So this blog comes a little delayed. As you know COVID and all its associated factors have become all-consuming time zappers, to state the least!
I am thrilled to share the latest BAPM and NNAP Quality Improvement Toolkit 'Optimal Cord Management in Preterm Babies'.
This document recognises the significant harms associated with the continued use of the unindicated intervention of early cord clamping. It also fulfils the current void in practical guidance for perinatal professionals wanting to make service and safety improvements using optimal cord clamping.
Let's remember that early cord clamping increases neonatal mortality by 28% in preterm infants! (Fogarty et al, 2018)
This work feeds into national UK quality workstreams such as the 'Maternity and Neonatal Safety Improvement Programme' (MatNeoSIP) in England, and the 'Maternity and Children Quality Improvement Collaborative-Scottish Patient Safety Programme' (MCQIC-SPSP) in Scotland and is aligned with the 'Saving Babies’ Lives Care Bundle' (SBLCB v2).
What is the meaning of Optimal Cord Management?
This quality improvement toolkit focusses on Optimal Cord Management defined by waiting for a minimum of 60 seconds before clamping the cord in preterm infants.
"But shouldn't that already be happening?" I hear you say...
As you know, delayed cord clamping was first advocated as best practice internationally sometime ago (WHO, 2014). However, as explained in the toolkit, statistics demonstrate poor uptake of the recommendations in many areas worldwide, including the UK, this leaving many preterm babies vulnerable to harm.
What's in the toolkit?
The toolkit provides users with a framework to undertake quality improvement within the workplace. Crucially the toolkit contains evidence, best practice solutions, advice and techniques that support quality improvement in 'Optimal Cord Management' for all babies who are likely to benefit from this practice. It helps define enablers and barriers to implementation and facilitates the embedding of Optimal Cord Management into perinatal team culture in order to achieve the aim of less babies being harmed by immediate cord clamping.
The toolkit is well structured with clear graphics and diagrams to aid comprehension of quality improvement processes. This is an example of what might be considered a best practice flowchart from the toolkit. Units may choose to adapt this to support their improvement activity or as a process flowchart to aid staff understanding.
What about physiological transition with an intact cord?
The toolkit discusses observations on the physiologic onset of breathing at birth and state:
"Proponents of physiological-based cord clamping oppose the idea of any time-based cord clamping and favour a baby-led approach, where the timing of cord clamping is determined by the behaviour and onset of spontaneous respiration of the baby as well as waiting for cord pulsations to cease. Until this debate has been resolved, we propose to adhere to the WHO guidance of using a minimum interval of one minute for deferring cord clamping."
BloodtoBaby supports physiological transition with an intact cord until the neonate has made it's transition to extra-uterine life. The benefits of this have been cited in a large amount of research articles (see BloodtoBaby research page).
That said, a pragmatic approach considering local resources, staff education and sustainability are important factors to consider when advocating for widespread change. Indeed, it is clear to see, the toolkit includes consideration for the use of bedside resuscitaires. This change in practice is likely to take time, as many services will wait for standard resuscitaires to become obsolete before considering bedside trolleys. I would argue that this is a very short sighted cost saving view, when the iatrogenic harm of immediate cord clamping intervention costs the NHS much more!
The toolkit also discusses the evidence for routine stabilisation with the cord intact (mother-baby dyad intact) where research reports favourably on feasibility and safety (Brouwer et al., 2018; Duley et al., 2018).
The toolkit goes a long way towards starting to change the narrative towards physiological transition with an intact cord. I am hopeful that it won't be too long before bedside stabilisation becomes more widely practiced at neonatal resuscitation (awaiting stronger recommendation and updates from NLS guidance).
A fantastic resource
This toolkit will no doubt support change in practice for the most vulnerable neonates, recognising the evidence based practice of optimal cord management as critical to improving preterm outcomes.
I particularly recommend the section 'understanding barriers and enablers of practice and finding solutions' which suggests the use of various QI tools during the change initiative. Here is one example below:
Given the statistics presented in the recent perinatal mortality MBRRACE report (2020) where almost three-quarters of both stillbirths and neonatal deaths were for preterm births (<37 weeks gestational age): 75% and 71% respectively. This quality improvement toolkit will contribute to the continued drive to reduce mortality rates.
I urge quality improvement leads, doctors, midwives and neonatal practitioners to consider a local change management project for optimal cord management within your places of work, particularly where audits highlight improvements are needed. It takes just one person with enterprise and passion to get the ball rolling and the toolkit will help you gain support of other stakeholders.
This toolkit is a valuable and comprehensive, practical step by step guide to support multidisciplinary perinatal teams in improving compliance to improve outcomes for preterm babies. Let's make sure the hard work and effort that went into the toolkit is utilised. Please visit the BAPM website for further information, access to the full toolkit, the case reporting tools, evidence and education slides.
Brouwer E, Knol R, Vernooij ASN, et al. Physiological-based cord clamping in preterm infants using a new purpose-built resuscitation table: a feasibility study. Arch Dis Child Fetal Neonatal Ed 2019;104(4):F396-f402. doi: 10.1136/archdischild-2018-315483 [published Online First: 2018/10/05]
Duley L, Dorling J, Pushpa-Rajah A, et al. Randomised trial of cord clamping and initial stabilisation at very preterm birth. Arch Dis Child Fetal Neonatal Ed 2018;103(1):F6-f14. doi: 10.1136/archdischild-2016- 312567 [published Online First: 2017/09/20] 19.
Fogarty M, Osborn DA, Askie L, et al. Delayed vs early umbilical cord clamping for preterm infants: a systematic review and meta-analysis. Am J Obstet Gynecol 2018;218(1):1-18. doi: 10.1016/j.ajog.2017.10.231 [published Online First: 2017/11/04]
WHO Guideline: Delayed Umbilical Cord Clamping for Improved Maternal and Infant Health and Nutrition Outcomes Geneva: World Health Organization. Copyright © World Health Organization 2014.