOD

Cross-sectional study, with 300 mothers-infants, in a university hospital. Clamping time and medical records were observed, and a structured questionnaire was applied to postpartum women for sociodemographic variables. Bivariate analysis, multivariate Poisson Regression model, and Kappa concordance test were performed.

RESULTS

The percentage of late/optimal clamping observed was 53.7%. The associated factors were skin-to-skin contact in the delivery room (PR = 0.76; 0.61-0.95; p = 0.014), position of the newborn below the vaginal canal (PR = 2.6; CI95%: 1.66-4.07; p < 0.001), position of the newborn at the vaginal level (PR = 2.03; CI95%: 1.5-2.75; p < 0.001), and need for newborn resuscitation in the delivery room (PR = 1.42; CI95%; 1.16-1.73; p = 0.001). Kappa concordance level of the professionals, records compared to the observation was: nurse 0.47, obstetrician 0.59, and pediatrician 0.86.

CONCLUSION

the identification of associated factors and the comparison between recording and observing the clamping time can help in the planning and implementation of improvements for adherence to good practices at birth.

Predictors for timely initiation of breastfeeding after birth in the hospitals of Nepal- a prospective observational study

Background

Timely initiation of breastfeeding can reduce neonatal morbidities and mortality. We aimed to study predictors for timely initiation of breastfeeding (within 1 h of birth) among neonates born in hospitals of Nepal.

Method

A prospective observational study was conducted in four public hospitals between July and October 2018. All women admitted in the hospital for childbirth and who consented were included in the study. An independent researchers observed whether the neonates were placed in skin-to-skin contact, delay cord clamping and timely initiation of breastfeeding. Sociodemographic variables, obstetric and neonate information were extracted from the maternity register. We analysed predictors for timely initiation of breastfeeding with Pearson chi-square test and multivariate logistic regression.

Results

Among the 6488 woman-infant pair observed, breastfeeding was timely initiated in 49.5% neonates. The timely initiation of breastfeeding was found to be higher among neonates who were placed skin-to-skin contact (34.9% vs 19.9%, p - value < 0.001). The timely initiation of breastfeeding was higher if the cord clamping was delayed than early cord clamped neonates (44.5% vs 35.3%, p - value < 0.001). In multivariate analysis, a mother with no obstetric complication during admission had 57% higher odds of timely initiation of breastfeeding (aOR 1.57; 95% CI 1.33, 1.86). Multiparity was associated with less timely initiation of breastfeeding (aOR 1.56; 95% CI 1.35, 1.82). Similarly, there was more common practice of timely initiation of breastfeeding among low birthweight neonates (aOR 1.46; 95% CI 1.21, 1.76). Neonates who were placed skin-to-skin contact with mother had more than two-fold higher odds of timely breastfeeding (aOR 2.52; 95% CI 2.19, 2.89). Likewise, neonates who had their cord intact for 3 min had 37% higher odds of timely breastfeeding (aOR 1.37; 95% CI 1.21, 1.55).

Conclusions

The rate of timely initiation of breastfeeding practice is low in the health facilities of Nepal. Multiparity, no obstetric complication at admission, neonates placed in skin-to-skin contact and delay cord clamping were strong predictors for timely initiation of breastfeeding. Quality improvement intervention can improve skin-to-skin contact, delayed cord clamping and timely initiation of breastfeeding.

Delayed cord clamping was not associated with an increased risk of hyperbilirubinaemia on the day of birth or jaundice in the first 4 weeks

AIM

Our aim was to investigate the effects of timing of cord clamping on the risk of hyperbilirubinaemia.

METHODS

We recruited 540 normal vaginal deliveries at the Paropakar Maternity and Women's Hospital in Kathmandu, Nepal, from October 2 to November 21, 2014. They were randomised into two groups: 257/270 were cord clamped within 60 seconds and 209/270 after 180 seconds. Transcutaneous bilirubin was measured at discharge and 24 hours. At 4 weeks, 506 mothers were successfully contacted by phone, and the health status of the baby and their history of jaundice and treatment was recorded.

RESULTS

Based on transcutaneous bilirubin at discharge, 22/261 (8.4%) in the early group and 25/263 (9.5%) in the delayed group (P = 0.76) were at high risk of subsequent hyperbilirubinemia. At the 4-week follow-up, jaundice was reported in 13/253 (5.1%) in the early and 17/253 (6.7%) in the delayed group (P = 0.57) and 3/253 (1.2 %) of the early and 1/253 (0.4%) of the delayed group (P = 0.62) received treatment. All analyses were based on intention-to-treat.

CONCLUSION

Delayed cord clamping was not associated with an increased risk of hyperbilirubinaemia during the first day of life or risk of jaundice within 4 weeks compared with the early group.

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.

Delayed cord clamping with stabilisation at all preterm births - feasibility and efficacy of a low cost technique

OBJECTIVES

Meta-analysis data suggests that Delayed cord clamping (DCC) in preterm infants is associated with a 32% reduction in mortality. Reported rates of this intervention are low, particularly for caesarean deliveries. Perceived difficulties providing respiratory support and thermal care during DCC may be barriers to implementation of this intervention. Commercially available equipment to facilitate this can be expensive. This study aimed to evaluate the feasibility and efficacy of a simple, low cost technique to deliver respiratory support and thermal care during DCC at all preterm deliveries (including caesarean), with the hypothesis that this could increase rates of preterm infants receiving DCC.

STUDY DESIGN

Data was collected retrospectively from 46 infants born at <32 weeks gestation in 2015. The technique was introduced in early 2017, as part of a perinatal Quality Improvement project. Data was collected prospectively from 63 infants born at <32 weeks gestation in 2017-2018.

RESULTS

Rates of DCC in infants born <32 weeks gestation have increased from 12.5% in 2015 to 89.4% in 2017-2018. In 2017-2018, thermal care and respiratory support was provided to all infants who received DCC.

CONCLUSION

Multidisciplinary perinatal team working allowed development of a simple, low cost technique to deliver DCC at all preterm deliveries. We have demonstrated feasibility and efficacy of this technique, and a significant and sustained improvement in rates of DCC in our preterm population. We hope that by sharing this approach, other centres will be able to implement a similar strategy, closing the gap between evidence base and translation into clinical practice, and allowing provision of DCC for preterm infants as a standard part of high quality perinatal care.

Effect of Delayed Cord Clamping of Term Babies on Neurodevelopment at 12 Months: A Randomized Controlled Trial

BACKGROUND

Delayed cord clamping (DCC) is associated with an improved iron status at 8 months, a reduction of anemia at 12 months, and an improved development at 4 years. Assessment of the development after DCC has not been performed earlier in a setting with a high prevalence of iron deficiency.

OBJECTIVE

The aim of this paper was to investigate the effects of DCC compared to early cord clamping (ECC) on the development evaluated with the Ages and Stages Questionnaire (ASQ) at 12 months of age.

METHOD

We conducted a randomized controlled trial investigating the effect of DCC (≥180 s) versus ECC (≤60 s) in 540 full-term deliveries. Twelve months after delivery, the parents reported their infant's development by ASQ. Infants having a score < 1 standard deviation (SD) under the mean score were considered "at risk" of affected neurodevelopment.

RESULTS

At 12 months of age, 332 (61.5%) infants were assessed. Fewer children in the DCC group were "at risk" of having affected neurodevelopment measured by the ASQ total score, 21 (7.8%) versus 49 (18.1%) in the ECC group. The relative risk was 0.43 (0.26-0.71). Infants in the DCC group had higher mean total scores (SD), 290.4 (10.4) versus 287.2 (10.1), p = 0.01. Significantly fewer infants in the delayed group were "at risk" and had higher scores in the domains "communication", "gross motor", and "personal-social".

CONCLUSIONS

DCC after 3 min was associated with an improvement of the overall neurodevelopment assessed at 12 months of age as compared to infants in the group with cord clamping within 1 min.