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

Abstract

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.