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A campaign re-born

Physiological transition of the newborn with optimal cord clamping

Hannah Tizard – Midwife at Blackpool Teaching Hospitals NHS Foundation Trust and Midwifery Media Consultant at All4Maternity and The Practising Midwife

This blog post provides an update about the progress and validity of the #BloodtoBaby campaign.  Progress is evolutionary and whilst continuing to promote optimal cord clamping for newborns, focus also considers how practice can be improved in other areas;

  • delayed cord clamping and cord milking at cesarean section
  • optimal cord clamping at instrumental deliveries
  • optimal cord clamping to reduce preterm mortality
  • resuscitation with an intact cord

Hence the new title which encompasses all of the above; physiological transition of the newborn with optimal cord clamping. Today I want to focus on optimal cord clamping at instrumental deliveries and resuscitation with an intact cord.


Continued efforts

The #BloodtoBaby campaign, facilitated by sponsor Inspiration Healthcare continues to be a huge success with over 18K resources printed and delivered free of charge, to individuals across the world, including Australia, New Zealand, Sweden, India and Palestine. The campaign has and continues to support changes to the practice of immediate cord clamping.

UK NICE guidelines now recommend delayed or optimal cord clamping, so some people question why a campaign like this is necessary. The answer is fairly straightforward:

Change to practice takes time

In February 2018 Tommy’s reported on a survey completed by The Positive Birth Movement. The survey questioned over 3500 women and families which highlighted that many clinicians are not waiting for the recommended 1-5 minutes before clamping the umbilical cord, contrary to guidance from NICE and consequently

40% of UK babies are not having delayed/optimal cord clamping.


Case study example – optimal cord clamping at instrumental delivery

Student midwives continue to report that delayed/optimal cord clamping is not happening in practice.

Recently qualified midwife Gemma Dickinson used her degree dissertation module to complete ‘An audit to assess the rates of deferred cord clamping in a central London Trust Hospital and to explore whether factors surrounding birth may impact on timing of cord clamping’. As a consequence she made a poster highlighting the need for practitioners to consider delayed/optimal cord clamping particularly at instrumental deliveries.

Click poster for free PDF download #BloodtoBaby

Gemma comments:

“As a 2nd year student midwife in 2016, I was captivated by Amanda Burleigh and her presentation on optimal cord clamping at King’s College University. I started to become silently outraged at the endless births I witnessed with early cord clamping when on placement, especially at instrumental deliveries. Whenever I asked doctors after instrumental births why they didn’t leave the cord to pulsate when the newborn didn’t need resuscitation, I was greeted with rolling eyes and patronising, feeble excuses. In January 2017 we were given a Public Health assignment to create a poster to display in hospitals, reminding staff of a key issue regularly being forgotten in practice. Naturally I jumped at the idea and created this poster. After wonderful feedback from my hospital and university, I went on to do an audit on cord clamping for my 3rd year dissertation. The Hospital is keen to act upon my significant results and plans are being set in place to develop a local cord clamping guideline, change the hospital computer documentation system and arrange education for the staff! My poster is currently being copied and laminated and I can’t wait to see it displayed.. more importantly I can’t wait to see more and more beautiful umbilical cords left to pulsate.”

Resuscitation with an intact cord

Optimal cord clamping for all babies is the fundamental aim of the #BloodtoBaby campaign and this includes those babies born needing resuscitation at birth. In clinical practice, discussion about newborn resuscitation with an intact cord is fairly infrequent, sometimes contentious, however the evidence to support it is mounting.

New study:

Delayed Cord Clamping in Newborns Born at Term at Risk for Resuscitation: A Feasibility Randomized Clinical Trial by Katheria, A., Brown, M., Faksh, A., Hassen, K., Rich, W., & Lazarus, D. et al. (2017). The Journal Of Pediatrics, 187, 313-317.e1.

Helping to expand knowledge base and understanding in this area (other studies provided as references at the end), this randomised clinical trial suggests infants may benefit if resuscitation could be provided with an intact umbilical cord. Infants identified at risk for resuscitation were randomised to 1- or 5-minute cord clamping. The 5-minute group had greater cerebral oxygenation and blood pressure. The authors acknowledge that further studies are needed to determine whether this translates into improved outcomes over the long term.

As with all change comes challenge. These need to be examined. Indeed lack of appropriate resources in an already underfunded NHS may cause frustration to those seeking to make early change in line with evidence. Bedside resuscitation trolleys such as the LifeStart are priced attractively to compete with traditional stand alone resuscitaires, however there will, for some Trusts, be a long wait for the old models to be discontinued before new improved models can be purchased.

These images are provided by © 2018 Katheria, Sorkhi, Hassen, Faksh, Ghorishi and Poeltler and demonstrate positioning of the bedside resuscitaire, which can be used in any number of positions, two shown below. Their study was focused in an obsteric led hospital setting in the US where vaginal birth is tended to by an obstetrician in lithotomy. Indeed we know that this is not optimal for the birth of the baby, but that’s another issue.

The same principals can be applied to birth centre and home birth settings where a bag and mask resuscitation can occur ensuring physiological transition with an intact cord.

In respect of the clinical challenges to bedside resuscitation, practitioners describe concerns about:

  • Short cords
  • Poor access to the baby
  • Accessing necessary equipment
  • Uncomfortable with parents watching

These concerns are highlighted in

Katheria, A., Sorkhi, S., Hassen, K., Faksh, A., Ghorishi, Z., & Poeltler, D. (2018). Acceptability of Bedside Resuscitation With Intact Umbilical Cord to Clinicians and Patients’ Families in the United States. Frontiers In Pediatrics6

In this study about 50% of neonatal providers, including obstetricians, expressed some concerns regarding sub-optimal access to the baby and adverse impact on the delivery of care. It is postulated that these issues can be easily rectified with appropriate space design and adequate training for all clinical staff.

It is important to highlight that the challenges faced by practitioners should not be used as justification for not providing optimal cord clamping for all neonates, particularly those most at risk. Given all the evidence of the benefits of delayed cord clamping, the bedside resuscitaire seems to provide the highest standard of care in an obstetric setting.

The responses from parents were much more positive, most parents were able to see and make contact with their baby in the first few minutes of life. All parents had positive impression of both resuscitation at bedside and on a radiant warmer. No parent felt uncomfortable with neonatal interventions being provided at bedside. They also perceived that their close proximity improved communication.


Case study example – optimal cord clamping for all

Trusts such as Northumbria Specialist Emergency Care Hospital in Cramlington; a medium sized consultant led unit have been facilitating optimal clamping for all, including bedside resuscitation since 2009. Their audit review provides a leading case study example demonstrating improved neonatal outcomes, decreased need for resuscitative measures at birth and reduced admissions to the neonatal unit since implementation of delayed cord clamping for all.

Some of the secrets to the successful implementation of this included, having an experienced midwife of neonatal practitioner attend every birth to advocate for the baby and for optimal cord clamping, that allowing for normal physiological transition, most babies will resuscitate themselves. Those that do need additional support can be managed on a specially designed Lifestart resuscitaire, of which there is one in every birth room. In order to ensure the change in practice becomes embedded actions to ensure junior staff and trainee doctors are reminded at induction.


An in depth look…

David Hutchon is a retired Obstetrician and Gynaecologist. His research investigating the true effect of prematurely closing the placental circulation with a cord clamp is extensive and seminal. Please see this informative powerpoint presented at the 4th International Neonatal Conference in Poland, 2016 from Professor Hutchon.

Can we do resuscitation on intact cord – David Hutchon 2016

Moving forward with the evidence

This is a perfect time to highlight that the #BloodtoBaby website has had a revamp. I have worked tirelessly on this over the past few weeks and I’m really pleased with the results. Here are some of the new features:

Over and out – Hannah x

References

Batey, N., Yoxall, C., Fawke, J., Duley, L., & Dorling, J. (2017). Fifteen-minute consultation: stabilisation of the high-risk newborn infant beside the mother. Archives Of Disease In Childhood – Education & Practice Edition102(5), 235-238. http://dx.doi.org/10.1136/archdischild-2016-312276

Finn, D., Roehr, C., Ryan, C., & Dempsey, E. (2017). Optimising Intravenous Volume Resuscitation of the Newborn in the Delivery Room: Practical Considerations and Gaps in Knowledge. Neonatology112(2), 163-171. http://dx.doi.org/10.1159/000475456

Fulton, C., Stoll, K., & Thordarson, D. (2016). Bedside resuscitation of newborns with an intact umbilical cord: Experiences of midwives from British Columbia. Midwifery34, 42-46. http://dx.doi.org/10.1016/j.midw.2016.01.006

Katheria, A., Brown, M., Faksh, A., Hassen, K., Rich, W., & Lazarus, D. et al. (2017). Delayed Cord Clamping in Newborns Born at Term at Risk for Resuscitation: A Feasibility Randomized Clinical Trial. The Journal Of Pediatrics187, 313-317.e1. http://dx.doi.org/10.1016/j.jpeds.2017.04.033

Katheria, A., Sorkhi, S., Hassen, K., Faksh, A., Ghorishi, Z., & Poeltler, D. (2018). Acceptability of Bedside Resuscitation With Intact Umbilical Cord to Clinicians and Patients’ Families in the United States. Frontiers In Pediatrics6. http://dx.doi.org/10.3389/fped.2018.00100

Lefebvre, C., Rakza, T., Weslinck, N., Vaast, P., Houfflin-debarge, V., Mur, S., & Storme, L. (2017). Feasibility and safety of intact cord resuscitation in newborn infants with congenital diaphragmatic hernia (CDH). Resuscitation120, 20-25. http://dx.doi.org/10.1016/j.resuscitation.2017.08.233

Thomas, M., Yoxall, C., Weeks, A., & Duley, L. (2014). Providing newborn resuscitation at the mother’s bedside: assessing the safety, usability and acceptability of a mobile trolley. BMC Pediatrics14(1). http://dx.doi.org/10.1186/1471-2431-14-135

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