2. Materials and Methods
2.2. Setting and Design
3.1. Theme 1: Sterility
3.2. Theme 2: Equipment
3.3. Theme 3: Mobility
3.4. Theme 4: Space and Workflow
3.5. Theme 5: Communication
Conflicts of Interest
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|World Health Organization (WHO) [6,7]||2006, most recently updated 2017||“In newly-born term or preterm babies who do not require positive-pressure ventilation, the cord should not be clamped earlier than one minute after birth.”|
“Delayed umbilical cord clamping (not earlier than 1 min after birth) is recommended for improved maternal and infant health and nutrition outcomes.”
|International Liaison Committee on Resuscitation (ILCOR) ||2010, updated 2015||“DCC for longer than 30 s is reasonable for both term and preterm infants who do not require resuscitation at birth”|
|Neonatal Resuscitation Program (NRP) guidelines from the American Academy of Pediatrics (AAP) ||2017||“Delay in umbilical cord clamping for at least 30–60 s for most vigorous term and preterm infants.”|
|American College of Obstetricians and Gynecologists (ACOG) ||2010, recently updated in 2017||“Delay in umbilical cord clamping in vigorous term and preterm infants for at least 30–60 s after birth”|
|National Institute for Health and Care Excellence (United Kingdom) [11,12]||2014, updated 2017||“Do not clamp the cord earlier than 1 min from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heart rate below 60 beats/minute that is not getting faster.”|
|American College of Nurse–Midwives ||2014||“For term newborns, delaying the clamping of the cord for 5 min if the newborn is placed skin-to-skin or 2 min with the newborn at or below the level of the introitus ensures the greatest benefit. For preterm newborns, the benefits of delaying cord clamping for 30 to 60 s include a significant reduction in intraventricular hemorrhage and a reduced need for blood transfusion.”|
|Society of Obstetricians and Gynecologists of Canada ||2009, reaffirmed 2018||“Whenever possible, delaying cord clamping by at least 60 s is preferred to clamping earlier in premature newborns (<37 weeks’ gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping.”|
|Increased hemoglobin levels at birth|
Increased iron stores in first several months of life
|Increased hematocrit levels|
Reduced need for blood transfusions
Reduced incidence of intraventricular hemorrhage
Reduced incidence of necrotizing enterocolitis
Decreased hospital mortality
|Sterility||● Current available respiratory equipment (CPAP mask, ventilation tubing) is not sterile, forcing clinicians to use a nonsterile piece of equipment adjacent to a sterile field with the theoretical risk of increasing surgical site infections.|
● An ideal surface would provide adequate warmth to the vulnerable preterm infant. Current commercially available thermal mattresses are not sterile and require a workaround.
● Maintaining sterility requires more personnel than community hospitals may be able to staff.
|Equipment||● CPAP is ideally performed on a flat surface. However, there are limited options on how to best provide CPAP during DCC. Currently there is not an ideal surface and respiratory setup that allows for all infants to receive CPAP during DCC. |
● Providers are often limited by the umbilical cord length to reach any available surfaces.
|Mobility||● Following DCC, the infant needs to be moved from the DCC site to a resuscitation bed or the intensive care unit. Concerns raised about the safety of moving a patient vulnerable to intraventricular hemorrhages multiple times in a short period (DCC to resuscitation bed to the ICU bed). An ideal setup would include minimal transportation and lifting of the infant.|
|Space and Workflow||● In this new arrangement, the workflow was awkward. As there are multiple team members present at the mother’s side in a small space to provide DCC with CPAP, neonatal providers will often start from far away. There needs to be adequate time, space, and communication for the neonatal providers to safely approach the bed.|
|Communication||● Obstetric providers voiced concerns about safety for the mother during DCC and emphasized the need for clear communication between the multidisciplinary teams.|
● Neonatal providers request communication about when they are able to approach the mother safely in order to care for the infant.
● There is a need for protocols on when to discontinue DCC due to the infant or maternal status.
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