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Orton M, Theilen L, Clark E, Baserga M, Lauer S, Ou Z, Presson AP, Dupont T, Katheria A, Singh Y, Chan B. Thermoregulation-Focused Implementation of Delayed Cord Clamping among <34 Weeks' Gestational Age Neonates. Am J Perinatol 2024; 41:e3099-e3106. [PMID: 37989208 DOI: 10.1055/s-0043-1776916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE Delayed cord clamping (DCC) is recommended for all neonates; however, adapting such practice can be slow or unsustainable, especially among preterm neonates. During DCC neonates are exposed to a cool environment, raising concerns for neonatal hypothermia. Moderate hypothermia may induce morbidities that counteract the potential benefits of DCC. A quality improvement project on a thermoregulation-focused DCC protocol was implemented for neonates less than 34 weeks' gestational age (GA). The aim was to increase the compliance rate of DCC while maintaining normothermia. STUDY DESIGN The DCC protocol was implemented on October 1, 2020 in a large Level III neonatal intensive care unit. The thermoregulation measures included increasing delivery room temperature and using heat conservation supplies (sterile polyethylene suit, warm towels, and thermal pads). Baseline characteristics, the compliance rate of DCC, and admission temperatures were compared 4 months' preimplementation and 26 months' postimplementation RESULTS: The rate of DCC increased from 20% (11/54) in preimplementation to 57% (240/425) in postimplementation (p < 0.001). The balancing measure of admission normothermia remained unchanged. In a postimplementation subgroup analysis, the DCC cohort had less tendency to experience admission moderate hypothermia (<36°C; 9.2 vs. 14.1%, p = 0.11). The DCC cohort had more favorable secondary outcomes including higher admission hematocrit, less blood transfusions, less intraventricular hemorrhage, and lower mortality. Improving the process measure of accurate documentation could help to identify implementation barriers. CONCLUSION Performing DCC in preterm neonates was feasible and beneficial without increasing admission hypothermia. KEY POINTS · Thermoregulation-focused DCC protocol was implemented to increase DCC while maintaining normothermia.. · DCC rate increased from 20 to 57% while admission normothermia rate remained the same.. · DCC practice on preterm neonates is safe and feasible while maintaining normothermia..
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Affiliation(s)
- Melissa Orton
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Lauren Theilen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Erin Clark
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Sarah Lauer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Tara Dupont
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Anup Katheria
- San Diego Neonatology, Department of Pediatrics, Sharp Mary Birch Hospital for Women and Newborn, San Diego, California
- Division of Neonatology, Department of Pediatrics, University of California at San Diego, San Diego, California
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California
| | - Belinda Chan
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States; Division of Newborn Medicine, Harvard Medical School, Boston MA, United States.
| | - Justin Goldstein
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States
| | - Henry C. Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford CA, United States
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States,Division of Newborn Medicine, Harvard Medical School, Boston MA, United States
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3
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Prevention of iron deficiency anemia in infants and toddlers. Pediatr Res 2021; 89:63-73. [PMID: 32330927 DOI: 10.1038/s41390-020-0907-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/08/2022]
Abstract
Anemia, defined as a low blood hemoglobin concentration, is a major global public health problem. Identification of anemia is crucial to public health interventions. It is estimated globally that 273 million children under 5 years of age were anemic in 2011, and about ~50% of those cases were attributable to iron deficiency (Lancet Global Health 1:e16-e25, 2013). Iron-deficiency anemia (IDA) in infants adversely impacts short-term hematological indices and long-term neuro-cognitive functions of learning and memory that result in both fatigue and low economic productivity. IDA contributes to death and disability and is an important risk factor for maternal and perinatal mortality, including the risks for stillbirths, prematurity, and low birth weight (Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. Ch. 3 (World Health Organization, Geneva, 2004)). Reduction in early infantile anemia and newborn mortality rates is possible with easily implemented, low- to no-cost intervention such as delayed cord clamping (DCC). DCC until 1-3 min after birth facilitates placental transfusion and iron-rich blood flow to the newborn. DCC, an effective anemia prevention strategy, requires cooperation among health providers involved in childbirth, and a participatory culture change in public health. Public intervention strategies must consider multiple factors associated with anemia listed in this review before designing intervention studies that aim to reduce anemia prevalence in infants and toddlers. IMPACT: Anemia, defined as a low blood hemoglobin concentration, is a major global public health problem and identification of anemia is crucial to public health interventions. Delayed cord clamping (DCC) until 1-3 min after birth facilitates placental transfusion and iron-rich blood flow to the newborn. Reduction in early infantile anemia and newborn mortality rates is possible with easily implemented, low- to no-cost intervention such as DCC.
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Blank D, Niermeyer S. Going "the Last Mile" With Guidelines for Deferred Umbilical Cord Clamping. Pediatrics 2020; 146:peds.2020-027151. [PMID: 33087549 DOI: 10.1542/peds.2020-027151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Douglas Blank
- Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia; and
| | - Susan Niermeyer
- School of Medicine, University of Colorado and Colorado School of Public Health, Aurora, Colorado
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Mwakawanga DL, Mselle LT. Early or delayed umbilical cord clamping? Experiences and perceptions of nurse-midwives and obstetricians at a regional referral hospital in Tanzania. PLoS One 2020; 15:e0234854. [PMID: 32569338 PMCID: PMC7307749 DOI: 10.1371/journal.pone.0234854] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 06/03/2020] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Dorkasi Lushindiho Mwakawanga
- Department of Community Health Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- * E-mail:
| | - Lilian Teddy Mselle
- Department of Clinical Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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6
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Association of a Delayed Cord-Clamping Protocol With Hyperbilirubinemia in Term Neonates. Obstet Gynecol 2020; 133:754-761. [PMID: 30870273 DOI: 10.1097/aog.0000000000003172] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the implementation of a delayed cord-clamping protocol at an academic medical center, and its short-term associations on term neonates. METHODS This was a retrospective cohort study of women aged 18 years or older delivering a term neonate at an academic medical center before and 5-7 months after implementation of a universal delayed cord-clamping protocol (October-December 2015 and October-December 2016, respectively). The primary outcome measure was the mean peak neonatal transcutaneous bilirubin level, with secondary outcome measures including mean initial transcutaneous bilirubin levels, mean serum bilirubin levels, number of serum bilirubin levels drawn, incidence of clinical jaundice, and phototherapy. RESULTS Protocol adherence was 87.8%. Data are presented on 424 neonates. The mean peak neonatal transcutaneous bilirubin levels were significantly higher among neonates in the postprotocol group (10.0±3.4 mg/dL vs 8.4±2.7 mg/dL, P<.01). More neonates in the postprotocol group were diagnosed with jaundice (27.2% vs 16.6%; odds ratio [OR] 1.88; 95% CI 1.17-3.01) and required serum blood draws (43.7% vs 29.4%; OR 1.86; 95% CI 1.25-2.78). However, there were no differences in mean peak serum bilirubin levels between groups (9.7±3.0 mg/dL vs 9.1±3.1 mg/dL, P=.17) or need for phototherapy (5.2% vs 6.6%, OR 1.28; 95% CI 0.57-2.89). CONCLUSION Implementation of a delayed cord-clamping protocol for term neonates was associated with significantly higher mean transcutaneous bilirubin levels, an increased number of serum blood draws, and more clinical diagnoses of jaundice, although there was no increase in the incidence of phototherapy.
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Anton O, Jordan H, Rabe H. Strategies for implementing placental transfusion at birth: A systematic review. Birth 2019; 46:411-427. [PMID: 30264508 DOI: 10.1111/birt.12398] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Oana Anton
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK
| | - Harriet Jordan
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK
| | - Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK.,Academic Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK
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8
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Andersson O, Rana N, Ewald U, Målqvist M, Stripple G, Basnet O, Subedi K, Kc A. Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III) - a randomized clinical trial. Matern Health Neonatol Perinatol 2019; 5:15. [PMID: 31485335 PMCID: PMC6714434 DOI: 10.1186/s40748-019-0110-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/29/2019] [Indexed: 01/26/2023] Open
Abstract
Background Experiments have shown improved cardiovascular stability in lambs if umbilical cord clamping is postponed until positive pressure ventilation is started. Studies on intact cord resuscitation on human term infants are sparse. The purpose of this study was to evaluate differences in clinical outcomes in non-breathing infants between groups, one where resuscitation is initiated with an intact umbilical cord (intervention group) and one group where cord clamping occurred prior to resuscitation (control group). Methods Randomized controlled trial, inclusion period April to August 2016 performed at a tertiary hospital in Kathmandu, Nepal. Late preterm and term infants born vaginally, non-breathing and in need of resuscitation according to the ‘Helping Babies Breathe’ algorithm were randomized to intact cord resuscitation or early cord clamping before resuscitation. Main outcome measures were saturation by pulse oximetry (SpO2), heart rate and Apgar at 1, 5 and 10 minutes after birth. Results At 10 minutes after birth, SpO2 (SD) was significantly higher in the intact cord group compared to the early cord clamping group, 90.4 (8.1) vs 85.4 (2.7) %, P < .001). In the intact cord group, 57 (44%) had SpO2 < 90% after 10 minutes, compared to 93 (100%) in the early cord clamping group, P < 0.001. SpO2 was also significantly higher in the intervention (intact cord) group at one and five minutes after birth. Heart rate was lower in the intervention (intact cord) group at one and five minutes and slightly higher at ten minutes, all significant findings. Apgar score was significantly higher at one, five and ten minutes. At 5 minutes, 23 (17%) had Apgar score < 7 in the intervention (intact cord) group compared to 26 (27%) in the early cord clamping group, P < .07. Newborn infants in the intervention (intact cord) group started to breathe and establish regular breathing earlier than in the early cord clamping group. Conclusions This study provides new and important information on the effects of resuscitation with an intact umbilical cord. The findings of improved SpO2 and higher Apgar score, and the absence of negative consequences encourages further studies with longer follow-up. Trial registration Clinicaltrials.gov NCT02727517, 2016/4/4 Electronic supplementary material The online version of this article (10.1186/s40748-019-0110-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ola Andersson
- 1Department of Clinical Sciences Lund, Pediatrics/Neonatology, Skane University Hospital, Lund University, SUS, Barn- & Ungdomssjukh. Avd. Ped, 221 85 Lund, Sweden
| | - Nisha Rana
- 2International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Uwe Ewald
- 2International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Mats Målqvist
- 2International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | - Kalpana Subedi
- Paropakar Maternity and Women's Hospital, Kathmandu, Nepal
| | - Ashish Kc
- 2International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Mohammad K, Tailakh S, Fram K, Creedy D. Effects of early umbilical cord clamping versus delayed clamping on maternal and neonatal outcomes: a Jordanian study. J Matern Fetal Neonatal Med 2019; 34:231-237. [PMID: 30931665 DOI: 10.1080/14767058.2019.1602603] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To compare the effects of early versus delayed cord clamping of term births on maternal and neonatal outcomes.Method: A quasi-experimental study was conducted at the Jordan University Hospital in Amman. One hundred twenty-eight mothers expecting a full-term singleton baby were assigned to delayed cord clamping (90 seconds) or early cord clamping (<30 seconds).Results: Delayed cord clamping was associated with higher hemoglobin levels among newborns after 12 hours. On the other hand, early cord clamping was associated with an increased need for oxygen therapy among newborns and occurrence of postpartum hemorrhage among mothers. There were no differences between the groups on any other variable (Apgar score at 1 and 5 minutes, admission to NICU, baby bilirubin levels after 12 hours and day 3 of birth, and mothers' Hb levels after 12 hours of childbirth).Conclusion: Term babies receiving delayed cord clamping had improved hemoglobin levels with no adverse effect on other maternal and neonatal variables. Creating evidence-based practice guidelines for umbilical cord clamping in Jordanian hospitals is essential to improve neonatal and maternal health.
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Affiliation(s)
- Khitam Mohammad
- Maternal and Child Health Nursing and Midwifery Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Suha Tailakh
- Department of Maternal and Child Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Kamil Fram
- Department of Obstetrics and Gynaecology, University of Jordan, Amman, Jordan
| | - Debra Creedy
- Maternal, Newborn and Families Research Collaborative, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
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Leslie MS, Greene J, Schulkin J, Jelin AC. Umbilical cord clamping practices of U.S. obstetricians. J Neonatal Perinatal Med 2018; 11:51-60. [PMID: 29689745 DOI: 10.3233/npm-181729] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- M S Leslie
- School of Nursing, George Washington University, Washington, DC, USA
| | - J Greene
- Marxe School of Public and International Affairs, Baruch College, CUNY, NY, USA
| | - J Schulkin
- Department of Obstetrics and Gynecology, University of Washington, Washington, DC, USA
| | - A C Jelin
- John Hopkins University, Baltimore, USA
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11
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McAdams RM, Backes CH, Fathi O, Hutchon DJR. Revert to the original: time to re-establish delayed umbilical cord clamping as the standard approach for preterm neonates. Matern Health Neonatol Perinatol 2018; 4:13. [PMID: 29997896 PMCID: PMC6030773 DOI: 10.1186/s40748-018-0081-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/28/2018] [Indexed: 01/18/2023] Open
Abstract
Delayed cord clamping, the common term used to denote placental-to-newborn transfusion at birth, is a practice now endorsed by the major governing bodies affiliated with maternal-newborn care. Despite considerable evidence, delayed cord clamping, not early cord clamping, continues to be viewed as the “experimental” intervention category when discussed in research studies. We provide a brief overview of placental-to-newborn transfusion in relation to birth transitional physiology and discuss areas where we may need to modify our interpretation of “normal” vital signs and laboratory values as delayed cord clamping becomes standardized. We also assert that delayed cord clamping should now be viewed as the standard of care approach, especially given that multiple randomized controlled trials have revealed that early cord clamping, which lacks evidence-based support, is associated with a greater risk for morbidity and mortality than delayed cord clamping.
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Affiliation(s)
- Ryan M McAdams
- 1Department of Pediatrics, Division of Neonatology, University of Wisconsin School of Medicine and Public Health, 1010 Mound St., Rm 414, Madison, WI 53715 USA
| | - Carl H Backes
- 2Department of Pediatrics, The Center for Perinatal Research and The Heart Center, Nationwide Children's Hospital, Columbus, OH USA
| | - Omid Fathi
- 2Department of Pediatrics, The Center for Perinatal Research and The Heart Center, Nationwide Children's Hospital, Columbus, OH USA
| | - David J R Hutchon
- 3Obstetrics and Gynaecology, Darlington Memorial Hospital, Darlington, UK
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Clinical Outcomes in Preterm Infants Following Institution of a Delayed Umbilical Cord Clamping Practice Change. Adv Neonatal Care 2018; 18:223-231. [PMID: 29794839 DOI: 10.1097/anc.0000000000000492] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence supports a significant reduction in the incidence of intraventricular hemorrhage (IVH) in preterm infants receiving delayed umbilical cord clamping (DCC). PURPOSE This study evaluated clinical feasibility, efficacy, and safety outcomes in preterm infants (<36 weeks' gestational age) who received DCC following a practice change implementation intended to reduce the incidence of IVH. METHODS Infants receiving DCC (45-60 seconds) were compared with a sample of infants receiving immediate umbilical cord clamping (<15 seconds) in a retrospective chart review (N = 354). The primary outcome measure was the prevalence of IVH. Secondary safety outcome measures of 1- and 5-minute Apgar scores, axillary temperature on neonatal intensive care unit admission, and initial 24-hour bilirubin level were also evaluated. Gestational age was examined for its effect on outcomes. RESULTS Although the small number of infants with IVH precluded the ability to detect statistical significance, our raw data suggest DCC is efficacious in reducing the risk for IVH. For infants 29 or less weeks' gestational age, admission axillary temperature was significantly higher in those who received DCC. No differences were found in 1- and 5-minute Apgar scores, 24-hour bilirubin level, or hematocrit level between the two groups. Infants more than 29 weeks' gestational age who received DCC had significantly higher 1-minute Apgar scores, temperature, and 24-hour bilirubin level. IMPLICATIONS FOR PRACTICE Clinicians should advocate for the implementation of DCC as part of the resuscitative process for preterm neonates. IMPLICATIONS FOR RESEARCH Future studies are needed to evaluate the effect of DCC on other clinical outcomes and to investigate umbilical cord milking as an alternative approach to DCC.
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13
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Katheria AC, Lakshminrusimha S, Rabe H, McAdams R, Mercer JS. Placental transfusion: a review. J Perinatol 2017; 37:105-111. [PMID: 27654493 PMCID: PMC5290307 DOI: 10.1038/jp.2016.151] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/14/2016] [Accepted: 08/12/2016] [Indexed: 12/20/2022]
Abstract
Recently there have been a number of studies and presentations on the importance of providing a placental transfusion to the newborn. Early cord clamping is an avoidable, unphysiologic intervention that prevents the natural process of placental transfusion. However, placental transfusion, although simple in concept, is affected by multiple factors, is not always straightforward to implement, and can be performed using different methods, making this basic procedure important to discuss. Here, we review three placental transfusion techniques: delayed cord clamping, intact umbilical cord milking and cut-umbilical cord milking, and the evidence in term and preterm newborns supporting this practice. We will also review several factors that influence placental transfusion, and discuss perceived risks versus benefits of this procedure. Finally, we will provide key straightforward concepts and implementation strategies to ensure that placental-to-newborn transfusion can become routine practice at any institution.
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Affiliation(s)
- A C Katheria
- Division of Neonatology, Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA,Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, 3000 Health Center Drive, San Diego, CA 92123, USA. E-mail:
| | - S Lakshminrusimha
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA
| | - H Rabe
- Academic Department of Pediatrics, Brighton and Sussex Medical School, Brighton, UK
| | - R McAdams
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - J S Mercer
- Division of Midwifery, University of Rhode Island, Kingston, RI, USA,Division of Midwifery, Alpert School of Medicine, Brown University, Providence, RI, USA,Division of Midwifery, Women and Infants Hospital of Rhode Island, Providence, RI, USA
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Abstract
Hemolytic disease of the newborn (HDN), an alloimmune disorder due to maternal and fetal blood type incompatibility, is associated with fetal and neonatal complications related to red blood cell (RBC) hemolysis. After delivery, without placental clearance, neonatal hyperbilirubinemia may develop from ongoing maternal antibody-mediated RBC hemolysis. In cases refractory to intensive phototherapy treatment, exchange transfusions (ET) may be performed to prevent central nervous system damage by reducing circulating bilirubin levels and to replace antibody-coated red blood cells with antigen-negative RBCs. The risks and costs of treating HDN are significant, but appear to be decreased by delayed umbilical cord clamping at birth, a strategy that promotes placental transfusion to the newborn. Compared to immediate cord clamping (ICC), safe and beneficial short-term outcomes have been demonstrated in preterm and term neonates receiving delayed cord clamping (DCC), a practice that may potentially be effective in cases RBC alloimmunization.
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Affiliation(s)
- Ryan M McAdams
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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Niermeyer S. A physiologic approach to cord clamping: Clinical issues. Matern Health Neonatol Perinatol 2015; 1:21. [PMID: 27057338 PMCID: PMC4823683 DOI: 10.1186/s40748-015-0022-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 08/20/2015] [Indexed: 11/15/2022] Open
Abstract
Background Recent experimental physiology data and a large, population-based observational study have changed umbilical cord clamping from a strictly time-based construct to a more complex equilibrium involving circulatory changes and the onset of respirations in the newly born infant. However, available evidence is not yet sufficient to optimize the management of umbilical cord clamping. Findings Current guidelines vary in their recommendations and lack advice for clinicians who face practical dilemmas in the delivery room. This review examines the evidence around physiological outcomes of delayed cord clamping and cord milking vs. immediate cord clamping. Gaps in the existing evidence are highlighted, including the optimal time to clamp the cord and the interventions that should be performed before clamping in infants who fail to establish spontaneous respirations or are severely asphyxiated, as well as those who breathe spontaneously. Conclusion Behavioral and technological changes informed by further research are needed to promote adoption and safe practice of physiologic cord clamping.
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Affiliation(s)
- Susan Niermeyer
- Section of Neonatology, University of Colorado School of Medicine, 13121 E. 17th Avenue, Mail Stop 8402, Aurora, CO 80045 USA
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