MNSI's comment on the RCOG's recent umbilical cord care paper

During MNSI investigations we often see variation in cord clamping practices when neonatal resuscitation is required. In this blog, Paul Mannix, lead neonatal clinical advisor for MNSI, comments on the recent scientific impact paper (SIP) published by the Royal College of Obstetricians and Gynaecologists (RCOG).

What the paper says

The RCOG’s newest SIP focuses on the care of a newborn baby when they are adapting to life outside of their mother’s body. The paper explains how a knowledge of adaptive changes is required to understand the fetal and newborn circulatory system, and the impact of umbilical cord clamping on these changes. Readers are reminded of the importance of assessing the baby’s breathing and heart rate. Clear and current evidence is provided from physiological research into the adaptive processes around birth for the baby.

For the past 15 years, there have been ongoing discussions about the optimal management of the umbilical cord following birth. It is now widely recognised that it is rarely required for the cord to be immediately clamped and cut. In fact, there are wide ranging benefits for the baby when the cord clamping is delayed. Consequently, practice has now changed and clamping of the umbilical cord does not occur for at least one minute after birth, provided this is practical and possible. Many maternity and neonatal teams have worked hard to develop local guidance for how best this can be achieved.

Why timing matters

This SIP expands on this work. It explains that the inflation of the lungs gives the baby the greatest benefit in supporting circulatory changes. Most babies cry after birth; this inflates their lungs and eases the pressure on blood vessels around the air sacs (alveoli) which are not yet inflated.

This is the most important aspect of the baby’s transition. For a baby who has not started breathing on their own, giving inflation breaths whilst the cord is still intact will help as this supports the same fall in pressure on those blood vessels. This fall in pressure is the first step to their circulation system transitioning to an adult’s.

The SIP further explains that the target of one minute from birth to clamping is also unnecessary and that for an uncompromised baby, clinicians do not need to set a specific time frame. The RCOG makes an important point that staff should move away from clock-watching and instead focus on watching the woman and baby.

The group provides their take on general principles in relation to cord clamping. They point out actions they deem inappropriate and comment on the implications of this for policymakers and future research.

What this means in practice

They also provide a list of practical implications. I have quoted them here, and would encourage you to consider these within your own work environment:

• Cord function and closure should be explained to parents as part of information about a baby’s transitional state during the third stage of labour
• The indication and timing of cord clamping should be documented in medical notes in completed minutes and seconds in relation to heart rate and establishment of breathing
• Cord-intact bedside resuscitation has both a physiological and clinical rationale for those preterm and term babies that require airway manoeuvres and inflation breaths. It is feasible, safe and reduces anxiety in parents. However, it is not yet clear whether this further improves clinical outcomes beyond that gained by drying and stimulating with the cord intact for 1 minutes and then cutting for transfer to a resuscitation platform
• Clinical staff need to be aware of current guidance around cord management
• More education and training are required for maternity staff who are accustomed to handing over a baby immediately to neonatal practitioners
• Units that have solved and overcome obstacles to change should share their good practice learning with units initiating or undergoing the process.

Final thoughts

This is a well written and easy to follow paper. It explains the physiology, benefits and practical reasons for moving away from immediate cord clamping.

I would hope that readers will take the paper back to their own teams to discuss and to consider how they may be able to further improve their own practices for the benefit of the babies they provide care for.