Why are clinicians reluctant to adopt deferred umbilical cord clamping? Deferred cord clamping (DCC) facilitates a smooth transition to extrauterine life, and recent meta-analyses reveal reduced neonatal morbidity and mortality among preterm infants.1–3 In this issue of Pediatrics, Korale Liyanage et al4 present a systematic review of clinical practice guidelines on DCC and umbilical cord milking. All 44 statements from 35 organizations included in the review endorsed deferred umbilical cord clamping for uncompromised preterm infants. Despite the proliferation of guidelines, the authors note that >40% of preterm infants admitted to NICUs across California and Canada do not receive DCC. What is preventing the translation of evidence to practice?
Low uptake of clinical practice guidelines is not unique to cord management; however, the case of DCC highlights that publication of guidelines only begins the crucial phase of dissemination, local implementation, and evaluation.5,6 Less than half of guidelines adequately articulated the values and preferences informing their treatment recommendations or provided advice on implementation.4 Regional and national councils and professional organizations often create context-specific guidelines from a common evidence-evaluation base, such as the International Liaison Committee on Resuscitation Consensus on Science. When different regions, health systems, and professional groups apply different priorities and judgments, the resulting recommendations differ, thus giving rise to conflict among guidelines and confusion among end users. To minimize this confusion, some organizations incorporate new guidelines into educational programs (for example, the Neonatal Resuscitation Program). Only a few entities provide meaningful tools, measures, and protocols to operationalize guidelines into practice, generally in the context of national health systems or quality improvement networks.7,8
Bridging the “last mile” for implementation of guidelines also requires local adoption and adaptation and application within facilities. In the telecommunications and cable industry, the last mile refers to the relatively expensive and complex delivery of cables or wiring from the provider’s trunk to a home or business. Reaching clinicians at the frontline of care and effecting actual behavioral change requires deliberate strategies and investment to support and reward new behaviors that may not have perceived benefit to practitioners or systems but do benefit patients. Bridging the last mile calls for the use of social media and interprofessional online education as well as face-to-face discussions among colleagues. Within facilities and health systems, local educational programs, interdisciplinary perinatal team meetings, and facility- or system-specific protocols are necessary to address the multiple techniques for deferred clamping and cord milking, the uncertain evidence regarding details of technique (timing, exclusion criteria), and the perceived safety issues and conflicts among different guidelines.9,10 Professional organizations or quality improvement networks could provide standardized criteria and tools for monitoring and audit to help identify and track changes in process and outcomes. Quality improvement dashboards can provide incentive to be part of the change. At the same time, evaluation can alert providers to the occurrence of unintended consequences and can feed back into local practice and the process of guideline updating.
Changing individual behavior often requires visualizing a new understanding of transitional physiology at birth to resolve perceived conflicts that inhibit action. Placental circulation during DCC supplies blood to the left side of the heart, maintaining cardiac output and oxygenation until a newborn takes the first breaths.3,11,12 Envisioning that DCC serves to continue support of transition, rather than delay resuscitation, changes the priorities in the first minute after birth for newborns of any gestational age to maintaining thermal stability and stimulating the onset of spontaneous respiration.13
To offer DCC for many more newborns, providers caring for the infant need to be willing to stand shoulder to shoulder with those caring for the mother at birth. The assessment of a potentially compromised newborn needs to be made by a pediatrician or neonatal nurse specialist, not the obstetrical provider, who also must consider third-stage management of the mother. It is reasonable to stimulate breathing in the newborn during DCC with drying and tactile stimulation before umbilical cord clamping because half of nonvigorous infants will respond to tactile stimulation without needing to escalate to positive-pressure ventilation.14,15 Moreover, the vast majority of very preterm infants will initiate breathing by 60 seconds after birth.16 Sterile plastic wrap or “rain coats” and warming mattresses can facilitate thermal management during DCC even for extremely low birth weight infants at cesarean section. With focus on the basics of assessment and stabilization, many more infants can safely transition with DCC.
Future directions for umbilical cord management include improving the understanding of DCC in subpopulations often excluded now, such as depressed newborns and multiple gestations. There is growing evidence that resuscitating nonvigorous infants during DCC is feasible and preferred to immediate cord clamping.17–19 Trials in which the pediatrician is caring for the newborn during DCC have succeeded in achieving at least 60 seconds of DCC at high rates.16–19 Authors of recent studies advocate using signs of physiologic adaptation to birth as an indication the newborn is ready for umbilical cord clamping, rather than a time-based approach.3,11,18,19 Adapting monitors and resuscitation equipment to ensure sterility, portability, and functionality while working in the limited space determined by umbilical cord length will also facilitate studies of umbilical blood flow and help address the safety of umbilical cord milking.20,21 Traveling the last mile together as a perinatal team will make it possible to build on DCC and provide safer births for both mothers and newborns.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/20201429.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.