Delayed cord clamping (DCC) is recommended nationally and internationally.^1-3 It is one of the main evidence-based perinatal optimisation interventions that is recommended for preterm infants. It has well established short and long-term benefits. These include improved blood pressure and cardiovascular status, reduced requirement for inotropic support and reduced need for blood transfusion. Beyond this, DCC is associated with improved survival by a third.²

The British Association of Perinatal Medicine (BAPM) defines DCC as waiting for at least 60 seconds before clamping the cord.² The UK National Neonatal Audit Programme (NNAP) aims to assess whether babies admitted to neonatal units in the UK receive consistent care. It mentions in its guide for 2023 audit measures that DCC is defined as clamping the cord after at least 60 seconds.³ Therefore, in this quality improvement (QI) project 60 seconds is used as a cut-off to define DCC. The target population is those born below 34 weeks of gestation as this is the NNAP target.

This QI project was opted for because NNAP data from the authors’ unit showed that it was below average rates and some preterm babies were having immediate cord camping. The target was to establish a benchmark of progress in implementing DCC, identifying causes of immediate cord clamping. The aim was to use this data to educate staff on the unit, to develop local guidance to improve compliance and to share learning with other neonatal units.

The primary aim was to perform DCC with all babies <34 weeks’ gestation who were born in good condition. The secondary aim was to differentiate babies born in poor condition and needing resuscitation from those needing support during the transition to extrauterine life, while allowing DCC. Currently, there is no equipment for resuscitation on the unit while DCC is performed. Therefore, our thoughts are that our rate of DCC will increase if we are able to differentiate babies born in poor condition and requiring immediate resuscitation from those needing support during the transition. The latter babies usually breathe by themselves without needing active resuscitation. We decided to share this report, as we feel it will be beneficial for units that do not have equipment to perform respiratory support during DCC.

Methods

We retrospectively audited the electronic (BadgerNet) data for infants born <34 weeks, who were born on the unit from 1st September 2021 to 30th September 2022, and identified 82 eligible infants. We subsequently implemented changes in education and practice in our unit. We then collected data on a monthly basis using BadgerNet and a proforma sheet developed for that purpose during the period between 1st October 2022 to 31st August 2023 to measure the impact of these changes. We had 53 eligible infants during these 11 months.

Starting in October 2022 with our first cycle our primary aim was to perform DCC for all babies born in good condition (aiming to achieve 100% in this group of babies). We carried out a project charter, which was developed by the neonatal team and the trust’s QI team, to ensure formulation of a plan that meets the SMART criteria (specific, measurable, achievable, realistic and timely). We used the cause and effect fishbone tool for root cause analyses and to guide us with the first PDSA implementation (plan, do, study and act).

The main issue that we identified was lack of awareness among some members of the neonatal multidisciplinary team (MDT). Hence, we focused on increasing awareness within the neonatal MDT by implementing formal teaching sessions and raising awareness during morning safety briefings. We also developed a poster for display in the neonatal unit, delivery suite and obstetric theatres to increase awareness. We highlighted the benefits of DCC, contraindications, management of special situations such as complete placental abruption and addressed concerns that the MDT had regarding DCC, such as jaundice, polycythaemia, hypothermia and use of oxytocic drugs for the third stage of labour. Finally, we had monthly MDT meetings including neonatal, midwifery and obstetric members to discuss ongoing progress, future plans and troubleshoot any challenges. It was important to identify champion members in the project to lead the implementation process.

We noticed that some of the infants who are labelled as born in poor condition, and hence do not receive DCC, cry after stimulation, without needing any respiratory support. Therefore we planned to take further actions to improve our DCC compliance. We used current data from the first cycle, along with force field analysis to identify possible forces against change. This resulted in brainstorming among the MDT. In our second PDSA cycle, we developed a novel approach, encouraging neonatologists to start the Neonatal Life Support (NLS) algorithm by stimulation, while the cord is intact for 30 seconds. Then to assess whether the infant improved and DCC could be completed for 60 seconds, or if resuscitation is required and to proceed accordingly. This would be carried out by the senior neonatal trainee (registrar) while the rest of the neonatal team wait by the standard resuscitaire. We developed a poster (FIGURE 1) illustrating the new guideline in steps and asking the neonatologists to scrub-in in theatres in order to assess the baby. This addressed concerns regarding maintenance of the sterile field in theatre, which was an identified force against the change. We carried out simulation sessions involving the MDT to improve confidence and establish the practice.

FIGURE 1 The poster showing the DCC approach for preterm babies below 34 weeks’ gestation who do not cry at birth.

We monitored the temperature of the infants to ensure they were not adversely affected by the practice of DCC. This was maintained using the sterile plastic bag the infant was delivered into. Temperature measurement was checked on multiple occasions, such as after arrival to resuscitaire, before leaving theatre and on admission to the unit, in order to ensure normothermia.

Results

82 eligible infants (gestation at birth from 22 to 33 weeks with median gestation of 31 weeks) were identified before implemen-ting changes. Cause for immediate cord clamping was divided into infants born in poor condition (relative contraindication) and maternal haemorrhage (absolute contraindication) and infants born in good condition, who were eligible but did not receive it. The primary aim was to focus on those infants born in good condition, of which data indicated 54. Among these 54, 74% received DCC and 26% were eligible but did not receive it (FIGURE 2).

FIGURE 2 Before implementation of the changes, 26% of babies born in good condition were still having immediate cord clamping. (1st Oct 2022 to 31st Aug 2023)

Since implementation of our first PDSA changes and increasing awareness among the neonatal MDT, we have been achieving 100% of DCC among infants born in good condition from October 2022 to August 2023 (FIGURE 3).

FIGURE 3 Percentage of DCC among babies born <34 weeks in good condition.

After achieving the primary aim, the authors developed the required guideline and prepared simulations to train the team, in order to start the new approach for DCC for infants born in poor condition. The second PDSA cycle started in April 2023 and enhanced our average DCC rates among eligible infants. Our average rates showed continuous improvement from 51% before implementing the changes, to 62% after starting the first PDSA cycle, to 83% after starting the new approach (FIGURE 4). Since implementing the new approach, infants who have no contraindication for DCC received at least 30 seconds DCC. Those who did not receive the full 60 seconds were infants born in poor condition. Nevertheless, they managed to have between 30 to 57 seconds, except for one infant who had immediate cord clamping due to concerns regarding prolonged bradycardia and difficult extraction.

FIGURE 4 Percentage of DCC among all eligible infants born <34 weeks (born in good and poor condition, excluding absolute contraindications).

Discussion

Increasing awareness by teaching sessions and posters was successful in highlighting the importance of DCC. It enabled us to achieve our primary aim among the targeted population in the prospective data collection. It was important because it allowed discussions among the MDT and helped in answering their concerns. Additionally, it was a good opportunity to discuss how to deal with special situations such as complete placental abruption, when the placenta is delivered with the baby. Many members of the team did not know that we can still perform DCC in this condition. It was an opportunity to refer them to BAPM advice on managing this, which is to hold the placenta above the baby with gentle pressure for 60 seconds before clamping the cord.²

Furthermore, assessing the infants and starting the NLS algorithm with intact cord helped to differentiate between those infants who require resuscitation and those who improve with stimulation and airway positioning and hence receive the full 60 seconds of DCC. This will not only help differentiate between those who will improve with stimulation, but will also allow all infants to have at least 30 seconds of DCC while starting the NLS algorithm. Even if an infant is born in poor condition, the aim is to utilise the first 30 seconds, using the NLS algorithm to provide as much DCC as possible, while giving stimulation and opening the airway, followed by clinical assessment. The approach was based on the fact that the NLS algorithm can be started while the cord is still intact, if needed, for the first 30 seconds, which will give enough time to provide support during transition to extra-uterine life, to have time to assess the baby appropriately and to allow all infants to have at least 30 seconds of DCC.

It would be beneficial to assess infants who do not cry at birth before clamping the cord. This approach will be particularly helpful in units where there is no equipment to start resuscitation with intact cord during DCC. It helped us to maintain 100% of DCC among those born in good condition, in contrast to the 74% before implementation of the changes.

Our novel approach came from the observation that despite some infants not spontaneously taking a breath at birth, they will breathe by the time they reach the resuscitaire without any active respiratory support. This observation is consistent with other studies, such as Katheria et al (2016)¹¹ and Murphy et al (2020)¹². They noticed that almost 90-92% of preterm infants cry by 60 seconds, whether respiratory support is provided or not, and this suggests that the condition of many infants is better than the clinician originally thinks. Also, the majority of infants who receive full 60 seconds of DCC will breathe on their own. As a result: “Stabilisation should start with gentle but deliberate stimulation, good thermal care and optimal positioning so that the airway is patent and does not get obstructed, while actively encouraging the onset and maintenance of spontaneous respiration” [BAPM, 2020²].

It is worth mentioning that the optimal timing for DCC is not agreed universally. The European Resuscitation Council (ERC) Guidelines 2021¹ mention that there are systematic reviews that use 30 seconds as a cut off. The ERC recommends at least 60 seconds of DCC and ideally this should be after lungs are aerated, except when contraindicated.¹ Likewise, BAPM² and the NNAP³ define DCC as waiting for at least 60 seconds before clamping the cord. However, two other studies suggest that longer timing of at least two minutes is better to optimise the placental transfusion.^4,13 Furthermore, others suggest a physiological-based approach, such as initiation of spontaneous breathing, or the fact that cord pulsation has ceased, rather than a time-based approach for DCC.^5-7 This came from the experiments on preterm lambs. It showed that DCC until lung aeration is achieved will mitigate changes in cardiac output, blood pressure and cerebral perfusion, which allows for smooth transition to extrauterine life.^6,8-10 Katheria et al (2016)¹¹ conducted a randomised controlled trial to assess whether ventilation during DCC increases placental transfusion in comparison to DCC alone. It showed that there was no difference in peak haematocrit, perinatal or neonatal outcomes in the first 24 hours between infants who breathed spontaneously and those who did not breath before clamping the cord. However, they mention that a larger trial is needed to clarify any clinical benefits.

The limitation to our project is that we are a local neonatal unit, which means that we mainly receive infants born between 27 to 33 weeks’ gestation. Therefore, units that deal with infants at or below 26 weeks’ gestation might have a different experience. However, we have had infants born by emergency c-section at 26 weeks who managed to receive full 60 seconds of DCC. Hence, applying the new approach will be still useful to provide at least 30 seconds of DCC while allowing time to properly assess infants before clamping the cord. Having the neonatologist scrubbed-in in theatres is useful so that those infants who will cry or start to breathe will have appropriate support during the 60 seconds of DCC. This involves making sure that they are placed in a sterile plastic bag, supporting their airway and keeping it in neutral position to avoid occlusion.

The greater challenge will be performing DCC for those infants who are born in poor condition and do not respond to adequate stimulation and airway positioning. This will require increased effort to establish. It might be necessary to move the resuscitaire to be close to the mother if feasible, or to use a mobile resuscitaire. Training sessions and simulations are essential for implemenation. Developing a local guideline is essential. Parents would ideally be informed before birth, as resuscitation will take place near the mother while the cord is still intact. Therefore, a patient information leaflet may be useful.

How this project might affect practice or policy

Our project encourages neonatologists to avoid immediate cord clamping even for infants who do not cry immediately after birth. We suggest starting the NLS algorithm by placing the infant in a plastic bag, providing deliberate stimulation with optimal positioning of the airway, maintaining neutral position for the first 30 seconds. Then assess improvement and whether DCC can be completed for 60 seconds or whether resuscitation is required and then to proceed accordingly (except when DCC is contraindicated, eg placental abruption, snapped cord). If heart rate can be maintained during the transitional period, these infants can be offered 60 seconds of DCC.

Conclusion

Implementation of any perinatal optimisation intervention needs collaborative effort from the neonatal and maternity MDT. Additionally, simple methods such as proper clinical assessment and provision of appropriate initial steps of the NLS algorithm can be helpful in deferring cord clamping in infants presumed in need of resuscitation, but actually just need support with transition, in contrast to those who actually need cord clamping and resuscitation.