Optimal Cord Clamping Clinical Guideline V2 · Delayed cord clamping in very preterm infants reduces the incidence of intraventricular haemorrhage and late-onset sepsis: a randomized,

Optimal Cord Clamping Clinical Guideline

V2.0

Optimal Cord Clamping Clinical Guideline V2.0

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Key Considerations

Warmth – Ensure the baby is kept warm during Optimal Cord Clamping, use

warmed towels from the resucitaire or skin to skin to achieve this

Maternal or Neonatal Deterioration – In the event that the condition of either the

mum or baby deteriorates i.e. maternal PPH or neonatal respiratory distress

Optimal Cord Clamping should be abandoned and emergency measures initiated.

Optimal Cord Clamping should never be performed at the expense of the health of

mother or baby.

Third Stage Management - Syntometrine/Syntocinon or Carbetocin can be

administered as normal if required

Yes

Yes

Yes

No

No

No

Assess and stimulate baby on warmed towels on mother’s abdomen or at the foot of the bed. Remember, whilst the cord is still pulsating the

neonate is receiving an oxygenated blood supply.

If ventilation is necessary consider initiating this with the cord intact. Cord separation is only

necessary when transfer to the resuscitaire is required.

Timing of cord separation for a compromised infant should ultimately be decided on a case

by case basis.

Has the baby been born in good condition (AT ANY GESTATION) NEW 2018?

Summary: Optimal Cord Clamping

Clamp and cut the cord immediately after birth whilst

initiating skin to skin

Is there meconium? If the baby is born in good

condition and cries immediately Optimal Cord Clamping is appropriate.

However if they do not cry, avoid stimulation as normal and separate the cord for transfer to the resuscitaire

Are there any contraindications to Optimal Cord Clamping? (See

Section 2.3)

Wait to clamp the cord for

three minutes unless the

baby’s condition

deteriorates


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1. Aim/Purpose of this guideline To inform all Midwives and Obstetricians on the topic of Optimal Cord Clamping including rationale, contraindications and guidance on when to implement. Optimal Cord Clamping is a routine part of a physiological third stage. It can also be safely implemented when active management is required. There is a growing body of evidence to support Optimal Cord Clamping and it is recommended by the Royal College of Midwives (RCM), World Health Organisation (WHO) and the UK Resuscitation Council. Optimal Cord Clamping has clear benefits to both mum and baby, alongside a discussion on management of the third stage of labour, parents should be informed that Optimal Cord Clamping will:

Increase their baby’s blood volume by up to 40% and subsequently

improve iron stores for the first 6 months of life. Iron is essential for brain

development.

Ensure baby receives stem-cell rich cord blood

Increase their baby’s weight as they receive a normal circulating blood

volume

Maximise the amount of oxygenated blood their baby receives and help

establish breathing

Stabilise blood pressure

Although the benefits are present for all babies the findings have more significance for babies that are: premature, have a low birth weight or are born to an anaemic mother. In preterm infants Optimal Cord Clamping has additionally been shown to decrease infant sepsis, intraventricular haemorrhage, rates of neonatal blood transfusion and the incidence of necrotising enterocollitis.

For the mother Optimal Cord Clamping can decrease the volume of the placenta, reduce rates of feto-maternal transfusion (important for rhesus negative mothers) and assist in creating a calm and unhurried environment.

2. The Guidance

2.1. Active Management of Third Stage of an Uncompromised Baby at any Gestation

Following delivery of the baby give oxytocic

Wait for a minimum of three minutes; clamp the cord before 5 minutes if active management of the third stage is planned. NEW 2018

Clamp and cut the cord

Wait for signs of separation before attempting to deliver the placenta

The position of the baby during Optimal Cord Clamping is not thought to influence the amount of blood the baby receives


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2.2. Optimal Cord Clamping for Babies Requiring Resuscitation

Those neonates requiring positive pressure ventilation and resuscitation would especially benefit from Optimal Cord Clamping. A policy of ‘wait a minute’ may be appropriate unless the baby has a heartbeat below 60bpm which is not getting faster NEW 2018. Consider that neonatal assessment and stimulation usually happens during this first minute which can be carried out on warm towels on the delivery bed or on the mother’s abdomen. Remember that while the cord continues to pulsate the baby is still receiving oxygenated blood.

Should transfer to the resuscitaire be deemed necessary the cord should be promptly clamped and cut. In these situations ‘cord milking’ towards the baby may be performed

Timing of cord clamping for a compromised infant should ultimately be decided on a case by case basis, being mindful of the clinical context

2.3. Contraindications to Optimal Cord Clamping

Severe Fetal Growth Restriction (FGR)

If a neonate is at significantly increased risk of polycythaemia i.e. born to a poorly controlled diabetic mother or suffering severe FGR

Severe fetal distress in 1st stage

Meconium Stained Liquor, unless in good condition and cries immediately

Maternal Haemorrhage

Vasa Previa

2.4. Operative Vaginal Delivery Optimal Cord Clamping should be performed at instrumental delivery as for spontaneous vaginal birth. Good communication with the neonatal team is crucial during this time and if at any point they feel that Optimal Cord Clamping should be abandoned this should be respected.

2.5. Caesarean Section (CS)

Upon delivery of the baby Carbetocin/Oxytocin should be given

Cord clamping should be deferred for 45 seconds, evidence suggests that this results in comparable benefits to 3 minutes OCC following vaginal birth. NEW 2018

A short delay in cord clamping at CS may reduce maternal bleeding by allowing more time for separation before the surgeon removes the placenta. Heavy bleeding not controlled by Green Armitage clamps should prompt immediate cord clamping and placenta removal.

2.6. Cord Blood Sampling A delay of three minutes does not appear to adversely affect the validity of umbilical cord blood gas analysis. Samples should, however, be taken immediately after cord clamping. If this is not possible blood should be taken from a segment of cord isolated between two clamps.


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2.7. Documentation The timing of Optimal Cord Clamping must be documented in the maternal delivery notes.

3. Monitoring compliance and effectiveness

Element to be monitored

Correct management of Optimal Cord Clamping

Lead Audit Midwife

Tool Was Optimal Cord Clamping performed when contraindicated

Was Optimal Cord Clamping offered to women having a CS

At CS was Optimal Cord Clamping performed for 45 seconds

Frequency 1% or 10 sets, whichever is the greater, of all health records of women who have delivered will be audited once over the 3 year lifetime of the guideline or

sooner if indicated.

Reporting arrangements

Clinical Audit Forum

During the process if the audit compliance is below 75% or other deficiencies identified, this will be identified by the Audit Midwife and an action plan agreed

Acting on recommendations and Lead(s)

The Audit midwife will set a time frame for the action to be completed

The action plan will be monitored by the Audit midwife

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within an agreed time frame

The Audit Midwife will lead to take each change forward where appropriate

Maternity Patient Safety Newsletter.

4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS

Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx


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Appendix 1. Governance Information

Document Title Optimal Cord Clamping Clinical Guideline V2.0

Date Issued/Approved: 6th September 2018

Date Valid From: 10th October 2018

Date Valid To: 10th October 2021

Directorate / Department responsible (author/owner):

Lizzie Anstey Midwife

Contact details: 01872 252879

Brief summary of contents

This guideline gives guidance to Midwives and Obstetricians in the management of Optimal Cord clamping of the baby’s umbilical cord at delivery

Suggested Keywords:

Delayed, deferred, cord, clamping, DCC, new-born, physiological, placenta, 3rd, third, stage

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: 6th September 2018

This document replaces (exact title of previous version):

Delayed Cord Clamping (DCC) - Clinical Guideline V1.0

Approval route (names of committees)/consultation:

Maternity Guidelines Group Obs and Gynae Directorate Divisional Board Policy Review Group

Divisional Manager confirming approval processes

Tunde Adewopo

Name and Post Title of additional signatories

Not Required

Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings

{Original Copy Signed}

Name: Caroline Amukusana


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Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Clinical/Midwifery and Obstetrics

Links to key external standards CNST 5.2 & 5.4

Related Documents:

Farrar D, Airey R, Law G, Tuffnell D, Cattle B, Duley L. (2011). Measuring placental transfusion for term births: weighing babies with cord intact. BJOG: An International Journal of Obstetrics & Gynaecology. 118 (1), 70-75.

McDonald S, Middleton P, Dowswell T, Morris P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews (2013) Issue 7. Art. No.: CD004074.

Rabe H et al. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews (2004) Issue 4. Art. No.: CD003248.

Mercer J, Vohr B, McGrath M, Padbury J, Wallach M, Oh W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular haemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics. 117 (4), 1235-42.

Airey R, Farrar D, Duley L. Alternative positions for the baby at birth before clamping the umbilical cord. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD007555.

World Health Organisation. (2012). Guidelines on Basic Newborn Resuscitation. WHO. Geneva.

Rabe H, Diaz-Rossello J, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental


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transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003248

UK Resuscitation Council. (2010). Guidelines on Newborn Life Support. Resuscitation Council (UK). London.

Erickson-Owens D, Mercer J. (2012). Rethinking placental transfusion and cord clamping issues. The Journal of Perinatal and Neonatal Nursing. 26 (3), 202-17.

Andersson O et al. (2013). Effects of delayed compared with early umbilical cord clamping on maternal postpartum haemorrhage and cord gas analysis: a randomized trial. Acta Obstet Gynecol Scand. 92, 567-74

RCOG. (2015) Clamping of the Umbilical Cord and Placental Transfusion

Andersson O, Hellström-Westas L, Domellöf M. Elective caesarean: does delay in cord clamping for 30 s ensure sufficient iron stores at 4 months of age? A historical cohort control study. BMJ Open 2016 NEW 2018

Al-Wassia H, Shah PS. Efficacy and Safety of Umbilical Cord Milking at Birth: A Systematic Review and Meta-analysis. JAMA Pediatr. 2015;169(1):18–25. NEW 2018

Training Need Identified? Yes, Multidisciplinary PROMPT training day.

Version Control Table

Date Version No

Summary of Changes Changes Made by

(Name and Job Title)

18th June 2015

V1.0 Initial Issue Elizabeth Cowan

Midwife


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6th September 2018

V2.0

Reviewed, ‘deferred’ changed to ‘optimal’, some points clarified, cord milking recommended when Optimal Cord Clamping cannot be facilitated.

Lizzie Anstey Midwife (nee Cowan)

All or part of this document can be released under the Freedom of

Information Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge,

Procedural and Web Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line

Manager.


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Appendix 2. Initial Equality Impact Assessment Form

This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups.

Name of Name of the strategy / policy /proposal / service function to be assessed Optimal Cord Clamping Clinical Guideline V2.0

Directorate and service area: Obs and Gynae Directorate

Is this a new or existing Policy? Existing

Name of individual completing assessment: Lizzie Anstey

Telephone: 01872 252879

1. Policy Aim*

Who is the strategy / policy / proposal /

service function aimed at?

To provide all health professionals guidance on Deferred Cord Clamping for the neonate

2. Policy Objectives*

To maximise the amount of oxygenated blood the baby receives through the cord at delivery

3. Policy – intended Outcomes*

Improved neonatal outcomes

4. *How will you measure the

outcome?

Compliance Monitoring Tool

5. Who is intended to benefit from the

policy?

All new-born babies and their mothers

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

X

Please record specific names of groups Maternity Guidelines Group Obs and Gynae Directorate Policy Review Group


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Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age X All new-born babies and their mothers

Sex (male,

female, trans-gender / gender reassignment)

X All new-born babies and their mothers

Race / Ethnic communities /groups


Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.


Religion / other beliefs


Marriage and Civil partnership


Pregnancy and maternity


Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian


You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have

been identified as not requiring consultation. or

What was the outcome of the consultation?

Guideline agreed

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


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Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No X

9. If you are not recommending a Full Impact assessment please explain why.

No areas indicated

Signature of policy developer / lead manager / director Lizzie Anstey

Date of completion and submission 6th September 2018

Names and signatures of members carrying out the Screening Assessment

1. Lizzie Anstey

2. Human Rights, Equality & Inclusion Lead

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust’s web site. Signed Sarah-Jane Pedler Date 6th September 2018