Cord Clamping In Preterm Infants Research Articles

Improving the Rate of Delayed Cord Clamping in Preterm Infants: A Quality Improvement Project.

Delayed cord clamping (DCC) provides many benefits for preterm infants. The aim of this quality improvement project was to increase the rate of DCC by 25% within 12 months for neonates <34 weeks' gestation born at a tertiary care hospital. A multidisciplinary team investigated key drivers and developed targeted interventions to improve DCC rates. The primary outcome measure was the rate of DCC for infants <34 weeks' gestation. Process measures were adherence to the DCC protocol and the rate of births with an experienced neonatology provider present at the bedside. Balancing measures included the degree of neonatal resuscitation, initial infant temperature, and maternal blood loss. Data were collected from chart review and a perinatal research database and then analyzed on control charts. The preintervention period was from July 2019 to June 2020 and the postintervention period was from July 2020 to December 2021. 322 inborn neonates born at <34 weeks' met inclusion criteria (137 preintervention and 185 postintervention). The rate of DCC increased by 63%, from a baseline of 40% to 65% (P <.001), with sustained improvement over 18 months. Significant improvement occurred for all process measures without a significant change in balancing measures. Using core quality improvement methodology, a multidisciplinary team implemented a series of targeted interventions which was associated with an increased rate of DCC in early preterm infants.

Embracing Change: A Quality Improvement Project to Introduce Deferred Cord Clamping.

The aim of this quality improvement (QI) project was to increase deferred cord clamping (DCC) rates in preterm infants (≤36 + 6 weeks) to 50% of eligible infants over an 18-month period. The multidisciplinary neonatal quality improvement team collaboratively developed a driver diagram to address the key issues and tasks to launching DCC. Serial plan-do-study-act cycles were used to implement successive changes and integrate DCC as normal practice. Statistical process control charts were used to track and share project progress. This QI project has increased rates of deferred cord clamping for preterm infants from zero to 45%. Our DCC rates have sequentially increased with each plan-do-study-act cycle and have shown sustained increases without significant compromise in other aspects of neonatal care, such as thermoregulation. DCC is a core element of good quality perinatal care. This QI project encountered several limiting factors to progress, including resistance to change from clinical staff and the impact on staffing and education secondary to the coronavirus disease 2019 pandemic. Our QI team used a range of approaches, such as virtual education strategies and narrative storytelling to overcome these obstacles to QI progress.

Influence of umbilical cord milking versus delayed cord clamping on the early prognosis of preterm infants with a gestational age of

To study the influence of umbilical cord milking versus delayed cord clamping on the early prognosis of preterm infants with a gestational age of <34 weeks. PubMed, Web of Science, Embase, the Cochrane Library, CINAHL, China National Knowledge Infrastructure, Wanfang Data, Weipu Database, and SinoMed were searched for randomized controlled trials on umbilical cord milking versus delayed cord clamping in preterm infants with a gestational age of <34 weeks published up to November 2021. According to the inclusion and exclusion criteria, two researchers independently performed literature screening, quality evaluation, and data extraction. Review Manger 5.4 was used for Meta analysis. A total of 11 articles were included in the analysis, with 1 621 preterm infants in total, among whom there were 809 infants in the umbilical cord milking group and 812 in the delayed cord clamping group. The Meta analysis showed that compared with delayed cord clamping, umbilical cord milking increased the mean blood pressure after birth (weighted mean difference=3.61, 95%CI: 0.73-6.50, P=0.01), but it also increased the incidence rate of severe intraventricular hemorrhage (RR=1.83, 95%CI: 1.08-3.09, P=0.02). There were no significant differences between the two groups in hemoglobin, hematocrit, blood transfusion rate, proportion of infants undergoing phototherapy, bilirubin peak, and incidence rates of complications such as periventricular leukomalacia and necrotizing enterocolitis (P>0.05). Compared with delayed cord clamping, umbilical cord milking may increase the risk of severe intraventricular hemorrhage in preterm infants with a gestational age of <34 weeks; however, more high-quality large-sample randomized controlled trials are needed for further confirmation.

Umbilical cord clamping and management of the third stage of labor: A telephone-survey describing Swedish midwives' clinical practice.

INTRODUCTIONThe timing of cord clamping impacts children’s short- and long-term well-being. When making clinical decisions, midwives incorporate their tacit and professional knowledge, experience and current evidence. There appears to be a lack of knowledge regarding Swedish midwives’ management of the third stage of labor and cord clamping practice. The aim of this study was to explore Swedish midwives’ clinical practice concerning umbilical cord clamping and the third stage of labor in spontaneous vaginal births.METHODSThe study was designed as a cross-sectional telephone survey including 13 questions. Midwives were randomly selected from 48 births units in Sweden. Two midwives from each unit were interviewed. The primary outcome was timing of umbilical cord clamping practice in full-term infants. Secondary outcomes were the management of the third stage of labor including prophylactic use of synthetic oxytocin, the timing of cord clamping in preterm infants, controlled cord traction, uterine massage, and cord milking.RESULTSAltogether, 95 midwives were interviewed. In full-term infants, all midwives preferred late cord clamping. Considerable heterogeneity was seen regarding the practices of synthetic oxytocin administration postpartum, controlled cord traction, uterine massage or cord milking, and cord clamping in preterm infants.CONCLUSIONSMidwives in Sweden modify recommendations regarding delayed cord clamping in a way they might perceive as more natural and practical in their daily, clinical work. The study revealed a reluctance toward the administration of prophylactic oxytocin due to fear that the drug could pass to the infant. An overall large variation of the management of the third stage of labor was seen.

Current Resources for Evidence-Based Practice, March 2022

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.

Immediate vs delayed cord clamping in preterm infants: A systematic review and meta-analysis.

To compare and evaluate the efficacy and safety of immediate cord clamping (ICC) and delayed cord clamping (DCC) in preterm infants. We performed a comprehensive and systematic meta-analysis of randomised controlled trials (RCTs) assessing ICC and DCC in preterm infants by searching PUBMED, EMBASE, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Database (from inception to 30 September 2020). Summary odds ratios or mean differences with 95% confidence intervals were calculated using a fixed- or random-effect model. A total of 20 RCTs with 1807 preterm infants were included in the study. DCC provided more benefits in increasing the haematocrit and haemoglobin levels at 24hours of life (%), thus reducing the incidence of anaemia, necrotising enterocolitis, length of hospital stay and mortality than when ICC was performed. No significant differences were found between ICC and DCC in terms of peak bilirubin level; need for blood transfusion, mechanical ventilation (MV) and phototherapy; duration of MV and phototherapy; and incidences of intraventricular haemorrhage, retinopathy of prematurity, patent ductus arteriosus, respiratory distress syndrome, sepsis, jaundice, polycythaemia, periventricular leukomalacia and bronchopulmonary dysplasia. DCC is a safe, beneficial and feasible intervention for preterm infants. However, rigorously designed and large-scale RCTs are necessary to identify the role and ideal timing of DCC.

Umbilical cord clamping in preterm infants

For several years now, the survival of preterm infants has been increasing, which has shifted our concern to preterm infants born before 28 weeks of gestation in particular. The timing of umbilical cord clamping may lead to several disorders, especially when done early (10-15 seconds). In the last two decades, several investigations have shown the considerable benefits of delayed cord clamping (2-3 minutes). Delayed cord clamping has been practiced in obstetrics and neonatal care based on the recommendations made by scientific societies and in systematic reviews, which have provided solid evidence to support this practice in preterm infants. This review describes the most relevant articles from the last years, which strongly support the use of delayed cord clamping versus early cord clamping. In addition, this practice reduces the rate of severe disorders in preterm infants.

Timing of umbilical cord clamping for preterm infants in low-and-middle-income countries: A survey of current practice

IntroductionThe optimal timing of umbilical cord clamping in preterm infants has been contested for years. Previously, it was common practice to clamp the cord immediately after birth. There is now high-quality evidence that delayed cord clamping (DCC) (>60 seconds) reduces mortality in preterm infants by allowing placental transfusion. However, it is unclear how well DCC has been implemented into practice. This study aims to assess current practice of timing of cord clamping for both stable and unstable preterm infants in LMICs, where rates of preterm birth and neonatal mortality are high and where there is the potential to see the greatest benefit from implementation of DCC. MethodsAn online survey was created and, following user-testing, circulated to maternity workers in LMICs via The International Federation of Gynaecology and Obstetrics (FIGO), social media and other existing collaborators. Analyses were conducted using SPSS. Results70 responses were received across 10 LMICs. 42/70 (60%) participants reported practising DCC for stable preterm infants, compared to only 4/70 (6%) for unstable infants. For stable infants, 22/42 (52%) of those who practised DCC gave their main reason as being “recommended by guidelines”. 13/70 (19%) participants said they didn’t follow any guidelines for the timing of cord clamping. Only 25/70 (36%) were aware of guidelines for cord clamping in their hospitals, and 9/70 (13%) were aware of related quality improvement projects (QIPs). DiscussionDespite evidence to support the use of DCC, timing of cord clamping in LMICs is variable. Unstable infants requiring stabilisation could benefit most from placental transfusion, yet few respondents practised DCC and few hospitals had QIPs in place. Higher-quality guidelines and training could increase implementation of DCC, and development of affordable equipment to allow bedside resuscitation with the cord intact could aid in reducing neonatal mortality.

Association of Umbilical Cord Milking Versus Delayed Umbilical Cord Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants

(JAMA. 2019;322:1877–1886) Umbilical cord milking has been cited as an alternative to delayed umbilical cord clamping, which is the current standard of care. Like delayed umbilical cord clamping, umbilical cord milking provides placental transfusion that has been associated with neonatal benefits, including fewer deaths in preterm infants. The aim of this study was to examine whether umbilical cord milking was noninferior to delayed umbilical cord clamping in preterm infants.

Is delayed cord clamping in preterm infants as safe as immediate clamping regarding 2-years outcomes?

Delayed cord clamping (DCC) has already been established in healthy term infants,1 and there is growing evidence that DCC might also have beneficial effects in preterm infants.1-4 Current ERC guidelines recommend DCC for at least 30 seconds in preterm infants who do not need resuscitation.5 So far, approaches of incorporating DCC into stabilisation or resuscitation of preterm infants have not been widely established. However, stabilisation of preterm infants with umbilical cord intact has been described in individual studies2, 3, 6, 7 but long-term follow-up data are scarce. This prospective randomised trial compared DCC after at least 120 seconds and immediate neonatal care with cord intact, with prompt cord clamping within 20 seconds followed by neonatal care, evaluating the survival and neurodevelopmental outcome at two years corrected age. Short-term outcomes of enrolled infants were published separately.7 Initially created as a feasibility study, no formal sample size calculation was done. Neurodevelopmental outcome was assessed by means of Bayley-III Scale and/or parent-completed ASQ-3 questionnaire, if available; otherwise by routine clinical data. Study design aimed at delaying cord clamping for at least 2 minutes and was achieved in 60% of patients.8 This time-based approach of cord clamping contrasts with studies favouring physiological-based cord clamping (PBCC), this fact highlighting the ongoing search for optimal time of clamping.1-3 The study showed a non-significant decrease in the compound measure of mortality or adverse neurodevelopmental outcome in the DCC group. Regarding adverse neurodevelopmental outcome alone there were no differences between the two groups. Despite a tendency towards better outcome at 2 years corrected age in the DCC group, a higher loss to follow-up was observed in infants with poor outcome at discharge in the DCC group. Strengths of the present study include its prospective character, the inclusion of preterm infants and its focus on long-term neurodevelopmental follow-up. However, median GA was 29 weeks in both groups, and only a minority of infants (13%) was born below 26 weeks’ GA.7 Heterogeneity of assessment and classification of neurodevelopmental outcome as well as missing data are important limitations of this study. Overall data were available in 80.7% of cases; valid Bayley-III results exist in nearly half of all infants. The remaining data were assessed by means of ASQ-3 parents' questionnaire potentially lacking objectivity, and in a minority of cases by means of routine clinical data. However, ASQ-3 questionnaires have been evaluated as a screening tool in neonatal neurodevelopmental follow-up.9 In conclusion, this study reported neurodevelopmental outcome at 2 years corrected age in a large proportion of infants. However, assessment was heterogenous and the study was not sufficiently powered to allow for proper analyses of benefits and harms of DCC in preterm infants, thus hampering meaningful conclusions on outcome. Further randomised controlled trials adequately designed and powered to assess short-term and long-term outcomes are needed. https://ebneo.org/2020/03/delayed-cord-clamping-preterm-infants/ None.

Umbilical cord milking in preterm infants: a systematic review and meta-analysis

ObjectiveTo conduct a systematic review and meta-analysis of the efficacy and safety of umbilical cord milking in preterm infants.DesignRandomised controlled trials comparing umbilical cord milking with delayed cord clamping/immediate cord...

The “DUC” trial: a pilot randomized controlled trial of immediate versus delayed cord clamping in preterm infants born between 24 and 32 weeks gestation

Purpose To determine the feasibility of a randomized controlled trial of delayed umbilical cord clamping in preterm infants. Methods Following informed consent, women between 24 to 32 weeks gestation experiencing imminent preterm birth were randomly assigned to either an immediate cord clamping (ICC) or delayed cord clamping (DCC) group. Umbilical cord clamping directions were 0–15 s for the ICC group and 30–45 s for the DCC group. Information regarding recruitment rate and trial compliance was collected. Neonatal outcomes of intraventricular hemorrhage (IVH), sepsis, anemia, and hyperbilirubinemia were also compared between the two groups. This trial was registered at https://clinicaltrials.gov/. (ClinicalTrials.gov Identifier: NCT00562536). Results Thirty-eight women were recruited in total, 19 each to the ICC and DCC groups respectively. The study recruitment rate was 33% and study compliance rate was 97%. The average time for cord clamping was 5.4 s in the ICC group and 39.7 s in the DCC group (p < .05). The incidence of IVH and sepsis was the same in both groups (16 and 11% respectively). Thirty-seven percent of the ICC group and 21% of the DCC group required a blood transfusion. Hyperbilirubinemia requiring phototherapy occurred in 37% of the ICC group and 26% of the DCC group. Conclusion This study demonstrates that a trial of a short delay in umbilical cord clamping (30–45 s) is feasible for women and physicians. Larger scale studies of long term outcomes are warranted.

125 Delayed cord clamping for preterm infants with restricted growth for age

125 Delayed cord clamping for preterm infants with restricted growth for age

Optimal Timing and Methodology of Umbilical Cord Clamping in Preterm Infants: a Review

We examine current recommendations for the timing of umbilical cord clamping in term and preterm infants and review available literature in support of these recommendations. Additionally, we explore potential barriers to practice change and identify opportunities for ongoing research. Available literature supports the practice of delayed cord clamping (DCC) in neonates, with clear benefits over immediate cord clamping (ICC) when comparing both short- and longer-term outcomes. Additional studies suggest similar benefits may be conferred by the practice of umbilical cord milking (UCM). Despite recommendation updates, significant variability in practice surrounding the timing of umbilical cord clamping persists. DCC and UCM show definite advantages over ICC. Perceived risks associated with either practice may lead to decreased adherence to current practice recommendations. Additional studies comparing these two practices are warranted and might help to further delineate best practice guidelines or potentially identify populations better suited to one method vs the other. Further education regarding the benefits of DCC and UCM are needed to improve recommendation adherence.

Delayed Umbilical Cord Clamping in Preterm Infants.

Please view Videos 1 and 2 showing delayed cord clamping of a preterm infant born via cesarean delivery and a preterm infant born via vaginal delivery. Video 1. Delayed Cord Clamping in a Cesarean Delivery. Click here to view the video. Video 2. Delayed Cord Clamping in a Vaginal Delivery. Click here to view the video. Which of the following scenarios is an absolute contraindication to delayed cord clamping? There is a growing body of evidence that delaying umbilical cord clamping in preterm infants may improve neonatal outcomes by increasing infant blood volume through placental transfusion. (1) Better outcomes may include improved neonatal transition, decreased intraventricular hemorrhage, decreased necrotizing enterocolitis, and decreased mortality. (1)(2)(3) Term infants receiving delayed cord clamping have evidence of increased hemoglobin levels in the immediate newborn period, as well as a reduction in iron deficiency at 3 to 6 months of age. (4) Most published studies define cord clamping as “delayed” …

Optimizing Cord Clamping in Preterm Infants: One Strategy Does Not Fit All.

Optimizing Cord Clamping in Preterm Infants: One Strategy Does Not Fit All.

Associations of measures of systemic blood flow used in a randomized trial of delayed cord clamping in preterm infants.

To determine associations of low superior vena cava (SVC) flow (≤55 ml/kg/min) and low right ventricular output (RVO) (≤150 ml/kg/min) in preterm infants. An observational study in infants <30 weeks gestation randomized to receive immediate (<10 s) or delayed cord clamping (DCC) (≥60 s). The study enrolled 265 infants with a mean (SD) gestation 28 (2) weeks. Eighty-six (33%) infants had low SVC flow and 81 (31%) infants had low RVO. In multivariate analysis, low SVC flow was associated with gestation; low RVO was associated with DCC, gender and 5-minute Apgar; whereas mean RVO was negatively associated with both FiO2 and mean airway pressure (MAP) at 9 h and 24 h. Low SVC flow was associated with ductus arteriosus (DA) treatment. Infants with low RVO had higher mortality on univariate analysis, but this was not significant after adjusting for gestation. SVC flow was associated with gestation, whilst RVO was associated with placental transfusion, gender, condition at birth, and early respiratory adaptation. Compared to infants with normal values, more infants with low SVC flow were treated for DA, but infants with low RVO had no significant difference in mortality or morbidity.

Delayed clamping vs milking of umbilical cord in preterm infants: a randomized controlled trial

It has been established that delayed umbilical cord clamping in preterm infants results in improvement in neonatal anemia, need for transfusion, incidence of necrotizing enterocolitis, and intraventricular hemorrhage by increasing neonatal circulating blood volume. However, the effects of umbilical cord milking as an alternative to delayed clamping in preterm infants are unclear. The primary objective of this study was to compare the effect of delayed clamping vs milking of the umbilical cord on the initial hematocrit concentration in preterm births (23-34 weeks gestation). In addition, we sought to compare the effects of delayed clamping vs milking on the incidences of intraventricular hemorrhage, necrotizing enterocolitis, and need for transfusion (secondary objectives). The study was an unblinded randomized controlled trial of singleton preterm infants who were born 23 weeks 0 days to 34 weeks 6 days gestation and were assigned to 1 of 2 controlled study groups: delayed cord clamping for 60 seconds or milking of the cord towards the infant 4 times before clamping. Randomization occurred via block randomization with an allocation ratio of 1 to 1. The patients' third stage of delivery was standardized for route of delivery and randomization arm. All comparisons were preformed with an intent-to-treat analysis approach. The study was powered at 80% with a probability value of .05 for the primary outcome measure of a hematocrit difference of 3% between the 2 groups. Of the 204 randomized patients, 104 were assigned to the delayed subgroup, and 100 were assigned to the milking subgroup. There were no significant differences in baseline maternal characteristics noted between groups. Though there was not any statistically significant difference in neonatal outcomes between the cord clamping and milking groups, the occurrences of transfusion (15.5% vs 9.1%; P=.24), necrotizing enterocolitis (5.8% vs 3.0%; P=.49), and intraventricular hemorrhage (15.5% vs 10.1%; P=.35) were all lower in the milking group. The milking group had higher initial hematocrit concentration compared with the delayed clamping group, although this was not significant (51.8 [6.2%] vs 49.9 [7.7%]; P=.07]. Peak bilirubin levels and need for phototherapy were similar between groups. This study demonstrates that milking the umbilical cord may be an acceptable alternative to delayed cord clamping because there were similar effects on neonatal hematocrit concentrations and the need for neonatal transfusions and no increased risk for complications or neonatal morbidity. The present data support the concept that milking of the umbilical cord may offer an efficient and timely method of providing increased blood volume to the infant.

Delayed cord clamping in preterm infants: is it time to become standard practice?

Delayed cord clamping in preterm infants: is it time to become standard practice?

Delayed Versus Early Umbilical Cord Clamping for Preterm Infants: A Systematic Review and Meta-Analysis

(Am J Obstet Gynecol. 2018;218(1):1–18) Delayed umbilical cord clamping may benefit preterm infants by increasing the volume of blood transferred to the neonate as well as allowing time for physiological transition, which may result in improved outcomes. The effects of delayed cord clamping are still unclear and an updated systematic review was needed. This systematic review included randomized controlled trials (RCTs) though July 31, 2017 in order to evaluate the effects of delayed clamping without cord milking compared to early clamping in reducing mortality in preterm infants.