Available online 19 April 2024, 151905

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Delayed 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.

Section snippetsBackground

Delayed cord clamping (DCC) has been widely studied in the last five decades and has been shown to be beneficial in both term and preterm infants.1, 2, 3, 4, 5 Studies in term infants have shown that DCC is associated with higher oxygen saturations in the first 5 minutes of life, higher blood pressure, higher hemoglobin level at 24-48 hours, higher iron stores at 3-6 months, improved brain myelination at 4 and 12 months of life, and higher scores in fine motor and social domains at 4 years.2,6

Successful QI Efforts Targeting Optimal Cord Management

Recognizing that implementing DCC is not a simple task, several teams have reported on their QI experiences and successes.32, 33, 34, 35, 36, 37 We have summarized a number of published initiatives implementing DCC in Table 1 A/B. The six QI initiatives described in Table 1 A/B have occurred in various settings including in the United States and Internationally. These studies include both single center and multi-institution, collaborative QI efforts. Each QI report documented improvements in

Key Elements of Successful QI Efforts to Implement DCC

Implementation of an evidence-based approach to umbilical cord management requires a systems approach and benefits from rigorous application of QI methods including multidisciplinary team collaboration, development of a theory for change, standardization through protocol development, adoption of proven implementation strategies, and robust outcome and balancing measurements.39 In the sections below, we highlight key elements for the successful implementation of DCC based on lessons learned from

Data Collection

Adequate real time documentation and ease of data collection for DCC is necessary to evaluate the implementation and effects of DCC. The delivery summary of the electronic health record (EHR) should have a dedicated area for documentation of the different cord management strategies, including DCC duration, reasons for not performing DCC, UCM, timing of onset of respirations, and the first steps of resuscitation during DCC. Figure 4 demonstrates an example screenshot of the delivery summary in

Conclusion

Based on the current evidence, multiple professional organizations recommend optimal umbilical cord management in the delivery room. Increasing number of institutions have adopted DCC; however, there is significant room for improvement. Key elements of a successful QI effort targeting optimal cord management include, 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

Disclosure

The authors report no financial, proprietary or commercial interest in any product mentioned or concept discussed in this article or personal relationships with other people or organizations that could potentially and inappropriately influence (bias) their work and conclusions.

Acknowledgements

Gratitude is expressed to our patients and families and for the dedicated staff at Santa Clara Valley Medical Center neonatal intensive care unit and labor and delivery, and Santa Clara County First Five and Valley Medical Center Foundation. We are grateful to Dr. Balaji Govindaswami, MBBS, MPH and Dr. James Byrne, MD for their leadership in implementing delayed cord clamping starting in 2007 and for Claudia Flores, BA for bibliography support.

References (54)NE Vain et al.Effect of gravity on volume of placental transfusion: a multicentre, randomised, non-inferiority trial

Lancet

(Jul 19 2014)

H Rabe et al.Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes

Cochrane Database Syst Rev

(2019)

SJ McDonald et al.Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes

Cochrane Database Syst Rev

(Jul 2013)

Americn College of Obstetrics et al.Delayed Umbilical Cord Clamping After Birth: ACOG Committee Opinion, Number 814

Obstetrics and gynecology

(Dec 2020)

AL Seidler et al.Umbilical Cord Management for Newborns <34 Weeks' Gestation: A Meta-analysis

Pediatrics

(Mar 2021)

J Gomersall et al.Umbilical Cord Management at Term and Late Preterm Birth: A Meta-analysis

Pediatrics

(Mar 2021)

O Andersson et al.Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age: A Randomized Clinical Trial

JAMA Pediatr

(Jul 2015)

JS Mercer et al.Effects of Placental Transfusion on Neonatal and 18 Month Outcomes in Preterm Infants: A Randomized Controlled Trial

J Pediatr

(Jan 2016)

L Armstrong-Buisseret et al.Randomised trial of cord clamping at very preterm birth: outcomes at 2 years

Archives of disease in childhood Fetal and neonatal edition

(May 2020)

OMC Carvalho et al.Late umbilical cord clamping does not increase rates of jaundice and the need for phototherapy in pregnancies at normal risk

The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstet

(Nov 2019)

O Andersson et al.Effects of delayed compared with early umbilical cord clamping on maternal postpartum hemorrhage and cord blood gas sampling: a randomized trial

Acta Obstet Gynecol Scand

(Aug 2012)

SE Purisch et al.Effect of Delayed vs Immediate Umbilical Cord Clamping on Maternal Blood Loss in Term Cesarean Delivery: A Randomized Clinical Trial

JAMA

(2019)

A Chiruvolu et al.The effects of placental transfusion on mothers

The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstet

(Dec 2022)

C Salcido et al.Maternal bleeding complications and neonatal outcomes following early versus delayed umbilical cord clamping in cesarean deliveries for very low birthweight infants

Journal of perinatology: official journal of the California Perinatal Association

(Jan 2023)

AC Katheria et al.Placental transfusion: a review

Journal of perinatology: official journal of the California Perinatal Association

(2017)

H Al-Wassia et al.Efficacy and safety of umbilical cord milking at birth: a systematic review and meta-analysis

JAMA Pediatr

(Jan 2015)

A Jeevan et al.Umbilical cord milking versus delayed cord clamping in term and late-preterm infants: a systematic review and meta-analysis

The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstet

(Dec 2022)

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