Neonatal transitional support with intact umbilical cord in assisted vaginal deliveries: a quality-improvement cohort study

Abstract

Background: Deferring cord clamping has proven benefits for both term and preterm infants, and recent studies have demonstrated better cardio-respiratory stability if clamping is based on the infant's physiology, and whether the infant has breathed. Nevertheless, current guidelines for neonatal resuscitation still recommend early cord clamping (ECC) for compromised babies, unless equipment and competent personnel to resuscitate the baby are available at the mother's bedside. The objective of this quality improvement cohort study was to evaluate whether implementing a new delivery room protocol involving mobile resuscitation equipment (LifeStart™) reduced the prevalence of ECC in assisted vaginal deliveries. Methods: Data on cord clamping and transitional care were collected 8 months before and 8 months after implementing the new protocol. The Model for Improvement was applied to identify drivers and obstacles to practice change. Statistical Process Control analysis was used to demonstrate signals of improvement, and whether these changes were sustainable. Multivariate logistic regression was used to evaluate the impact of the new protocol on the primary outcome, adjusted for possible confounders. Results: Overall prevalence of ECC dropped from 13 to 1% (P < 0.01), with a 98% relative risk reduction for infants needing transitional support on a resuscitation table (adjusted OR 0.02, P < 0.001). Mean cord clamping time increased by 43% (p < 0.001). Although fewer infants were placed directly on mothers' chest (n = 43 [42%] vs n = 69 [75.0%], P < 0.001), there were no significant differences in needs for immediate transitional care or transfers to Neonatal Intensive Care Unit. A pattern of improvement was seen already before the intervention, especially after mandatory educational sessions and cross-professional simulation training. Conclusions: A new delivery-room protocol involving mobile resuscitation equipment successfully eliminated early cord clamping in assisted vaginal deliveries of term and near-term infants. A systematic approach, like the Model for Improvement, seemed crucial for both achieving and sustaining the desired results.

A hybrid type I, multi-center randomized controlled trial to study the implementation of a method for Sustained cord circulation And VEntilation (the SAVE-method) of late preterm and term neonates: a study protocol

“…Staff experiences will be assessed using an adaptation of the questionnaire developed by Thomas et al [ 9 ] and translated into Norwegian by Sæther et al [ 30 ]. This questionnaire will be used in a feedback loop process and be sent to the staff that has experienced the ICR procedure.…”

Toward greater nuance in delayed cord clamping

“…Recent examples include the implementation of a delivery room QI bundle including DCC, which was associated with reduced rates of mechanical ventilation during NICU admission of infants <32 weeks [71]. Using simulation to introduce mobile resuscitation equipment in the delivery room essentially eliminated ECC in term and near-term vaginal deliveries at another site [72]. QI initiatives have also been helpful in resource-constrained settings to increase rates of DCC [73].…”

A review of different resuscitation platforms during delayed cord clamping

“…This study highlighted the importance of oximetery, and the fact that it has been difficult to acquire such data during DCC. Quality improvement and feasibility projects have improved the compliance of using the LifeStart Trolley [ 17 – 19 ]. Further technology improvements will allow faster acquisition by oximeters and thus provide the team with critical physiologic data to allow better and more timely decision making and intervention.…”