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Amanda Burleigh 

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Why isn’t delayed cord clamping in new-born babies requiring resuscitation implemented in UK hospitals as standard practice?

 

There is a very clear need to examine current practice with regards to resuscitation of premature and compromised babies and delaying cord clamping.   This is because immediate cord clamping (ICC) is a non-evidence based practice performed routinely at most births for the past 50-60 years but due to the absence of literature around the subject appears to have been implemented with no consideration on the effect on the fetus.  However there is increasing evidence that this practice has a negative impact on the fetus for example, Andersson et al (2011, 2015) has shown through studies the benefits of DCC in term babies of a reduction in iron deficiency anaemia and improved fine motor and social skills by the age of 4. All national and much international guidance over the past ten years has been updated to recommend a delay in clamping for at least one minute. (WHO 2013, NICE 2014). Mercer (2009, 2012) shows that resuscitation with the cord intact provides premature and compromised babies with the greatest benefits and resuscitation is more likely to be successful. ILCOR (2015) recommend a delay of one minute in uncompromised babies although ERC (2015) state that for babies that require resuscitation there is insufficient evidence available to be able to recommend timing for clamping the cord in these circumstances.  Despite the evidence, local audit and anecdotal evidence shows that anticipating resuscitation and prioritising ICC rather than first assessing or initially implementing resuscitation with the cord intact remains clinical current practice.   

As bedside resuscitation equipment, initially developed in 2011 is available (Weeks, et al.,2015) and assessment of the new-born, stimulation and rescue breaths take place within the first 60 seconds following delivery of the baby, this study will  examine whether an understanding of the benefits of placental resuscitation via delayed cord clamping and the availability of bedside resuscitation equipment (whether a bedside trolley or bag and mask) could lead to all babies that require resuscitation benefiting from having delayed cord clamping of at least 60 seconds.

Benefits of delayed cord clamping

There has been extensive research into the benefits of delayed cord clamping for both term and pre-term babies. A Cochrane Systematic review (McDonald, et al., 2013) identified benefits as illustrated below, along with Swedish studies (Andersson, et al., 2011, 2015) and studies by American Midwife (Mercer 2002, 2008, 2010, 2012) as well as others.

Benefits of Delayed Cord Clamping

Benefits for Term Infants

Higher levels of haemoglobin and haematocrit (McDonald, et al., 2013)

Higher ferritin levels for six months (McDonald, et al., 2013)

Improved social and fine motor skills aged 4 particularly in males (Andersson, et al., 2015)

Reduced risk of iron deficiency anaemia up to 6 months of age  (McDonald, et al., 2013; Mercer et al., 2012., Andersson,et al.,2011,2016)

Benefits for Preterm Infants

Decreased risk of necrotising enterocolitis (Backes, et al. 2014;

Increased haematocrit (Rabe, et al., 2012).

Reduced incidence of intraventricular haemorrhage (Mercer, et al., 2006; Rabe, et al., 2012).

Reduced need for blood transfusions for low blood pressure + anaemia (Mercer, et al., Rabe, et al., 2012).

Decreased respiratory distress (Kinmond, et al., 1993)

Decreased late onset sepsis (Mercer, et al., 2006; Hofmeyr, et al., 1993)

Improved neurological outcomes (Mercer et al., 2010)

 

 

Perceived risks of delayed cord clamping

Perceived barriers to implementation of delayed cord clamping have been found to be a fear of increased jaundice and polycythaemia due to the “increased” blood volume as described in work by Mercer and Erickson-Owens, (2012) who then state that these claims have not been supported by any research since 1980. Andersson et al. (2011) showed there were no significant increase in polycythaemia, or hyperbilirubinaemia requiring phototherapy in an RCT on 400 babies receiving ICC or DCC. The “increased” blood volume is only a perception based on non-evidence based practice which deprives the baby of their intended total blood volume. 

 

The effects of cord clamping on respiration and fetal to neonatal circulation

Mercer and Erikson (2010) show that at birth, an increase from 10% to 40% in cardiac pulmonary output is required during the transition from fetal circulation to extra-uterine circulation in order for the lungs to transform into organs capable of gaseous exchange.  An increase of 40 mls is required to enable the pulmonary capillary bed and initiate respiration. When there is insufficient blood circulating, the volume will be diverted away from vital organs in order to perfuse the lungs.

A study by Graves (2013) showed that babies with ICC had 20 to 30 ml/kg less volume compared to babies with DCC which suggests that optimal lung perfusion took precedence and other vital organs were left compromised. 

There are older studies which examine the direct effects of cutting the umbilical cord prior to the onset of respirations. Brady and James (1962) showed by a consistent fall in heart rate following clamping of the cord prior to the onset of respirations but no fall in heart rate if the cord was clamped after respirations had commenced. Tiisala et al. (1966) found that babies with ICC had smaller cardiac volume than babies that had DCC.

A more recent study which directly studies the link between cord clamping and respiration was carried out by Bhatt et al. (2013) who studies on pre-term lambs showed an immediate decrease in heart rate in lambs that experienced ICC. The lambs who experienced clamping sometime after respirations had occurred maintained their heart rate and also a higher blood pressure. MacDonald et al (2013) also identified stable blood pressures as a benefit of DCC in their systematic review.

Timing of cord clamping on initiating respirations

Babies who require resuscitation at birth are usually excluded from randomised controlled trial (RCT) criteria, however Kaempf et al. (2012) showed in an RCT which only excluded babies requiring major resuscitation that babies with ICC received more resuscitation than those with DCC.

Katheria et al. (2016) compared DCC and stimulation with DCC and Ventilation support (Continuous Positive Airway Pressure) in 26-31 week babies and found that there was no significant difference in the measurements of improvements or reduction in neonatal morbidity, proposing that adequate stimulation whilst DCC may be an effective alternative to establishing ventilation.

When DCC was first advocated, a number of clinicians told me that babies required cord clamping in order to initiate breathing, however the effect of cord clamping and the interruption of the physiological transition on a compromised baby may lead to these babies requiring resuscitation as proposed by Niermeyer and Velaphi (2013) and supported by Walsh (2012) who theorises that ICC prevents blood transfer and reduces pulmonary perfusion and reduces respiratory function.

“Helping babies breathe” (Singhal, 2012) is an initiative used for teaching new-born resuscitation in low resource settings and advocates DCC during the “golden minute,” which states that if a new-born is not crying or breathing at birth, drying and stimulating the baby should be performed before the cord is cut. This initiative is in comparison to ILCOR (2015) which advocates that babies in developed countries who are limp or apnoeic at birth receive immediate cord clamping.

 

Other benefits of delayed cord clamping

Farrer (2010) shows that babies lose approximately one quarter of their intended blood volume through ICC. (Appendix 4) This blood also contains haematopoietic stem cells which play an essential role in organ development. There is a high concentration of stem cells in the new-born, this concentration is even higher in premature babies. Extensive research shows that stem cells have enormous potential for repairing damage.  Tolosa et al (2010) argue that “artificial loss of stem cells at birth could . . . predispose infants to diseases such as chronic lung disease, asthma, diabetes, cerebral palsy, infection, and neoplasm.”(p491) It is highly probable that the stem cells around at birth will repair any damage from traumatic deliveries or continue to contribute to organ development in premature babies. Morley (2002) conducted experiments on monkeys and found that monkeys who had ICC either died or developed non reversible hypoxic brain injury.

 

Timing of umbilical cord clamping

There is no guidance for the optimal timing of DCC and definitions of DCC vary from 60 seconds to when the cord has ceased pulsation. The European Resuscitation Council and International Liaison Committee of Resuscitation recommend at least one minute for uncompromised babies. (ERC, ILCOR, 2015)  In active management NICE (2014) recommends 1-5 minutes. Erickson-Owen (2011) recommends 5 minutes as optimal for completion of placental transfusion when baby is in skin to skin position with their mother. Farrar (2010) illustrated that a term baby will gain up to 214g (approximately 20% total blood volume) consisting of placental transfusion of blood within the first 5 minutes of life following vaginal or caesarean birth with an intact cord, whilst the baby is on scales and any delay in clamping will allow a proportional amount of blood to transfer.

 

Current recommendations for compromised babies

UK and European Resuscitation Council (2015) states “As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in infants who are severely compromised at birth. For infants requiring resuscitation, resuscitative intervention remains the immediate priority”. Their algorithm states that actions to be taken in the first 60 seconds after delivery consist of assessment, 5 inflation breaths (air) and reassessment. (Appendix 5)

ILCOR state “We suggest delayed umbilical cord clamping for preterm infants’ not requiring immediate resuscitation after birth….there is insufficient evidence to recommend an approach to cord clamping for preterm infants who do receive resuscitation immediately after birth” (2015).

 

Incidences of neonatal resuscitation

Van Rheenen (2011) states levels of resuscitation are approximately 10% but doesn’t describe the levels of assistance required.  Globally Wylie et al (2015)   International Consensus on Cardiopulmonary Resuscitation state that approximately 85% of term babies breathe spontaneously, 10% respond to drying and stimulation, 3% require positive pressure ventilation, 2% require intubation and 0.1% require further support. However Wylie, Ainsworth and Tinnion, UK Resuscitation Council. (2015)  report that incidences of resuscitation in the UK are poorly reported.

 

Wansbeck Hospital

Wansbeck (Ashington) Hospital in the North of England implemented DCC in 2009 after a Midwife, Neonatal Practitioner and an Obstetric Consultant attended a study day presentation on neonatal physiology and the benefits of DCC. A retrospective study (Brooks et al. 2009) of 1973 babies showed that by implementing DCC they significantly decreased the incidence of babies receiving resuscitative measures at birth (15% down to 4.08%) and admissions to NNU for respiratory care (4.5% down to 2.55%). The results were so significant that Ashington “very much supports the practice of “assisted transition” from placental to pulmonary respiration.” Induction to the hospital includes training for every clinician on bedside resuscitation. (Brooks et al. 2009).

 

Bedside resuscitation trollies

In 2010 a group of clinicians who recognised the evidence based short and long term benefits of DCC for premature and compromised babies contested the guidelines that recommend resuscitation with ICC as primary management. To overcome this barrier they devised a mobile resuscitation unit designed specifically to facilitate new-born resuscitation at the bedside, with an intact cord and is currently used in units and trials around the world. The BASICS bedside trolley enables Bedside Assessment, Stabilisation and Initial Cardiorespiratory Support and allows evaluation of a more physiological approach to cord clamping for all births, including sick and very premature babies. (Weeks et al. 2015).

This trolley has been used in trials which assess clinicians’ views (Yoxall et al. 2015) and found most providing immediate neonatal care at the bedside was an improved experience, particularly as parents’ perceptions were so positive. They reported improved communication with parents but recognised the need for staff training and support. 

Parents’ perceptions of witnessed resuscitation using the same trolley were examined and concluded that parents felt reassured about the health and care of their baby and felt involved as a family and were positive about the trolley although some reported experiencing negative emotions as a result of witnessing their baby being resuscitated.  (Sawyer et al. 2015)

Fulton (2016) a Canadian Midwife concluded that although intact cord resuscitation is primarily carried out in the home setting, it is rare in hospitals settings due to hospital culture, protocols and lack of training.  Another study by Katheria (2016) utilised the trollies for his study comparing resuscitation with an intact cord and stimulation and resuscitation with an intact cord and positive ventilation.

Logistics obtained from the manufacturing company show that the trolley is being used extensively at isolated hospitals Wansbeck, Bath and Liverpool in the UK and Sharp Mary Birch Hospital for Women and New-borns in San Diego. However, despite the strong evidence base to support DCC, particularly in compromised and premature babies along with the facilities to accommodate bedside resuscitation either by Basics/Lifestart trolley or by facilitating 60 seconds assessment and rescue breaths on the bedside with the cord intact, ICC remains current practice due to unclear current national and international resuscitation guidelines (ERC, ILCOR 2015).

 

Implications of literature for research proposal

The literature review shows very clearly there are short term and long term benefits for compromised and pre-term babies in receiving resuscitation whilst the umbilical cord is intact.

  • There is no clear guidance from the resuscitation councils with regards to delayed cord clamping and resuscitation.

  • Immediate cord clamping has been standard practice for 50-60 years and change management in implementing “new” practice is contentious, particularly as there is currently no clear guidance.

  • Clinicians may be unaware of the benefits of physiology of birth transition and the benefits of delayed cord clamping in resuscitation.

  • There is an ethical issue in that currently parents are not being made aware of the benefits of resuscitation with the cord intact and informed consent is not obtained.

  • Babies “at risk” of requiring resuscitation (premature or suspected compromise during labour) are experiencing immediate cord clamping as a need for resuscitation is anticipated rather than assessing and stimulating the baby for 30 seconds with an intact cord.

 

References:

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Andersson, O., Lindquist, B., Lindgren, M., Stjernqvist, K., Domellöf, M. and Hellström-Westas, L. (2015). Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age. JAMA Pediatrics, 169(7), p.631.

 

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Description by Andrew Weeks

 

Great work by the neonatologists at Liverpool Women’s Hospital UK on optimal cord clamping.

We are now deferring cord clamping successfully for at least 2 minutes in 100% of eligible babies <32 weeks. It has been a bit of an effort, but we had a very successful QI project over the past 12 months.

The video is available at:

http://bit.ly/LWHLifeStart

It is probably a bit site specific. We use a 2 minute delay in cord clamping (as per the CORD Trial protocol) , We start preterm resus in 40% and adjust based on pulse oximetry (based on the Torpido trial results), we dont use it for monochorionic twins (these babies were not recruited in CORTD or APTS).