Deferred Cord Clamping Research Articles

Deferred Cord Clamping in Twin Pregnancies Across Canada: A National Survey of Practices

ObjectiveGuidelines recommending deferred cord clamping (DCC), delaying cord clamping for at least 30 seconds post-birth, have shown significant benefits in preterm singleton births. However, evidence supporting DCC in twins is scarce due to limited trial data, leading to practice variations. This study aims to assess current reported DCC practices for twin pregnancies in tertiary hospitals across Canada. MethodsA web-based survey was distributed to neonatologists and obstetrician investigators associated with the Canadian Neonatal and Preterm Birth Networks operating maternity and neonatal units. ResultsThe site response rate was 93% (28/30 sites), with 83% (25/30) for neonatologists and 56% (17/30) for obstetricians. The majority had a local protocol for twin pregnancies (obstetricians 13/17, neonatologists 21/25). While all centres practised DCC in dichorionic-diamniotic twins, a difference was noted for monochorionic-diamniotic twins, with 56% of neonatologists and 65% of obstetricians performing DCC. During cesarean delivery, most obstetricians (76.5%) placed the firstborn on the mother’s thighs. Neonatologists varied in their practices, with 32% placing the baby on the mother’s abdomen, 32% on the mother’s thighs, and 28% holding the baby at the height of the perineum. Divergent opinions were observed regarding contraindications, including risks of postpartum hemorrhage and velamentous cord insertion. ConclusionsDCC is reported to be practised in most twin deliveries among Canadian Neonatal and Preterm Birth Network centres. However, there are wide variations in practice, especially concerning the characteristics of the twins in which DCC is performed. Future research should investigate optimal cord clamping management in twins to standardize practices and maximize benefits.

Deferred Cord Clamping, Cord Milking, and Immediate Cord Clamping at Preterm Birth: A Systematic Review and Individual Participant Data Meta-analysis

(Abstracted from Lancet 2023;402:2209–2222) Deferring or delaying umbilical cord clamping for at least 60 seconds is an increasingly common practice for infants. For term neonates, this practice has been shown to improve hemoglobin and hematocrit levels and lower the risk of iron deficiency.

Blood pressure and cerebral oxygenation with physiologically-based cord clamping: sub-study of the BabyDUCC trial

BackgroundCord-clamping strategies may modify blood pressure (BP) and cerebral tissue oxygen saturation (rStO2) immediately after birth.MethodsWe conducted a sub-study nested within the Baby-Directed Umbilical Cord-Clamping trial. Infants ≥32+0 weeks’ gestation assessed as requiring resuscitation were randomly allocated to either physiologically-based cord clamping (PBCC), where resuscitation commenced prior to umbilical cord clamping, or standard care where cord clamping occurred early (ECC). In this single-site sub-study, we obtained additional measurements of pre-ductal BP and rStO2. In a separate observational arm, non-randomised vigorous infants received 2 min of deferred cord clamping (DCC) and contributed data for reference percentiles.ResultsAmong 161 included infants, n = 55 were randomly allocated to PBCC (n = 30) or ECC (n = 25). The mean (SD) BP at 3–4 min after birth (primary outcome) in the PBCC group was 64 (10) mmHg compared to 62 (10) mmHg in the ECC group, mean difference 2 mmHg (95% confidence interval −3–8 mmHg, p = 0.42). BP and rStO2 were similar across both randomised arms and the observational arm (n = 106).ConclusionWe found no difference in BP or rStO2 with the different cord clamping strategies. We report reference ranges for BP and rStO2 for late-preterm and full-term infants receiving DCC.ImpactAmong late-preterm and full-term infants receiving varying levels of resuscitation, blood pressure (BP, at 3–4 minutes and 6 min) and cerebral tissue oxygen saturation (rStO2) are not influenced by timing of cord clamping in relation to establishment of ventilation.Infants in this study did not require advanced resuscitation, where cord clamping strategies may yet influence BP and rStO2.The reference ranges for BP and rStO2 represent the first, to our knowledge, for vigorous late-preterm and full-term infants receiving deferred cord clamping.rStO2 > 90% (~90th percentile) may be used to define cerebral hyperoxia, for instance when studying oxygen supplementation after birth.

Quality improvement efforts directed at optimal umbilical cord management in delivery room

Delayed or deferred cord clamping (DCC) and umbilical cord milking (UCM) benefit all infants by optimizing fetal-neonatal transition and placental transfusion. Even though DCC is recommended by almost all maternal and neonatal organizations, it has not been universally implemented. There is considerable variation in umbilical cord management practices across institutions. In this article, we provide examples of successful quality improvement (QI) initiatives to implement optimal cord management in the delivery room. We discuss a number of key elements that should be considering among those undertaking QI efforts to implement DCC and UCM including, multidisciplinary team collaboration, development of theory for change, mapping of the current and ideal process and workflow for cord management, and creation of a unit-specific evidence-based protocol for cord management. We also examine important strategies for implementation and provide suggestions for developing a system for measurement and benchmarking.

Early Breathing in Very Preterm Infants during Deferred Cord Clamping (DCC) Is Related to Gestational Age and Is Not Independently Associated with Important Neonatal Outcomes: A 5-Year Cohort Study.

Deferred cord clamping (DCC) has been associated with reduced mortality in preterm infants, and a period of at least 30 s has been recommended before clamping. However, preterm infants assessed as being in need of resuscitation have often had earlier cord clamping. In this study, we aimed to compare neonatal outcomes for preterm infants undergoing DCC who established early breathing movements compared to those who were not breathing. After a 5 yr recruitment period, we recently completed the ABC study, in which preterm infants <31 weeks undergoing 50 s of DCC who were not breathing by 15 s of age were randomised into two groups: one received intermittent positive pressure ventilation (IPPV) and the other was a standard group, which received no breathing support. The outcomes in the two groups were similar, and for the present analysis, the groups were combined. Infants in the ABC study were compared with the cohort excluded from the original ABC study because they were breathing by 15 s (called the Breathing Before Clamping or BBC group). There were significant differences in demographics between the ABC and BBC groups. Spontaneous preterm labour was more common in the BBC group, and these infants were more likely to be delivered vaginally. Gestational age and birth weight were significantly higher in the BBC group (p < 0.01). Soon after birth, Apgar scores were significantly higher in the BBC group, with a lower base deficit on first obtained blood gas, and a smaller proportion were intubated in the delivery room. Fewer BBC infants were hypothermic (<36.5 °C) on admission. Multivariate regression analysis indicated whether infants were breathing or not at 15 s of age was linked predominantly to gestation. Important neonatal outcomes and a composite of these outcomes (mortality, severe intraventricular haemorrhage, bronchopulmonary dysplasia) were not significantly different between the ABC and BBC groups (odds ratio for the composite outcome was 1.77 CI 0.84-3.76 corrected for gestation). For very preterm infants undergoing DCC, important neonatal outcomes were related to gestational age and not independently associated with early breathing. There was a small group (7% of total) who were deemed compromised at birth and did not undergo DCC. These infants had significantly worse neonatal outcomes.

Process and Outcome Measures for Infants Born Moderate and Late Preterm in Tertiary Canadian Neonatal Intensive Care Units

ObjectiveTo describe the prevalence of and between-center variations in care practices and clinical outcomes of moderate and late preterm infants (MLPI) admitted to tertiary Canadian neonatal intensive care units (NICUs). Study designA retrospective cohort study including infants born at 320/7 through 366/7 weeks’ gestation and admitted to 25 NICUs participating in the Canadian Neonatal Network between 2015 and 2020. Patient characteristics, process measures represented by care practices, and outcome measures represented by clinical in-hospital and discharge outcomes were reported by gestational age weeks. NICUs were compared using indirect standardization after adjustment for patient characteristics. ResultsAmong 25,669 infants (17% of MLPI born in Canada during the study period) included, 45% received deferred cord clamping, 7% had admission hypothermia, 47% received non-invasive respiratory support, 11% received mechanical ventilation, 8% received surfactant, 40% received antibiotics in the first 3 days, 4% did not receive feeding in the first 2 days, and 77% had vascular access. Mortality, early onset sepsis, late onset sepsis, or necrotizing enterocolitis occurred in <1% of the study cohort. Median (IQR) length of stay was 14 (9-21) days among infants discharged home from the admission hospital, and 5 (3-9) days among infants transferred to community hospitals. Among infants discharged home, 33% were discharged on exclusive breastmilk and 75% on any breastmilk. There were significant variations between NICUs in all process and outcome measures. ConclusionsCare practices and outcomes of MLPI varied significantly between Canadian NICUs. Standardization of process and outcome quality measures for this population will enable benchmarking and research, facilitating systemwide improvements.

Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis

Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth. We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640. We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality. This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations. Australian National Health and Medical Research Council.

Deferred cord clamping and cord milking: Certainty and quality of the evidence in meta-analyses, and systematic reviews of randomized control trials, guidelines, and implementation studies

Deferred11“Deferred” cord clamping is selected to imply a deliberate choice rather than “delayed” cord clamping, which has a potential negative connotation of being later than intended. cord clamping (DCC) saves lives, so why is it not implemented more routinely? Despite neonatal benefits, DCC is under-utilized, particularly in preterm births. Umbilical cord milking (UCM) also improves some outcomes for preterm infants such as decreasing the need for transfusions. At term, DCC and UCM improve hematological indices. ObjectiveThe objective of this chapter is to examine the quality of evidence for both preterm and term DCC (and UCM), clinical practice guidelines and implementation issues. MethodsKey evidence, primarily from network meta-analyses, meta-analyses and systematic reviews on both preterm and term DCC (and UCM) from randomized clinical trials, clinical practice guidelines and implementation studies, are summarized through a lens of the certainty and quality of the evidence. Regarding the certainty of evidence, for network meta-analysis the Confidence in Network Meta-analysis tool was used, and for meta-analyses the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used. Guideline quality was appraised with two tools: Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) and AGREE-Recommendation EXcellence (AGREE-REX). Implementation study quality was evaluated using The Mixed Method Appraisal tool. ResultsIn a network meta-analysis of 56 RCTs of cord management strategies, DCC reduced the odds of mortality in preterm infants by 30% compared to immediate cord clamping (ICC), including in the subgroup of infants born before 33 weeks’, both with a moderate confidence assessment using the Confidence in Network Meta-analysis tool. DCC reduced the odds of any intraventricular hemorrhage (IVH) by 30%, and the odds of red blood cell transfusion by more than 50%, both with high ratings on the Confidence in Network Meta-analysis. Umbilical Cord Milking (UCM) did not reduce mortality compared to ICC. In contrast to the benefits shown in preterm birth with DCC, a systematic review showed that at term, there were no mortality benefits and few benefits at all except for improved hematological indices. A systematic review of clinical practice guidelines demonstrated that all of them endorsed DCC for uncompromised preterm infants, and 11 more cautiously noted that cord milking might be considered when DCC was not feasible. However, only half (49%) of the recommendations in the guidelines on the optimal duration of DCC were supported by high-quality evidence per AGREE-II and AGREE-REX. Fewer than one in 10 statements (8%) cited a mortality benefit with DCC for preterm infants. Regarding the uptake of DCC, a systematic review of 18 studies on facilitators and barriers to implementation found that almost all (12 of the 14 studies) focused on strategies such as protocols, policy, or toolkits; additionally, 8 of 14 studies used didactic teaching sessions. Only 8 of 18 studies scored high on all four domains of the Mixed Method Appraisal tool. ConclusionsCompared to ICC, DCC in preterm infants conferred significant benefits for mortality, IVH and red blood cell transfusion, with confidence ratings of moderate (mortality) or high. Although guidelines worldwide encouraged preterm (and term) DCC, the quality of the clinical practice guidelines had room for improvement; only half of the recommendations on the optimal duration of preterm DCC were supported by high-quality evidence. Most guidelines did not mention a mortality benefit with preterm DCC and lacked details on practical aspects of implementation. Among implementation studies, which have focused mainly on protocols, policies, toolkits or didactic teaching, quality also demonstrated an opportunity for improvement.

PHYSIOLOGICAL BASED CORD CLAMPING- AN ARCHAIC STEP RELEARNED CLINICAL STUDY AT A TERTIARY CARE CENTRE.

Objective: To study maternal and perinatal outcomes in physiological based cord clamping in third stage of labour. Method: We conducted prospective observational study, in the Department of Obstetrics and Gynecology of Govt. Medical college &amp; hospital, Aurangabad for 2 years to study physiological based cord clamping which is a method of deferred cord clamping until natural delivery of placenta. The placenta was allowed to deliver physiologically without any cord traction or cord pull, encouraging mothers own uterine contractions and taking help of gravity. Oxytocin was given intramuscularly to the mother only after complete placental delivery. Results: Out of 200 women most of them belong to age group 21-25 years (41.5%) with mean age of 24.78 ± 6.72 years. 47.5% were from upper lower class, 53.5% were G2 followed by 26.5% were primigravida's. About 72% women's GA was ranging between 37-40 weeks. In 89.5% women the time required for 3rd stage of labour ranged between 5-10 minutes while in 99% women's placenta expelled in &lt;15 minutes. In our study 75% of women had outstanding experience after PCC. Among 200 neonates who delivered vaginally, had birth weight 2.5-3 kg (71%). majority of neonates had APGAR score ≥7 at 1 min were 97.50%, at 5 minute (100%) and 10 minute (100%) had Apgar score ≥7. It was observed that majority of neonates had heart rate 121-140 bpm at 1 minute (91.5%) and 5 minutes. (96%). Also, it was observed that mean temperature at 5 minutes was 98.32 ±1.08 F. Only 1.5% required NICU admission for neonatal jaundice. No case of hypothermia seen.

Different Placental Transfusion Strategies and Their Effects on Short - Term Hematological Parameters in Term Infants

Background: Deferring the umbilical cord clamping produces more satisfactory neurological and hematological outcomes. Another alternative for the deferred umbilical cord clamping is the umbilical cord milking. Objectives: This study aimed to evaluate different placental transfusion techniques in terms of hematological parameters for term neonates. Methods: This observational study included 120 term infants assigned to groups of deferred cord clamping for 60 seconds (DCC), cut cord milking for four times with a speed of 10 cm/second (CCM), intact cord milking for four times (ICM), and a historical control group of immediate cord clamping (ICC). The primary outcome of this study was hematological parameters at birth and 24th hours. Hyperbilirubinemia, polycythemia, or respiratory distress were secondary outcomes. Results: The median gestational ages and birth weights of neonates were 39 (37 - 40) weeks and 3270 (2365 - 4850) grams, respectively. Umbilical cord hemoglobin (Hb) and hematocrit (Hct) levels were significantly higher in the ICM group (P &lt; 0.01). Hemoglobin and Hct levels at 24th hours of life were similar in DCC, CCM, and ICM groups and significantly higher than those in the ICC group (P &lt; 0.01). No significant difference was found among the groups in terms of hyperbilirubinemia, polycythemia, and respiratory distress. Conclusions: To the best of our knowledge, this study was one of the most comprehensive studies evaluating the effects of different placental transfusion strategies on hematological parameters in term infants and the first study exploring intact cord milking in term infants. Intact cord milking was suggested to be associated with higher hemoglobin levels at birth. All DCC, ICM, and CCM techniques were found to be more effective than ICC in terms of early hematological parameters.

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.

Does physiological-based cord clamping improve cerebral tissue oxygenation and perfusion in healthy term neonates? - A randomized controlled trial.

To evaluate cerebral tissue oxygenation index (cTOI) during neonatal transition in a group of healthy full-term neonates receiving either a physiological-based approach of deferred cord clamping (CC) after the onset of stable regular breathing (PBCC group) or a standard approach of time-based CC < 1 min (control group). Secondary aim was to evaluate changes in cerebral blood volume (ΔCBV), peripheral arterial oxygen saturation (SpO2) and heart rate (HR) in those neonates. We conducted a randomized controlled trial (clinicaltrials.gov: NCT02763436) including vaginally delivered healthy full-term neonates. Continuous measurements of cTOI and ΔCBV using near-infrared spectroscopy, and of SpO2 and HR using pulse oximetry were performed within the first 15 min after birth. Data of each minute of the PBCC group were compared to those of the control group. A total of 71 full-term neonates (PBCC: n = 35, control: n = 36) with a mean (SD) gestational age of 40.0 (1.0) weeks and a birth weight of 3,479 (424) grams were included. Median (IQR) time of CC was 275 (197-345) seconds and 58 (35-86) seconds in the PBCC and control group, respectively (p < 0.001). There were no significant differences between the two groups regarding cTOI (p = 0.319), ΔCBV (p = 0.814), SpO2 (p = 0.322) and HR (p = 0.878) during the first 15 min after birth. There were no significant differences in the course of cTOI as well as ΔCBV, SpO2 and HR during the first 15 min after birth in a group of healthy full-term neonates, who received either deferred CC after the onset of stable regular breathing or standard CC < 1 min. Thus, deferring CC ≥ 1 min following a physiological-based approach offers no benefits regarding cerebral tissue oxygenation and perfusion after uncomplicated vaginal delivery compared to a time-based CC approach.

JOINT SOGC-CPS CLINICAL PRACTICE GUIDELINE: Guideline No. 424: Umbilical cord management in preterm and term infants.

To assess the impact of deferred (delayed) cord clamping (DCC) and umbilical cord milking in singleton and twin gestations on maternal and infant mortality and morbidity. Women who are pregnant with preterm or term singletons or twins. In preterm singletons, DCC for (ideally) 60 to 120 seconds, but at least for 30 seconds, reduces infant risk of mortality and morbidity. DCC in preterm twins is associated with some benefits. In term singletons, DCC for 60 seconds improves hematological parameters. In very preterm infants, umbilical cord milking increases risk for intraventricular hemorrhage. Searches of Medline, PubMed, Embase, and the Cochrane Library from inception to March 2020 were undertaken using Medical Subject Heading (MeSH) terms and key words related to deferred cord clamping and umbilical cord milking. This document represents an abstraction of the evidence rather than a methodological review. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation.

Globally, the majority of newborns requiring resuscitation at birth are full term or late-preterm infants. These infants typically have their umbilical cord clamped early (ECC) before moving to a resuscitation platform, losing the potential support of the placental circulation. Physiologically based cord clamping (PBCC) is clamping the umbilical cord after establishing lung aeration and holds promise as a readily available means of improving early newborn outcomes. In mechanically ventilated lambs, PBCC improved cardiovascular stability and reduced hypoxia. We hypothesised that PBCC compared to ECC would result in higher heart rate (HR) in infants needing resuscitation, without compromising safety. Between 4 July 2018 and 18 May 2021, infants born at ≥32+0 weeks' gestation with a paediatrician called to attend were enrolled in a parallel-arm randomised trial at 2 Australian perinatal centres. Following initial stimulation, infants requiring further resuscitation were randomised within 60 seconds of birth using a smartphone-accessible web link. The intervention (PBCC) was to establish lung aeration, either via positive pressure ventilation (PPV) or effective spontaneous breathing, prior to cord clamping. The comparator was early cord clamping (ECC) prior to resuscitation. The primary outcome was mean HR between 60 to 120 seconds after birth, measured using 3-lead electrocardiogram, extracted from video recordings blinded to group allocation. Nonrandomised infants had deferred cord clamping (DCC) ≥120 seconds in the observational study arm. Among 508 at-risk infants enrolled, 123 were randomised (n = 63 to PBCC, n = 60 to ECC). Median (interquartile range, IQR) for gestational age was 39.9 (38.3 to 40.7) weeks in PBCC infants and 39.6 (38.4 to 40.4) weeks in ECC infants. Approximately 49% and 50% of the PBCC and ECC infants were female, respectively. Five infants (PBCC = 2, ECC = 3, 4% total) had missing primary outcome data. Cord clamping occurred at a median (IQR) of 136 (126 to 150) seconds in the PBCC arm and 37 (27 to 51) seconds in the ECC arm. Mean HR between 60 to 120 seconds after birth was 154 bpm (beats per minute) for PBCC versus 158 bpm for ECC (adjusted mean difference -6 bpm, 95% confidence interval (CI) -17 to 5 bpm, P = 0.39). Among 31 secondary outcomes, postpartum haemorrhage ≥500 ml occurred in 34% and 32% of mothers in the PBCC and ECC arms, respectively. Two hundred ninety-five nonrandomised infants (55% female) with median (IQR) gestational age of 39.6 (38.6 to 40.6) weeks received DCC. Data from these infants was used to create percentile charts of expected HR and oxygen saturation in vigorous infants receiving DCC. The trial was limited by the small number of infants requiring prolonged or advanced resuscitation. PBCC may provide other important benefits we did not measure, including improved maternal-infant bonding and higher iron stores. In this study, we observed that PBCC resulted in similar mean HR compared to infants receiving ECC. The findings suggest that for infants ≥32+0 weeks' gestation who receive brief, effective resuscitation at closely monitored births, PBCC does not provide additional benefit over ECC (performed after initial drying and stimulation) in terms of key physiological markers of transition. PBCC was feasible using a simple, low-cost strategy at both cesarean and vaginal births. The percentile charts of HR and oxygen saturation may guide clinicians monitoring the transition of at-risk infants who receive DCC. Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000621213.

Integrated review of the knowledge, attitudes, and practices of maternity health care professionals concerning umbilical cord clamping.

Umbilical cord clamp timing has implications for newborn health, which include increased iron stores up to 6months of age. National and International cord clamping guidelines differ as do health professionals' practices. The rationale for differences in cord clamping practice is unclear. Studies on the knowledge, attitudes, and practices of maternity health care professionals about cord clamp timing were synthesized. Similarities and differences between professional groups and understanding of the optimal timing of cord clamp timing for term newborns were compared. An integrative review was undertaken. PubMed, Scopus, MIDIRS, CINAHL, and Google Scholar were searched. Publication date limits were set between January 2007 and December 2020. Quality appraisal was undertaken using the Critical Appraisal Skills Program (CASP) tools. Eighteen studies met inclusion criteria, as they included primary research studies that investigated maternity health care professionals' knowledge, attitudes, and practices about umbilical cord clamping, and were written in English. Four main subject areas were identified: a) knowledge of optimal cord clamp timing; b) attitudes and perceptions of early vs deferred cord clamping; c) cord clamping practice; and d) rationale for cord clamping practice. Different attitudes and practices were identified between midwifery and medical professionals in relation to cord clamp timing together with health professional knowledge and practice gaps pertaining to optimal cord clamp timing. Contemporary evidence should inform guidelines for clinical practice and be embedded into maternity health professional curricula and professional development programs.

Maintaining Normothermia in Preterm Babies during Stabilisation with an Intact Umbilical Cord.

Background: We had experienced an increase in admission hypothermia rates during implementation of deferred cord clamping (DCC) in our unit. Our objective was to reduce the number of babies with a gestation below 32 weeks who are hypothermic on admission, whilst practising DCC and providing delivery room cuddles (DRC). Method: A 12 month quality improvement project set, in a large Neonatal Intensive Care Unit, from January 2020 to December 2020. Monthly rates of admission hypothermia (<36.5 °C) for all eligible babies, were tracked prospectively. Each hypothermic baby was reviewed as part of a series of Plan, Do, Study Act (PDSA) cycles, to understand potential reasons and to develop solutions. Implementation of these solutions included the dissemination of the learning through a variety of methods. The main outcome measure was the proportion of babies who were hypothermic (<36.5 °C) on admission compared to the previous 12 months. Results: 130 babies with a gestation below 32 weeks were admitted during the study period. 90 babies (69.2%) had DCC and 79 babies (60%) received DRC. Compared to the preceding 12 months, the rate of hypothermia decreased from 25/109 (22.3%) to 13/130 (10%) (p = 0.017). Only 1 baby (0.8%) was admitted with a temperature below 36 °C and 12 babies (9.2%) were admitted with a temperature between 36 °C and 36.4 °C. Continued monitoring during the 3 months after the end of the project showed that the improvements were sustained with 0 cases of hypothermia in 33 consecutive admissions. Conclusions: It is possible to achieve low rates of admission hypothermia in preterm babies whilst providing DCC and DRC. Using a quality improvement approach with PDSA cycles is an effective method of changing clinical practice to improve outcomes.

Introduction of a Quality Improvement Bundle Is Associated with Reduced Exposure to Mechanical Ventilation in Very Preterm Infants

Introduction: Exposure to mechanical ventilation (MV) is a risk factor for bronchopulmonary dysplasia (BPD) in very preterm infants (VPTIs). We assessed the impact of a quality improvement (QI) bundle in VPTIs (<32 week gestation) on exposure to MV. Methods: We introduced a QI bundle consisting of deferred cord clamping (DCC), nasal bubble continuous positive airway pressure (bCPAP) in the delivery room (DR), and minimally invasive surfactant therapy (MIST). We compared respiratory outcomes and neonatal morbidity in historical pre-QI (July–December 2017) and prospective post-QI (February–July 2019) cohorts (QICs) of VPTIs. We pre-specified an adjusted analysis to account for the effects of gestational age, sex, antenatal steroids, and any demographic data that significantly differed between cohorts. Results: The pre-QI and post-QICs included 87 and 98 VPTIs, respectively. The post-QIC had decreased rates of MV in the DR (adjusted odds ratio [aOR] 0.26, 95% confidence interval [CI] 0.09–0.71), in the first 72 h of life (aOR 0.27, 95% CI 0.11–0.62) and during admission (aOR 0.28, 95% CI 0.12–0.66). Rates of BPD, combined BPD/death, and BPD severity were similar. The post-QIC was less likely to be discharged with home oxygen (aOR 0.27, 95% CI 0.08–0.91). Necrotising enterocolitis grade ≥2 increased (aOR 19.01, 95% CI 1.93–188.6) in the post-QIC. Conclusion: In this rapid-cycle QI study, implementation of a QI bundle consisting of DCC, early nasal bCPAP, and MIST in VPTIs was associated with reduced rates of MV in the DR, in the first 72 h of life and during admission, and reduced need for home oxygen.

Impact of Deferred Cord Clamping on Mortality and Severe Neurologic Injury in Twins Born at

To determine whether deferred cord clamping (DCC) compared with early cord clamping (ECC) was associated with reduction in death and/or severe neurologic injury among twins born at <30weeks of gestation. We performed a retrospective cohort study including all liveborn twins of <30weeks admitted to a tertiary-level neonatal intensive care unit (NICU) in Canada between 2015 and 2018 using the Canadian Neonatal/Preterm Birth Network database. We compared DCC ≥30seconds vs ECC <30seconds. Our primary outcome was a composite of death and/or severe neurologic injury (severe intraventricular hemorrhage grade III/IV and/or periventricular leukomalacia). Secondary outcomes included neonatal morbidity and health care utilization outcomes. We calculated aORs and β coefficients for categorical and continuous variables, along with 95% CI. Models were fitted with generalized estimated equations accounting for twin correlation. We included 1597 twins (DCC, 624 [39.1%]; ECC, 973 [60.9%]). Death/severe neurologic injury occurred in 17.8% (n=111) of twins who received DCC and in 21.7% (n=211) of those who received ECC. The rate of death/severe neurologic injury did not differ significantly between the DCC and ECC groups (aOR 1.07; 95% CI, 0.78-1.47). DCC was associated with reduced blood transfusions (adjusted β coefficient, -0.49; 95% CI, -0.86 to -0.12) and NICU length of stay (adjusted β coefficient, -4.17; 95% CI, -8.15 to -0.19). The primary composite outcome of death and/or severe neurologic injury did not differ between twins born at <30weeks of gestation who received DCC and those who received ECC, but DCC was associated with some benefits.

Learning From Strengths: Improving Care by Comparing Perinatal Approaches Between Japan and Canada and Identifying Future Research Priorities.

Preterm birth (PTB) is the leading cause of infant morbidity and mortality worldwide. Canada and Japan each have strengths that can inform clinical decision-making, research, and health care policy regarding the prevention of PTB and its sequelae. Our objectives were to: 1) compare PTB rates, risk factors, management, and outcomes between Japan and Canada; 2) establish research priorities while fostering future collaborative opportunities; and 3) undertake knowledge translation of these findings. We conducted a literature review to identify publications that examined PTB rates, risk factors, prevention and management techniques, and outcomes in Japan and Canada. We conducted site visits at 4 Japanese tertiary centres and held a collaborative stakeholder meeting of parents, neonatologists, maternal-fetal medicine specialists, and researchers. Japan reports lower rates of PTB, neonatal mortality, and several PTB risk factors than Canada. However, Canadian PTB data is population-based, whereas, in Japan, the rate of PTB is population-based, but outcomes are not. Rates of severe neurologic injury and necrotizing enterocolitis were lower in Japan, while Canada's rates of bronchopulmonary dysplasia and retinopathy of prematurity were lower. PTB prevention approaches differed, with less progesterone use in Japan and more long-term tocolysis. In Japan, there were lower rates of neonatal transfers and non-faculty overnight care, but also less use of antenatal corticosteroids and deferred cord clamping. Research priorities identified through the stakeholder meeting included early skin-to-skin contact, parental well-being after PTB, and transitions in care for the child. We identified key differences between Japan and Canada in the factors affecting PTB management and patient outcomes, which can inform future research efforts.

Preparedness strategies in neonatology units during the COVID-19 pandemic: A survey conducted at maternity centers in Argentina.

The objective of this study was to analyze available resources, guidelines in use, and preparedness to care for newborn infants at maternity centers in Argentina during the COVID-19 pandemic. Cross-sectional study based on a survey administered to medical and nursing staff. In May 2020, Argentine facilities with more than 500 annual births were contacted; 58 % of these were from the public sector. In total, 104/147 facilities answered (71 %). All had guidelines for care during the pandemic, and 93 % indicated they had been trained on how to use them. A companion was not allowed during childbirth in 26 % of private facilities and in 60 % of public ones (p < 0.01). Deferred cord clamping was recommended in 87 %; rooming-in with asymptomatic newborns was promoted in 62 %; breastfeeding using protective measures was recommended in 70 %; and breast milk using a bottle, in 23 %. In 94 %, family visiting in the Neonatology Unit was restricted. Difficulties included the unavailability of individual rooms for symptomatic newborn infants and a potential shortage of health care staff and personal protective equipment. All facilities are aware of the national guidelines to fight the pandemic. Most have the resources to comply with the recommended protective measures. There is uncertainty as to whether personal protective equipment, staff, and physical space available at the different facilities would be enough if cases increased significantly.