National variation in delayed cord clamping implementation – A survey of the challenges in universal adoption of DCC in the United Kingdom

Background

The umbilical cord may retain 30% of circulating foetal blood volume. Allowing the cord to pulsate prior to clamping allows up to two thirds of this to re-enter the neonatal circulation. ¹ Delayed cord clamping has a direct impact on preventing early infantile anaemia by facilitating placental transfusion. ² Delaying cord clamping by at least 60 seconds after birth has been associated with increased birthweights, increased haemoglobin concentrations at 24–48 hours and increased iron stores at 3–6 months reducing iron micro deficiency which can result in abnormal neurobehavioural processing and poor memory and school performance.^3–6 A 2018 systematic review (2834 infants, 18 trials) provided high-quality evidence that delaying cord clamping in preterm infants by 60 s reduces mortality (RR 0.69, 95% CI 0.52–0.91, p = 0.009). ⁷ Additionally, it was shown that preterm infants who receive placental transfusion have decreased rates of sepsis, necrotising enterocolitis and decreased incidence and severity of intracranial haemorrhage.^8–11 In addition, placental transfusion increases availability of umbilical cord stem cells which may have long term benefits against age related diseases.^8–12 Preterm infants require more time to establish breathing than term infants making it more important that breathing is supported in these infants prior to clamping the cord. ¹²

The WHO has endorsed delaying cord clamping by 1–3 minutes for all births with simultaneous essential newborn care in 2014. ¹³ Subsequently in 2016, the RCOG recommended delaying clamping the cord for both preterm and term babies if there was no concern over baby’s wellbeing or placental integrity. ¹⁴ Both European and International Consensus guidelines now recommend delayed cord clamping (DCC) for preterm infants.^15–17

Pilot studies have shown that resuscitation with an intact cord is feasible for term sick newborns born by Caesarean section.^4–6 The UK pilot trial has also demonstrated feasibility of delaying cord clamping in preterm infants which account for a global burden of fifteen million births annually.^18,19

Delaying cord clamping in sick preterm and term infants has posed logistical challenges in practice. The implementation of DCC globally is still variable for term infants but particularly so for preterm infants or sick term infants requiring resuscitation. Even though DCC is significantly associated with reduced RBC transfusion, fewer preterm infants received DCC. ²⁰ In a French survey (350 midwives) 34.3% reported always or sometimes performing DCC in term infants. ²¹ A European survey (262 centres/33 countries) showed that <50% of centres practice DCC for preterm infants <1500 g with similar findings in United States, Sweden, Australia, New Zealand, and China supporting our findings.^22–26

A recent survey in low- and middle-income countries by Payne et al showed that while 60% (42/70) of the participants practiced DCC in stable preterm infants only 4(6%) reported DCC implementation in infants born in poor condition or requiring stabilisation. ⁷ The NNAP showed a performance of 60% in 2022.

Despite high-quality evidence, the implementation from research to bedside continues to be slow. There are numerous factors that need consideration when determining why an implementation succeeds or fails. Most studies addressing the implementation of DCC in this subgroup have considered the characteristics of users, context and strategies of implementation mainly using quality improvement methodologies.^8,15,27,28 Our survey has aimed to explore the healthcare ergonomic aspects that may be hindering adoption.

Methodology

The primary aim of this survey was to understand national variations in the practice of DCC particularly in the context of sick preterm and term infants. Our secondary aim was to interrogate what equipment was being used and the challenges it posed. The survey questions were user assessed for clarity prior to disseminating the survey. Neonatal units covering a wide geographic area were contacted and asked to provide the email contact of the most appropriate member of staff. A survey link and a word copy of the questionnaire were sent. The survey was also disseminated via social media platforms. Non-responders were directly contacted by telephone.

Results

Our responses covered a wide geographic area. (Figure 1) The survey responders included Neonatal/Paediatric consultants and trainees, advanced neonatal nurse practitioners, neonatal nurses, midwives, and obstetricians (Figure 2(a)).OPEN IN VIEWER

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Figure 2.

(a) Job role of respondents and (b) level of units taking part in the survey.

We had 58(50%) responses from Level 3 NICUs, 51(44%) from Level 2, and 7(6%) from Level 1 units (Figure 2(b)). Of the 116 responses, 90(78%) said their method of applying DCC does not allow them to undertake complex cord intact resuscitation. While 103(89%) respondents would abandon DCC in this setting, 13 (11%) said they would continue DCC and resuscitate later (Figure 3(a)). We had 113 responses to the question ‘Do you apply DCC in your practice?’ Although all but 1 respondent said they implemented DCC in their hospital, 30% (34) respondents said they only apply DCC for stable term babies. The remaining 70% implement DCC for both preterm and term stable babies (Figure 3(b)). Of 111 respondents, 23 (21%) said they implemented cord intact stabilisation for planned deliveries, while only 3 (3%) implemented it in emergency scenarios. 79 (71%) of respondents undertaking cord intact stabilisation use the Lifestart TM trolley, 29% (31) use the standard resuscitaire while one respondent identified using the maternal bed as a platform for planned (Figure resuscitation/stabilisation (Figure 3(c)). Respondents highlighted several challenges when using Lifestart TM trolley particularly the lack of familiarity with its use, need for advance planning and ineffective heating surface (Figure 4). When asked how the ideal equipment would differ from the current available equipment, respondents identified the importance of better space saving qualities allowing easier access to mother, a lighter and easier to carry device, larger size gas cylinders, t piece compatibility, better heating ability, and more intuitive usability (Figure 5). 55.7% (44/79) of respondents using Lifestart TM highlighted having to make device modifications to be able to use it effectively. Majority of respondents identified the need for training, teamwork, greater awareness and buy in from obstetric and midwifery colleagues as enablers of widespread DCC adoption.OPEN IN VIEWER

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Figure 4.

Number of respondents highlighting difficulties with the use of Lifestart TM Resuscitaire.

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Figure 5.

Survey respondents wish list for ideal resuscitation/stabilisation equipment.

Discussion

Embedding new practice needs to target the continuum of diffusion-dissemination and practical implementation. Implementation depends on several factors including acceptability and feasibility. ²⁹ Despite the high-quality evidence and the endorsement of global organisations with incorporation into local guidelines and protocols, it is evident that implementation and sustainability of DCC continues to be poor. ²⁷ Several studies have highlighted that concerns over an unwell baby and need to hand over to the neonatal team are a common reason for not delaying cord clamping. It is understandable that it is difficult to maintain equipoise in these situations and that resuscitation takes precedence. In line with this, the NLS (RCUK) guidance states that for infants requiring resuscitation, resuscitative intervention remains the immediate priority.^16,30,31 Approximately 10 % of infants born at or near term require tactile stimulation to begin breathing, while 3 % will require respiratory support such as bag valve-mask ventilation often unexpectedly. ³² In the case of unexpected need for resuscitation, 97% of our respondents said they would abandon DCC.

Emerging evidence suggests that for infants born requiring resuscitation providing this with the cord intact is beneficial. ³³ Seventy-eight percent of our respondents said that their method of applying DCC does not allow them to undertake complex resuscitation in any setting. While 103(89%) respondents would abandon DCC in favour of resuscitation, 13 (11%) said they would continue DCC and resuscitate later. There is convincing evidence that preterm infants with low Apgars or needing resuscitation at birth have higher rates of mortality, NEC and IVH.^34,35 These infants are thus being denied the benefits DCC has on these outcomes.

A substantial proportion of well preterm infants will need stabilisation with respiratory support in the first minutes after birth to satisfactorily undergo postnatal stabilisation.^36,37 Our survey highlighted that 70% of respondents said that while they practice DCC for stable preterm and term babies, only 21% undertake cord intact stabilisation suggesting that the majority of respondents are either implementing DCC only for term and late preterm infants who do not require airway support or delaying effective PEEP for preterm infants who are born breathing spontaneously. For preterm infants born breathing spontaneously the benefits of early PEEP for the establishment and maintenance of an early functional residual capacity are well established. ³⁷

The major challenge in providing cord intact stabilisation/resuscitation are spatial limitations for maternity and neonatal teams working next to birth canal. The Lifestart TM trolley, a compact resuscitative device, is often used for planned preterm stabilisation. However due to its need for advance planning, complex draping method, and need for a power supply which may not be immediately available it is challenging to use in unplanned emergencies. ⁴

Challenges in the use of the Lifestart and its cost led to improvised ways of delivering DCC raising safety concerns.^3,15 In planned preterm Caesarean sections, one method involves placing a trans warmer on maternal legs. This does not provide a stable surface to ensure effective airway management in non-breathing infants. Effective ventilations are difficult to perform, and a suboptimal technique may result in an insufficient clinical response in the infant. ³⁸

Even for the 71% of respondents purchasing Lifestart, 55.7% needed to make modifications to it including connecting additional respiratory equipment or bigger cylinders, raising safety concerns. Some units have abandoned Lifestart use over the ‘maternal leg’ method.

Only one respondent in our survey said they use the maternal bed as a resuscitation platform. The Swedish SAVER study explores this for babies born vaginally. ³ The challenges here are spatial limitations and soiled linen predisposing baby to hypothermia.

For well term babies, although a high percentage of units apply DCC, this is done by lifting baby on mother’s chest. There is evidence that raising/lowering baby 15–20 cm may influence placental transfusion, the impact of which on neonatal outcomes is unclear.^39,40

Our findings imply that DCC is not being implemented in sick infants that could benefit the most. In well preterm infants’ implementation may be suboptimal potentially negating early effective resuscitative measures such as early PEEP and lung expansion or exposing infants to safety hazards. ³⁴

Our survey highlights the ergonomic adoptability challenges in different settings in the United Kingdom. It covers a wide geographic area and demonstrates variability in practice among front line staff in line with findings in other countries. It clearly highlights that babies born unexpectedly sick or those needing more complex airway support are not receiving delayed cord clamping. As new evidence emerges on the importance of physiological cord clamping the need to provide more complex stabilisation with cord intact will become paramount.

The challenges of adopting delayed cord clamping in extreme preterm and sick infants while undertaking full stabilisation/resuscitation remain unaddressed. Respondents have identified more awareness and buy in from obstetric and midwifery teams, teamworking, and training as crucial factors in improving DCC practice, but that there were significant challenges with the device most used. We argue that implementing new methods needs to address not just the attitudes and professional behaviour, but also the health care service itself, in particular the efficiency and safety of the process. ³

Development of protocols, targeted education, and multidisciplinary team training through simulation on their own are not enough to overcome the practical issues and ensure universal adoption. The feasibility, acceptability, safety, and practicality of the equipment and its integration into the clinical process are necessary for the team to feel empowered to adopt the procedure. Thus, any research should look at the ergonomic implications for health care staff while attending to both mother and baby in proximity. It should also address the readiness of application even in the event of infants born unexpectedly sick. Such methods should be tested for adaptability to different environments.

For learning and consolidation of human practice, standardisation is key. Adopting a universal safe approach that is feasible in different settings will be necessary for improving adoption nationally and globally. Any implementation process must pair with equipment that is safe to both infant and mother and tested extensively with front line users. Our respondents highlighted the desirable features in an ideal equipment particularly transportability.

Research and innovation should aim to marry ergonomic needs of such devices while at the same time delivering these desirable features. It may be that we will not succeed in this using the current set up and need to be more creative in facilitating this transition safely.

Conclusion

There continues to be significant variations in the practice of implementing DCC in preterm infants and sick term infants who require stabilisation and resuscitation. Current devices on market pose significant challenges. There is a need for ergonomic research for a device that integrates well into the clinical process within different hospital settings and birth scenarios to standardise the process. This will allow consolidation of practice and universal adoption.

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