Benefits Of Delayed Cord Clamping

The timing of newborn cord clamping is an area of interest in nursing. For many years Obstetricians have been clamping the umbilical cord as soon as the baby is born; however, new evidence is arising showing delayed cord clamping to be beneficial to preterm and term newborns. Evidence has shown that delayed cord clamping has been proven beneficial to newborns, but many facilities and practitioners have not successfully adopted it. Studies show that organizations have had little success in changing a provider’s conduct to incorporate evidence-based research into their practice (Leslie, Wrickson-Owens, & Cseh, 2015). Additional research is needed to educate and customize a delayed cord clamping policy to present to stakeholders so implementation
of the policy can be used in practice.
Research Overview
A variety of research currently exists on the topic of delayed cord clamping. Some of the areas being researched is the effects of umbilical cord clamping in term infants, maternal neonatal outcomes, timing of cord clamping and neonatal complications, the timing of cord clamping and oxidative stress in newborns, the timing of umbilical cord clamping on anemia months after birth, effect and timing of neurodevelopment in term and preterm infants, delayed umbilical cord clamping and cord blood banking, cord clamping with low birth weight, cord clamping when resuscitation is needed, cord clamping with postpartum hemorrhage and blood gas sampling, and other such studies exist. When a baby is born, it is attached to the mother’s placenta by the umbilical cord. The umbilical cord will need to be cut to separate the neonate from the placenta. The ritual of clamping the cord consisted of immediate cord clamping (ICC). After the baby is delivered, the cord would be clamped and cut by the father. Current research has showed that delayed cord clamping (DCC) is beneficial to the newborn. Iron deficiency is associated with impaired neurodevelopment, decreased growth and development, and fatigue. DCC has reduced anemia by sixteen percent and has shown fine motor function improvement at four years of age (KC, Malqvist, Rana, Ranneberg, & Andersson, 2016).
Increased ferritin levels by DCC have shown to marginally increase the need of neonatal phototherapy, but the occurrence of clinical jaundice was not noteworthy (Tillett, 2013). Fifteen trials were conducted which included 3,911 women and infant pairs. The study showed no significant differences between early and delayed cord clamping on the outcome of neonatal mortality or severe postpartum hemorrhage risks; however, DCC transfusion did show benefits of providing 30% more blood volume, 60% more red blood cells and improved iron stores up to 6months after birth (Mcdonald, Middleton, Dowswell, & Morris, 2014). DCC shows an increase in erythrocytes. The increase in erythrocytes also show an increase in the total antioxidant capacity and decrease in the inflammatory-mediated effects induced during the delivery, decrease in respiratory distress, anemia, mental retardation, and cerebral palsy (Castro et al, 2014). According to Downey and Bewley, “Delaying clamping in preterm infants decreases the need for blood transfusion, which has been associated with neonatal necrotizing enterocolitis and death in term infants”. Delayed clamping improves oxygen transport and red blood cell flow in
premature infants and is associated with fewer days on oxygen and ventilation (Lewenson & Truglio-Londrigan, 2015). If a newborn needs resuscitation, the blood volume gained from DCC or umbilical cord milking has the potential to stabilize the cardiovascular system, reduce the severity of an inflammatory response, reduce or prevent damage from hypoxia/ischemia, and help keep the newborn from harm (Mercer & Erickson Owens, 2014). DCC increases neonatal blood volume and decreases hypervolemia. This allows more time for spontaneous breathing, and in turn, reduces risks associated with resuscitation, increases iron stores decreasing long term anemia, increases stem cell transfers allowing for neurotropic and neuroprotective effects, and reduces Intraventricular hemorrhage (IVH) by 50% (Tarnow-Mordi et al., 2014). When there is an emergency situation or the provider does not want to wait the 1-3 minutes before clamping the cord, they can milk the cord so it transfers extra blood from the cord, which is as beneficial as delaying the clamping of the cord. Umbilical cord milking is the process of quickly transferring the blood in the umbilical cord to the newborn by squeezing the blood down the umbilical cord (Dang et al., 2015). While cord milking moves the cord blood rapidly, there is no need to rush the process. There are no benefits in rushing the transfer of blood from the cord. It is best to have a gentle transition from the womb to mother’s chest. Letting the baby simply lie on his mother’s chest lets the blood transfer naturally and allows for the baby to receive as much of his own blood as possible. The world health organization (WHO) recommends delayed cord clamping of approximately 1-3 minutes for all births (vaginal & C-section) anything under 1 minute is not recommended unless the neonate requires positive pressure ventilation (WHO, 2017).
Dissemination of Findings
The research method that will be used to help disseminate relevant information about delayed cord clamping will be the process of Evidence Based Practice (EBP). The EBP process consists of five steps. The five steps include asking a relevant clinically focused question, identifying the best available evidence that answers the question, critically appraise the evidence for validity, effectiveness, and clinical usefulness. These steps help integrate the evidence into clinical practice by incorporating patient values and beliefs and evaluate the effectiveness of the evidence in the clinical application for replication and sustainability (Lewenson & Londrigan, 2015, p. 165). The question formed using the PICO process would be, “Does the delay in umbilical cord clamping of 1-3 minutes compared to immediate umbilical cord clamping result in improved newborn health as evidence of blood volume increase?” To answer this question, searches were done through CINAHL on current EBP literature and random control trials (RCT) research within five years of date. This EBP information will then be organized into a presentation, along with an Institutional policy/protocol plan including timing parameters, operational definitions, and systemic documentation needs will be presented to all stakeholders (McAdams, Backes, & Hutchon, 2015). An Interdisciplinary team (IT) (e.g. NICU, RT, Labor and delivery Nurse, Obstetrician, and midwife) is a team comprised of educated and trained team members via educational meetings, simulated delivery/cord clamping scenarios, rapid response scenarios so to provide staff with knowledge, familiarity, confidence, effective communication, and competent teamwork. After much training and education with the readiness of the staff, the plan will be implemented based on a date set by IT. Parents will be educated and consents will be signed. A persistent approach to the policy will be upheld with systematic documentation of the amount of time delayed before the cord was clamped along with routine tracking of the newborns outcomes. Timely and correct documentation of monitoring allows for tracking compliance, shows median delayed clamping times, and benefits of delayed cord clamping along with any risks that arise. Audits will be done and monthly meetings to address any issues that may arise along with making sure everyone is compliant with the clamping times. Documentation and benefit/risk monitoring is upheld with the amount of time that will be at the discretion of the obstetricians and is based on the newborns/mothers status upon delivery. The status could include scenarios of resuscitation and hemorrhaging.
Conclusion
While observing different obstetricians at the hospital, only seven obstetricians delayed cord clamping by thirty-sixty seconds, while the others practiced their rituals of immediate cord clamping.
All deliveries were vaginal with no health risks to the mother or newborn. The reason that some chose immediate cord clamping versus delayed cord clamping was due to unfamiliarity, not being educated about all the benefits, and apprehension of not being able to resuscitate with the cord intact. More research is needed to provide EBP research to the hospitals and staff to educate them on the benefits of delayed cord clamping to the newborn compared to immediate clamping of the cord. The research done will help provide evidence that resuscitation can be achieved with delayed cord clamping. More research needs to be conducted so proper time of delayed cord clamping can be recorded. This also allows a set system of guidelines that are the same and the procedure followed would be strategic. EBP research has shown that delayed cord clamping can be done on pre-term, term babies, and babies that may need resuscitated. The delivery rooms can be set up and ready in case resuscitation or phototherapy is needed. If a provider does not want to wait due to resuscitation or other issues, milking the cord can provide the neonate with the extra blood from the cord in a shorter amount of time. A hospital wide policy needs to be constructed and set in place so that every obstetrician/provider in the
hospital are held to the same timing of delayed cord clamping that is most beneficial to every neonate.