Resuscitation and Delayed Cord Clamping; a reflection

I'd like to introduce Aster Purdey and her beautiful snuggly sling wrapped baby who I recently met at the RCM conference 2018. Aster is a second year midwifery student at the University of Cumbria, currently on maternity leave.  She is passionate about midwifery and feminism, with a specific interest in promoting physiological birth and home birth.

At the RCM our conversations led to resuscitation with an intact cord, we shared a fascination with physiology and how it makes sense to protect the newborn from the harms of immediate cord clamping at such a vulnerable time. Aster told me she'd written a reflection about it and I asked her if she'd share it with us... and she didn't disappoint. Thank you Aster xxx

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This reflection is about delayed cord clamping (DCC) in infants who are born requiring resuscitation. Critical reflection is a useful technique to bridge the gap between theoretical knowledge and clinical practice (Horton-Deutsch and Sherwood, 2008), enabling students to broaden their understanding of a situation from different personal, empirical and ethical perspectives (Johns, 1995). 

The reflection is structured using Bower’s Reflective Model (2015) (See Appendix A). I chose this model because it is designed to encourage exploration of a topic from multiple perspectives (Bowers, 2015), which is fundamental to critical reflection (Hatton and Smith, 1995). I have adapted the model by removing the second and final questions as I did not feel it was relevant to this reflection.

What happened?

Images are for visual learning only and not related to the reflection

I was working on labour ward when a primiparous woman was transferred from maternity ward due to a concerning cardiotocography (CTG) trace. The decision was made by the obstetric registrar to perform a Grade 2 caesarean section and a paediatrician was requested to attend. At delivery there was thick meconium stained liquor present, and the neonate was born with reduced tone, centrally cyanosed and made no initial respiratory effort. The obstetrician clamped and cut the cord immediately at delivery and the baby was subsequently taken to the resuscitation area and given inflation breaths, followed by ventilation breaths and oxygen.  

Why is it important to analyse this event? 

DCC refers to the intentional delay between the birth of a baby and the clamping of the umbilical cord, the duration being for at least one minute or until the cord stops pulsating (Burleigh and Uwins, 2018; Katheria et al. 2018). Robust evidence indicates that DCC has multiple physiological benefits for healthy term and pre-term infants (Andersson, et al. 2011; Rabeet al. 2012; Mercer and Erikson-Owens, 2014; McDonald et al. 2013) (see Appendix B), whilst immediate cord clamping (ICC) is associated with the harmful effects of hypoxia, hypovolaemia, a sudden drop in cardiac output and anaemia (Bhatt et al. 2013, Rabe et al. 2012, McDonald et al. 2013). Considering these associated risks, it is important to develop knowledge concerning the physiological impact that ICC has on compromised infants (Wylie et al., 2015). This will better facilitate a process of informed choice for parents, which is equally important during obstetric emergencies as in other aspects of care (Treharne and Beattie, 2015).

Analysis of the event with supporting literature/research

The National Institute of Clinical Excellence (NICE), the Resuscitation Council (UK), the World Health Organisation (WHO) and the Royal College of Obstetricians and Gynaecologists (RCOG) recommend the routine practise of DCC for healthy term and pre-term infants at birth (NICE 2017, Wyllie et al. 2015, WHO, 2012; RCOG, 2015). However, the benefits to practising DCC when neonates require resuscitation are less clear; there have been no large randomised controlled trials (RCTs) (Katheria et al. 2018).

Local Trust Guidance (2015), the Resuscitation Council (Wylie et al. 2015) and the Practical Obstetric Multi-Professional Training (PROMPT) Maternity Foundation (PMF) (2017), state that there is insufficient evidence to define an appropriate time to cut the cord in compromised neonates. WHO (2012) also take this stance.

However, they remark that this as a weak recommendation and state that ventilation can be initiated in compromised neonates before clamping the cord, if the attending practitioner has experience of this practice.

The ambiguity in WHO’s position may have been influenced by several small studies which have indicated benefits to the practise of intact cord resuscitation (ICR) (Bhatt et al. 2013; Mercer et al. 2008; Mercer and Erikson-Owens, 2012).

None of the key stakeholders directly refer to the available evidence on the practise of ICR. Therefore, I carried out my own search of the relevant literature.

Katheria et al. (2017) have carried out a pilot RCT to assess the feasibility of a larger RCT on the topic. 60 infants > 37 weeks gestation identified as at risk of requiring resuscitation were randomised to receive 1 minute or 5 minute DCC. Neonatal outcomes were compared between the two groups through a series of clinical measurements taken 12 hours post-delivery. The results found a trend for less resuscitation and improved Apgar scores in the 5-minute DCC group. They further found an association with improved haemodynamics by 12 hours of life in the 5-minute DCC group. The authors also concluded that 5 minute DCC could be carried out safely without compromising the provision of neonatal resuscitation (Katheria et al. 2018).

However, the research is limited; the results cannot be generalised and used as evidence to change current practice due to the small sample size. A larger sample size may also enable the exclusive comparison of those infants that were resuscitated, rather than including the infants that did not require resuscitation in the analysis. This would improve the validity of the results. Secondly, neonatal tests and observations were only carried out once at 12 hours; continuous measurements over a time frame would improve the reliability of the results. Overall the study does demonstrate that a larger RCT would be feasible to carry out, which is an important finding considering that NICE (2017), WHO (2012) and RCOG (2015) all recommend further research to improve clinical guidelines.

Research has also been carried out to explore the physiological effects of ICC compared with DCC in the compromised neonate. This is necessary to identify potential risks associated with either procedure. Bhatt et al. (2013) have carried out a study on 12 pre-term lambs investigating the physiological effect of DCC until ventilation had been initiated. Based on their results the authors hypothesise that DCC enables the neonate to aerate its lungs and increase pulmonary blood flow before the blood flow from the placenta is lost. This is thought to prevent significant decreases in heart rate enabling a more stable cardiovascular transition at birth (Bhatt et al. 2013). There are limitations to this evidence; the study is singular and the sample size in small which limits its reliability. It is also not fully transferable, having been carried out on lambs. However, the authors hypothesise that ICC puts infants at increased risk of physiological compromise and therefore more research is urgently required.

Authors Mercer et al. (2008) and Mercer and Erikson-Owens (2014) have also identified specific areas for research relating to the increased risk of hypovolemia that ICC may place on infants affected by shoulder dystocia and nuchal cord.

Images are for visual learning only and not related to the reflection

Reviewing this literature has led me to question why ICC is currently routine practise in hospitals for babies requiring resuscitation. ICC may be putting compromised infants at further risk, whereas there are no indications to suggest that ICR poses any physiological risk to neonates as long as resuscitation is not delayed (Bhatt et al.2013; Katheria et al. 2017). It is necessary to consider the factors which have influenced the routine use of ICC and presumption that it is a safer practice.

Qualitative research has found that there are practical barriers to ICR in a hospital setting as resuscitation areas are commonly set up on resuscitaires that are connected to the wall and difficult to manoeuvre (Fulton and Stroll, 2016). Thomas et al.(2014) have reviewed the feasibility of using a mobile resuscitation trolley alongside the mother’s bedside to perform ICR. They effectively managed the resuscitation of 78 babies using the trolley and the involved clinicians reported high levels of satisfaction (Thomas et al. 2014). This study indicates that the practical barriers to providing ICR have the potential to be overcome, through the development and availability of new equipment.

Further to the improvement of clinical outcomes, ICR may improve parent’s experiences of neonatal resuscitation. Research has found that families prefer to be present when a relative is being resuscitated (Bowden et al. 2009; Critchell and Marik, 2007). Qualitative research by Fulton and Stroll (2016) found that midwives perceive ICR as a more women-centred practice and that removing infants during emergencies may be of detriment to mother-infant bonding. There appears to be a scarcity of research relating to women’s experiences of neonatal resuscitation in general, as well as no direct research relating to whether families want to be present and observe their newborn being resuscitated (Burleigh and Uwins, 2018; Fulton and Stroll, 2016). Qualitative research in these areas would help facilitate informed choice, thereby furthering the provision of women-centred care.

Example of close proximity of the mother to the baby facilitating intact cord transition where necessary

What have I learned that could improve events in the future?

Through this reflection I have broadened my knowledge around the topic of DCC in neonates requiring resuscitation at birth. The situation I witnessed on labour ward was appropriately managed according to Local Trust Guidance (2015). However, I have learnt that this is an area in clinical practice in which the evidence is incomplete, current research indicates but cannot confirm that there are benefits to ICR.

Considering the potential risks of ICC to compromised infants, I feel that further research ought to be prioritised; particularly the development of large RCTs are required so that clinical guidance can be clarified. Having reflected on this topic I will now be able to accurately inform families why we do not currently practise DCC in compromised infants.

Appendix A

The Bowers Reflective Model  (Bowers, 2015)

• Why is this reflection important to me? 

• What happened?  

• Why is it important to analyse this event? 

• Analysis of the event with supporting literature/research. 

• What have I learned that could improve events in the future? 

• Action Plan – what do I need to do now?  

Appendix B

Benefits to delayed cord clamping in healthy term and pre-term infants

• Reduces the need for blood transfusions (Andersson et al. 2011; Mercer and Erikson-Owens, 2014; McDonald et al. 2013)

• Reduces the risk of iron deficiency anaemia (Andersson et al. 2011; Mercer and Erikson-Owens, 2014)

• DCC in preterm infants is associated with a 50% reduction in intraventricular haemorrhage and a decrease in the incidence of intracranial haemorrhage (Rabe et al. 2012).

• No increased risk of PPH, admission to NICU or lowered APGAR scores (Mercer and Erikson-Owens, 2014).

References

Andersson, O. et al. (2011). Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at four months: a randomised controlled trial. British Medical Journal. 343: d7157.

Bhatt et al. (2013). Delayed cord clamping until ventilation onset improves cardiovascular function at birth in perterm lambs. J Physiol. 15; 591. (8) Pp. 2113-2126.

Bowers, S. (2015). Bowers Reflective Model. The Journal of New Writing in Health and Social Care. 1 (2) pp. 31- 37 

Burleigh, A., Uwins, C. (2018). Campaigning for Change: Implementing optimal cord clamping. The Practising Midwife. 21 (2). Pp.7-11.  

Critchell, C., Marik, P. (2007). Should family members be present during cardiopulmonary resuscitation? A Review of the Literature. The American Journal of Hospice and Palliative Care. 24(4). Pp. 311-317.

Fulton, C., Stroll, K. (2016). Bedside resuscitation of newborns with an intact umbilical cord: Experience of midwives from British Coumbia. Midwifery. 34. Pp. 42-46

Hatton, N., Smith, D. (1995). Reflection in Teacher Education: Towards Definition and Implementation. Teaching and Teacher Education. 11 (1). Pp. 33-49.  

Horton-Deutsch, S., Sherwood, G. (2008). Reflection: an educational strategy to develop emotionally-competent nurse leaders. Journal of Nursing Management. 16. pp. 946-954. 

Johns, C. (1995). Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing. 22. Pp. 226-234.  

Wyllie, J. et al. (2015). Resuscitation and support of transition of babies at birth. [Accessed Online]. Available at : https://www.resus.org.uk/resuscitation-guidelines/resuscitation-and-support-of-transition-of-babies-at-birth/. Accessed on: 27th May 2018

Katheria, A. (2017). Delayed Cord Clamping in Newborns Born at Term at Risk for Resuscitation: A Feasibility Randomized Clinical Trial. The Journal of Pediatrics. 187. Pp. 313-317.  

Local Trust (2015). Newborn Life Support.

McDonald, S. et al. (2013). Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews. Issue 7. CD004074

Mercer, J., Erickson-Owens, D. (2012). Rethinking Placental Transfusion and Cord Clamping Issues. The Journal of Perinatal and Neonatal Nursing.26 (3). Pp. 202-217 

NICE (2017). Intrapartum Care for Healthy Women and Babies. [Accessed Online]. Available at: https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#third-stage-of-labour. Accessed on: 27th May 2018.  

PMF (2017). PROMPT Course Manual. 3rd edn. Cambridge: Cambridge University Press

Rabe, H. et al. (2012). Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews. 15 (8). CD003248.

RCOG (2015). Clamping of the Umbilical Cord and Placental Transfusion. [Accessed Online]. Available at : https://www.rcog.org.uk/en/guidelines-research-services/guidelines/sip14/. Accessed on: 27th May 2018.

Thomas et al. (2014). Providing newborn resuscitation at the mother’s bedside: assessing the safety, usability and acceptability of a mobile trolley.BMC Pediatrics.14; 135. Pp. 1-6.

Treharne, A., Beattie, M. (2015) Consent in clinical practice. The Obstetrician and Gynaecologist. 17. Pp. 251-255

Bowden, V. et al. (2009). Should family members be present when their child is being resuscitated? Pediatric Nursing. 35 (4). Pp. 254-6

WHO (2012). Guidelines on Basic Newborn Resuscitation. [Accessed Online]. Available at: http://www.who.int/maternal_child_adolescent/documents/basic_newborn_resuscitation/en/. Accessed on: 3rd June 2018.