Improving the Rate of Delayed Cord Clamping in Preterm Infants: A Quality Improvement Project

This study was conducted at our academic tertiary care children’s hospital with a 58-bed level IV intensive care nursery. There are ∼3000 births annually, with ∼140 infants born on-site at <34 weeks’ gestation per year. These births occur in an operating room (OR) regardless of the mode of delivery. In our center, resuscitation of preterm infants occurs in a room separate from the OR; preterm infants are passed through a window after delivery.

A multidisciplinary team attends the delivery of all infants born <34 weeks. The OB team includes an OB intern supervised by either a certified nurse-midwife or a maternal-fetal medicine fellow and/or an OB attending physician. A pediatric intern stays in the OR at the patient’s bedside to receive the infant and make the transfer through the window to the waiting neonatal team. The neonatal team includes a senior pediatric resident, neonatology fellow, neonatal nurse practitioner, and a neonatology attending.

Our institutional review board did not consider this project to be human subject research and therefore exempt from its review.

The study period was from July 1, 2019 to December 31, 2021. The preintervention period was from July 2019 to June 2020, the implementation period from July 2020 to June 2021, and the sustainment period from July 2021 to December 2021.

All infants born alive ≥23 0/7 weeks and <34 0/7 weeks were included in the study. Infants with a plan for comfort care after delivery were excluded.

A multidisciplinary QI team including OB and neonatology nurses, OB providers, and neonatology providers was formed and met monthly starting in April 2020. Using the Lean framework for improvement,¹⁷  we used A3 problem solving to understand the current state.¹⁸  Our team then developed a key driver diagram for improving DCC for preterm infants (Fig 1). Five primary drivers were identified: (1) knowledge about benefits/risks, (2) updated and published protocol for DCC, (3) predelivery planning, (4) real-time decision making, and (5) access to data.

After a review of this analysis, the team concluded that there were gaps in our current practice. It was clear that improved communication between the OB and neonatology teams was needed, in addition to an updated DCC protocol and further education about its importance. This QI project was approved by our local OB and neonatology patient safety and joint practice committees, as is standard for QI initiatives.

The first intervention was aimed to improve clinical knowledge about DCC. Continuing education with dedicated interactive conferences was held for providers and staff throughout the implementation period. Additionally, “DCC educational pearls” were presented at monthly joint OB and neonatology meetings along with displays of updated control charts.

The second targeted intervention included widespread dissemination and publication of an updated DCC protocol; the previous protocol was last updated in March 2017 and did not elaborate on the benefits of DCC or provide guidance on the initiation of resuscitation while DCC is performed.

After a literature review, the DCC QI team created an updated protocol that clarified the goal of at least 30 seconds of DCC in eligible infants, although 60 seconds was encouraged. It provided clear eligibility criteria and contraindications in addition to advising against cord milking in preterm infants. It also discussed the expectation for an experienced neonatology provider to be at the bedside for preterm deliveries as well as recommendations for initial steps of resuscitation while DCC was performed.

The protocol was presented at joint OB and neonatology meetings and edited based on multidisciplinary feedback. After agreement from both divisions, it was distributed in November 2020. The protocol was updated in several plan-do-study-act cycles after real-time data review and feedback from both teams. A finalized version of the protocol was published in March 2021.

The third intervention launched in August 2020 with the introduction of a formalized checklist called the “Pedi Pause.” Checklists have revealed success in other QI work, especially in the fast-paced environment of DRs.¹⁵  Our “Pedi Pause” checklist prompted labor and delivery nurses to report essential information to the pediatric team, including eligibility for DCC and the DCC plan, and also included the verbal introduction of the experienced neonatology provider at the bedside. The checklist was distributed to labor and delivery nurses and posted in the DRs. The “Pedi Pause” was rolled out in August 2020 and underwent modifications through plan-do-study-act cycles until the final version in March 2021.

Given that previous QI studies highlighted the importance of communication,^12,13  we aimed to improve real-time dialogue about the DCC decision between the OB and neonatal teams. In July 2020, a new practice was recommended to include an “experienced” neonatal provider at the bedside for all births <34 weeks. Before this, only the OB team and a pediatric intern were at the bedside to make the decision about the timing of DCC for premature infants; the remainder of the neonatology team received the infant in the adjacent resuscitation room after the cord was cut. An “experienced” provider included neonatology attending physicians, fellows, senior pediatric residents (with 2–3 months of neonatology experience in a level III–IV NICU), or neonatal nurse practitioners. Their role was to be at the bedside and support pediatric interns in real-time about DCC timing, and to actively communicate with the OB team. Documentation of their presence was added to the delivery note template in the electronic medical record (EMR) in July 2020.

The primary outcome measure was the overall rate of DCC for at least 30 seconds for infants born <34 weeks’ gestation. Because the determination of eligibility at our institution was not well defined or documented before this QI project, and the comparison rates of eligible infants at other centers are not known, the overall rate of infants receiving DCC was chosen as the primary outcome measure rather than only including eligible infants. Although some studies have defined DCC as 60 seconds or more, our study chose to define DCC as >30 seconds, which is the definition used by the CPQCC¹⁹  and has been shown to have benefits without adverse consequences.²⁰  Additionally, given the low baseline rate of DCC ≥30 seconds, we decided to choose 30 seconds to ensure our aim was attainable within the given timeframe for this initial QI effort. DCC was documented in the delivery summary section of the EMR filled out by the OB nurse, which included inputs detailing if DCC was performed and the duration. Secondary outcomes included metrics related to described benefits for DCC, such as initial hematocrit, receipt of blood transfusion during admission, overall rate of IVH, and necrotizing enterocolitis (defined as Bells Stage IIA or greater).

The process measures were (1) the rate of DCC for all eligible infants per the updated DCC protocol and (2) the rate of births <34 weeks’ gestation with an experienced neonatology provider present at the bedside. The rate of eligible infants receiving DCC was chosen as a process measure to track adherence to new eligibility guidelines and compliance with the updated protocol. Infants were considered eligible for DCC unless they met one of the following criteria: maternal hemodynamic instability, placental abruption with severe active bleeding, cord avulsion/tear or true knot, hydrops, rare critical congenital heart disease, congenital diaphragmatic hernia, congenital pulmonary airway malformation with thoraco-amniotic shunt in place, twin A of monochorionic gestation, recipient twin in twin/twin transfusion syndrome, or critical infant instability. Assessment of “critical infant instability” was based on the neonatology team’s real-time bedside assessment and documented in the delivery note. Both measures were determined via monthly chart review during the implementation period.

To determine eligibility for DCC before July 2020, a retrospective chart review of the pediatrics and OB delivery notes was performed, with agreement among the QI team if documentation was unclear. In July 2020, an updated delivery note template was distributed as part of this QI project. The new template included if an infant met exclusion criteria for DCC with a prompt to describe the reason. Additionally, a required drop-down menu was added to document if and which type of experienced neonatology provider was present for the DCC decision. Before this, it was unknown what type of provider was present, although based on our standard practice it was most often a pediatric intern.

The balancing measures were chosen to ensure that the intervention of DCC did not lead to adverse outcomes for the infant or mother. These included the degree of neonatal resuscitation needed, initial infant temperature, and estimated maternal blood loss.

Patients were identified by using a report generated from a perinatal research database, which included any inborn neonate delivered <34 weeks’ gestation. Any data points not included in the generated report were manually collected via chart review. Data were collected retrospectively in the preintervention period and prospectively during the implementation period.

Data were interpreted by using statistical process control charts and run charts created in Microsoft Excel with QI macros add-in (KnowWare International, Inc, Denver, CO) to monitor improvement over time. The primary outcome measure and process measures were assessed with P charts. Control limits were set at 3 standard deviations from the mean, and the centerline was shifted when sustained special cause variation (≥8 values above or below the baseline centerline) was established.²²  We compared the pre- and postintervention groups by using the 2-tailed t test or Pearson’s χ² test when appropriate. P values of <.05 were considered statistically significant.

During the project period of July 2019 to December 2021 there were 333 inborn neonates born at <34 weeks’ gestation. 11 were excluded from the study for planned comfort care because of periviability (n = 6) or known congenital anomaly (n = 5). Three hundred twenty-two neonates were included (137 preintervention and 185 postintervention). There was no difference in maternal and infant demographics in the pre- and postintervention groups (Table 1).

The overall rate of DCC increased from a baseline of 40% to 65%, which reflected significant and sustained improvement (Fig 2). Since the project launch, there has only been 1 month below the baseline rate (January 2021). This appeared to be secondary to a high rate of ineligible infants during that month (55%). There was no significant difference in the secondary outcomes during the study period (Table 1).

Of the 322 infants included in the study, 260 (81%) were considered eligible for DCC per our updated protocol. There was a significant improvement in the process measure of the rate of eligible infants receiving DCC, from 56% preintervention to 88% postintervention (P <.01, Fig 3). Common reasons for ineligibility were critical infant instability (57%, n = 51), mono-di twins (19%, n = 17), maternal indications (17%, n = 15), and other (6%, n = 5). Additionally, in the postintervention period, 92% of preterm births were documented to have an experienced neonatology provider at the bedside to help make the DCC decision (Fig 4).

Finally, there was no significant difference in the degree of neonatal resuscitation, infant hypothermia, or maternal blood loss between the 2 epochs (Table 1).

Through the implementation of multiple QI interventions, the overall rate of DCC in preterm infants significantly increased from 40% to 65%. We exceeded our original target of 50% without increasing adverse outcomes and showed sustained improvement over 18 months. Our improvement was associated with adherence to our process measures.

There is wide variability in the reported overall rate of DCC for preterm infants, despite the known benefits. For example, a state-wide survey of NICUs associated with CPQCC found that the average rate of DCC in preterm or acutely ill infants was 29%, with a wide range from 0% to 75%.²³  Although the optimal rate of DCC for preterm infants is unknown, we found that it was possible to safely increase our rate of DCC to >60%, which may be a relevant goal for other institutions. Our study found that only 19% were considered not eligible because of various infant and maternal indications, which was lower than the number of infants not receiving DCC before our project. In our initial analysis of barriers to DCC, we learned that there was confusion about which infants qualified. As part of our targeted interventions, we aimed to dispel the notion that frequent perinatal conditions, such as nonreassuring fetal status, maternal chorioamnionitis, or a short duration of maternal general anesthesia, were not automatic contraindications. The development of a clear list of eligibility criteria and contraindications was integral to the roll-out of this initiative. With the dissemination of the new protocol and interactive educational sessions, we sought to create a culture shift from perceiving DCC as an optional intervention to recognizing it to be the default with few reasons for opting out.

As stated in Lapcharoensap et al¹⁵  and other studies recognizing the complexities of interpersonal communication in the DR,^12,13  optimizing real-time communication was paramount. In the review of baseline data, we learned that a common reason DCC was not performed for eligible infants was because of concerns about delaying resuscitation for perceived neonatal instability. Including an experienced neonatology provider comfortable with assessing a preterm infant and guiding the initial resuscitation during DCC allowed for an extra layer of support for both disciplines to feel confident in moving forward with DCC. Additionally, our findings reflect what other QI projects found, which is that increased DCC is not associated with a statistically significant increase in the degree of neonatal resuscitation required.^4,13,14  Along with advertising the progress of this initiative in real-time, we also tracked and displayed balancing measures to reassure the delivery teams of the safety of increasing our DCC rate.

The creation of a multidisciplinary team was integral to our success. Our QI team consisted of physician, midwife, and nurse champions from both the OB and neonatal disciplines, all of whom were involved in both the conceptualization and implementation of each of the interventions. We believe this strategy was crucial in promoting buy-in from all members of the delivery teams. Once we created our multidisciplinary team in April 2020, we immediately saw some improvement in our overall DCC rate even before the first intervention roll-out in July, which may be related to increased awareness by staff.

Although we were successful in our primary outcome, we did not observe improvement in secondary outcomes as would be expected. It is possible that the group in the postintervention period was sicker; however, this is not clear from the chosen baseline characteristics. One possibility is that our DCC goal was at least 30 seconds, which may have less benefit in clinical outcomes compared with a minimum of 60 seconds. For example, 1 randomized control trial directly comparing DCC of 30 seconds versus 60 seconds revealed an increase in mean initial hematocrit by 3% with 60 seconds of DCC.²⁰  Several other studies revealing the benefits of DCC have also used 60 seconds as the definition.²⁴  Now that improvement in DCC has been sustained in our unit, our next step is to change the DCC recommendation to 60 seconds. We will continue to monitor secondary outcomes associated with this intervention and hope to see the expected improvement that other centers have shown.^5,14 

An important limitation to sustained success also cited in Pantoja et al,¹²  is the need for continued education on the DCC protocol. Many of our interventions require a knowledge base of the eligibility and workflow for DCC in our unit. Additionally, it will be important to continue to promote buy-in from neonatology providers that their bedside presence is necessary. We continue to track our adherence to this intervention as well as display our DCC rates in the birth center.

Additionally, the physical set-up at our institution is such that the resuscitations of preterm infants occur in a room separate from the DR; preterm infants must be passed through a window after delivery. The importance of having an experienced neonatology provider at the bedside may not be as relevant at institutions in which both teams are in the same room. However, we have learned that active and clear communication between teams is key to successful DCC, which would be true regardless of the DR environment.

DCC has a cumulative body of research revealing many clinical benefits in preterm infants. Increasing DCC rates can be challenging, but our study revealed that a bundle of interventions led by a multidisciplinary QI team can safely lead to increased DCC rates. The bundle described in this paper could be implemented by other centers.

We wish to acknowledge all clinical and administrative staff members at UCSF for their contributions to this project.