Perinatal Perspectives

Perinatal Perspectives A Publication of the Champlain Maternal Newborn Regional Program Spring 2013 www.cmnrp.ca Volume 3, Issue 1 Delayed cord clamping in term and preterm births: Current Evidence Introduction France Morin, RN BScN MScN Perinatal Consultant, CMNRP The optimal time to clamp the umbilical cord after birth has been a topic of much controversy and debate. This birth practice is inconsistent among health care providers and in various countries. 1, 2 Although many randomized controlled trials of term and preterm infants have studied the potential risks and benefits of early versus delayed umbilical cord clamping, the ideal time to perform this intervention has yet to be established. 3, 4, 5 Concerns surrounding the timing of cord clamping include maternal and neonatal considerations such as delay in initiating resuscitation and umbilical cord blood banking. This article will examine the effects of placental transfusion when cord clamping is delayed or when the cord is milked. It will summarize the evidence on the effects of delayed cord clamping (DCC) in preterm and term infants, as well as the effects on maternal outcomes. An overview of the recommendations from Canadian professional groups on optimal time for cord clamping will be presented. Physiology of placental transfusion At birth, blood flow in the umbilical vein usually continues for a few minutes. When cord clamping is delayed or the cord is milked, infants experience placental transfusion as whole blood is transferred from the placenta to the infant. 6 This blood contains not only volume and red blood cells but also stem cells and immune cells important in repairing tissue and building immunocompetence. 6,7,8 Red blood cells are a major source of iron during the first few months of life. 9 Allowing placental transfusion after birth can provide the infant with a 30% increase in blood volume and up to a 60% increase in red blood cells. 10 Placental transfusion is of great value as it provides essential life support during the fetal-to-neonatal transition. 11 It has an important role in opening the lungs, increasing pulmonary perfusion, enhancing lung fluid clearance, and improving oxygen delivery to the infant s tissues. This additional blood volume may reduce the vulnerability of infants to inflammatory processes and provide protection against infection. 12,13 Program Partners Almonte General Hospital Brockville General Hospital Consortium national de formation en santé (CNFS) Children s Hospital of Eastern Ontario Ottawa Public Health Community Health Centres of Eastern Ontario Cornwall Community Hospital Eastern Ontario Health Unit Faculties of Medicine and Health Sciences, University of Ottawa Faculty of Health Sciences, Queen s University Hastings and Prince Edward Counties Health Unit Hawkesbury and District General Hospital Hôpital Montfort Kingston, Frontenac, Lennox and Addington Public Health (KFL&A) Kingston General Hospital Midwifery Practice Groups in Eastern and Southeastern Ontario Pembroke Regional Hospital Perth and Smiths Falls District Hospital Queensway Carleton Hospital Quinte Health Care Renfrew County and District Health Unit Renfrew Victoria Hospital St. Mary s Home and the Young Single Parent Support Network The Ottawa Hospital Winchester District Memorial Hospital Inside: Delayed cord clamping in term and preterm births: Current evidence Pg. 1 BORN News: Enhancements to the Maternal Newborn Dashboard Pg. 4

Table 1 Factors that increase blood transfusion in the infant Factors Timing of umbilical cord clamping Gravity Uterine contractions Cord milking Uterotonic drugs Effects A delay in the time of cord clamping results in more blood being transferred to the infant. The amount of blood transferred is proportional to the time delayed. Holding the infant above the level of the placenta (> 10 cm) slows the placenta transfusion; lowering the infant accelerates it. A 5-minute delay in cord clamping allows the infant who is skin-to-skin to receive a full placental transfusion. Squeeze blood from the placenta to the infant via the umbilical vein if the cord is left intact. This role continues as long as the placenta is attached to the uterine wall. Suggested to be as effective in terms of accelerating placental transfusion as delaying cord clamping. Have been found to speed up the placental transfusion but do not increase the overall amount of blood transfused. (Mercer & Erickson-Owens, 2012) Effects of delayed cord clamping on neonatal and maternal outcomes The effects of delayed cord clamping in preterm and term infants, as well as the effects on maternal outcomes, are summarized below (compiled from systematic reviews): Benefits: Preterm infants Increased blood volume 4,5 Better circulatory stability 5 Reduced need for blood transfusions 4,5 Reduced incidence of intraventricular hemorrhage (all grades) 4,5,14,15 Reduced incidence of necrotizing enterocolitis 4 Benefits: Term infants Higher hemoglobin concentration levels, 2 to 3 months of age 15,16 Higher total body iron stores, 2 to 6 months of age 1,16 Higher circulating ferritin level, 2 to 6 months of age 16 Lower incidence of iron-deficiency anemia 1,15 Adverse outcomes: Preterm and term infants Increased incidence of jaundice requiring phototherapy 16 Increased incidence of asymptomatic polycythemia 1 Unchanged maternal and neonatal outcomes Incidence of postpartum hemorrhage 14,16 Incidence of retained placenta 14,16 Incidence of other obstetric outcomes (e.g. duration of the third stage of labor, use of uterotonic medications, maternal blood transfusion) 14,16 Infant Apgar scores, need for resuscitation, or umbilical cord ph values 5,14 Frequency of respiratory distress in the newborn 14 Overall, the evidence appears to suggest that delayed cord clamping is likely to result in better neonatal outcomes in both term and preterm infants. However, there is insufficient evidence to date to support or refute delayed cord clamping in infants requiring 17, 18 resuscitation. Recommendations from Canadian professional groups There are currently no formal clinical guidelines for the timing of umbilical cord clamping. As a result, the amount of time between birth and cord clamping is a decision made by the individual health care provider based mainly on personal preference. Many professional groups in Canada support the practice of delayed cord clamping. 2

The Society of Obstetricians and Gynaecologists of Canada 19 recommends that whenever possible, delaying cord clamping by at least 60 seconds is preferred to clamping earlier in premature newborns (< 37 weeks gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping. (p. 986). For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping (p. 987). They further suggest that DCC is recommended in the case of cord blood banking in order to improve recovery volume. 19 According to the Canadian Paediatric Society s Neonatal Resuscitation Program (NRP) 18, cord clamping should be delayed for at least 1 minute in babies not requiring resuscitation. There is insufficient evidence to recommend a time for clamping in babies who require resuscitation. (p. 291) The practice of delayed cord clamping for a minimum of 2 minutes after birth is also recommended in the Provincial Council for Maternal and Child Health (PCMCH) s 2012 mother-baby dyad care initiative. 20 It is imperative that health care providers seek to offer evidence-informed care. This ensures high quality care for childbearing families and emphasizes a culture of attentiveness to clinical evidence. References 1. Hutton, E. K., & Hassan, E. S. (2007). Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and metaanalysis of controlled trials. JAMA, 297(11), 1241-1252. doi: 10.1001/ jama.297.11.1241 2. Winter, C., Macfarlane, A., Deneux-Tharaux, C., Zhang, W., Alexander, S., Brocklehurst, P., Troeger, C. (2007). Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe. BJOG: An International Journal of Obstetrics and Gynaecology, 114(7),845-854 3. Oh, W. (2007). Timing of umbilical cord clamping at birth in full term infants. JAMA, 297, 1257 1258. 4. Rabe, H., Diaz-Rossello, J. L., Duley, L., & Dowswell, T. (2012). Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews, Issue 8. Art. No.: CD003248. doi: 10.1002/14651858.CD003248.pub3. 5. Rabe, H., Reynolds, G., & Diaz-Rossello, J. (2008). A systematic review and meta-analysis of a brief delay in clamping the umbilical cord of preterm infants. Neonatology, 93(2), 138 144. 6. Mercer, J. S., & Erickson-Owens, D. (2012). Rethinking placental transfusion and cord clamping issues. Journal of Perinatal & Neonatal Nursing, 26(3), 202-217. doi: 10.1097/JPN.0b013e31825d2d9a 7. Levy, T., & Blickstein, I. (2006). Timing of cord clamping revisited. Journal of Perinatal Medicine, 34(4), 293 297. 8. Sanberg, P. R., Park, D. H., & Borlongan, C. V. (2010). Stem cell transplants at childbirth. Stem Cell Reviews and Reports, 6(1), 27 30. 9. Dewey, K. G., & Chaparro, C. M. (2007). Session 4: Mineral metabolism and body composition iron status of breast-fed infants. Proceedings of the Nutrition Society, 66(3), 412 422. 10. Jahazi, A., Kordi, M., Mirbehbahani, N. B., & Mazloom, S. R. (2008). The effect of early and late umbilical cord clamping on neonatal hematocrit. Journal of Perinatology, 28(8), 523 255. 11. Mercer, J., Skovgaard, R. & Erickson-Owens, D. (2008). Fetal to neonatal transition: First, do no harm. In S. Downe (Ed.). Normal Childbirth: Evidence and debate (2 e ed.)(pp.149-174). Toronto, ON: Churchill Livingston Elsevier. 12. Molitoris, B. A., & Sutton, T. A. (2004). Endothelial injury and dysfunction: Role in the extension phase of acute renal failure. Kidney International, 66(2), 496 499. 13. Rajnik, M., Salkowski, C. A., Thomas, K. E., Li, Y. Y., Rollwagen, F. M., & Vogell, S. N. (2002). Induction of early inflammatory gene expression in a murine model of nonresuscitated, fixed-volume hemorrhage. Shock, 17(4), 322 328. 14. Mathew, J. L. (2011). Timing of umbilical cord clamping in term and preterm deliveries and infant and maternal outcomes: A systematic review of randomized controlled trials. Indian Pediatrics, 48(2), 123 129. 15. van Rheenen, P., & Brabin, B. J. (2004). Late umbilical cord-clamping as an intervention for reducing iron deficiency anaemia in term infants in developing and industrialized countries: A systematic review. Annals of Tropical Paediatrics, 24, 3 16. 16. McDonald, S. J., & Middleton, P. (2008). Effect of timing of umbilical cord of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. doi: 10.1002/14651858.CD004074.pub2 17. Perlman, J. M., Wyllie, J., Kattwinkel, J., Altkins, D. L., Chameides, L., Goldsmith, J. P., Neonatal Resuscitation Chapter Collaborators (2010). Part 11: Neonatal resuscitation: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation, 122 (suppl 2), S516-S538. doi: 10.1161/CIRCULATIONAHA.110.971127 18. Finan, E., Aylward, D., Aziz, K., & Canadian Paediatric Society, Neonatal Resuscitation Program Executive Committee (2011). Neonatal resuscitation guidelines update: A case-based review. Paediatrics & Child Health, 16(5), 289-291. 19. Leduc, D., Senikas, V., & Lalonde, A. (2009). Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage. SOGC clinical practice guideline No. 235. Journal of Obstetrics & Gynaecology Canada, 30(10), 980-993. 20. Provincial Council for Children s Health (PCMCH) (2012). Motherbaby dyad care. Implementation toolkit. Retrieved from http:// www.pcmch.on.ca/linkclick.aspx?fileticket=in9cl8of_a8% Views, opinions and advertisements in the Perinatal Perspectives are not necessarily endorsed by the editorial staff. Comments are welcome. 3

BORN News: Enhancements to the Maternal Newborn Dashboard Tammy Budwha, BORN Coordinator, BORN Ontario On November 19, 2012 BORN Ontario released the Maternal Newborn Dashboard (MND), an innovative, evidence-informed audit and feedback tool. The MND was designed to help hospitals monitor performance, identify evidence-practice gaps, and facilitate change. Since the MND was launched, appreciative users have provided positive feedback regarding its value. Given the keen interest in reviewing record level data related to dashboard results, BORN saw the need to enhance the sub-report for Key Performance Indicator (KPI) 4. The sub-report now provides links to the patient profile for all maternal records of low-risk women having a repeat cesarean section performed from 37 to <39 weeks' gestation and allows users to view the indicator criteria used to classify these records. MND highlight A BORN article related to the MND was published in the January 2013 edition of JOGC: Measuring Quality in Maternal-Newborn Care: Developing a Clinical Dashboard http://www.jogc.com/abs tracts/full/201301_obst etrics_2.pdf Other MND Related News BORN hosted a provincial webinar focusing on Newborn Screening on February 21 st in support of KPI1. For example, if the MND report shows 5 records that meet the criterion for KPI 4 for a given month, a user can click on the numerator value of 5 (hyperlink) and will be directed to the sub-report for this indicator. The 5 records are displayed with chart numbers that link to the patient profile, along with record level data values for all data elements that are used as criterion for the indicator (see chart above). The MND sub-report helps users quickly and easily review records for audit purposes. In addition, it clearly shows the data elements that are used to identify records meeting the criterion for KPI 4. Similar enhancements are being implemented for all other dashboard KPIs. BORN Ontario will notify users once they become available. Did you know? Newborn Screening Ontario (NSO) offers one-day workshops which include a component on sample collection. The NSO website also features blood collection resources that are available for download. http://www.newbornscre ening.on.ca/data/1/rec_ docs/407_unsatisfactor y_sample_educational_ Resource.pdf While audit and feedback does not guarantee that individuals or institutions will make practice changes and move towards quality improvement, they are an important first step. We can be sure that practice change and quality improvement will not occur without an awareness of the issues. http://www.jogc.com/abstracts/full/201301_obstetrics_2.pdf 4

Resources Cancer in Pregnancy and Lactation: The Motherisk Guide Editors: Gideon Koren & Michael Lishner Cambridge Univeristy Press, 2011 Cancer in pregnancy presents perinatal health care providers with a serious and ethical challenge, yet the sources of concise data and guidance for the management of this disease are scarce. This book provides evidence-based information needed to address the complex issues of maternal diagnosis, management, treatment, prognosis and long-term impact on the unborn child. It is an essential read for all maternal-fetal medicine physicians, obstetricians, neonatologists, oncologists and pharmacologists. This book can be purchased at http://www.parentbooks.ca Supporting parents when parents experience mental health challenges: Ready to use workshops for service provides. Best Start Resource Centre, 2013 A ready-to-use workshop to meet the needs of service providers who are working with parents experiencing mental health challenges. This workshop consists of four modules suitable for a full-day workshop or four 1 1.5 hour learning events. Each module provides information, links to other resources, highlights resources service providers can use on a day-to-day basis, and provides support through discussion of cases and reflective questions. This free resource can be downloaded at http://www.beststart.org/resources/ppmd/supporting_parents_modules.html The Canadian hospitals maternity policies and practices survey Public Health Agency of Canada, 2012 This report provides a description of routine maternity care practices in Canadian hospitals, including birth statistics, policy development, committee structure, health human resources, cultural consideration, educational undertakings and physical facilities. Practices and policies are also described for labour and birth, postpartum, infant feeding, neonatal intensive care/special care nursery, and families coping with grief and loss. A PDF version of this report can be obtained from http://www.publichealth.gc.ca/chmpps. Oxorn-Foote Human labor and birth (6 th ed) Editors: Glenn Posner, Jessica Dy, Amanda Black, Griffith Jones McGraw Hill Professional, 2013 This classic childbirth handbook, completely revised and updated, provides vital information on labor and birth in a concise, easy-to-read presentation. It covers nearly every conceivable obstetrical topic (e.g. hemorrhage, fetal concerns, preterm and prolonged labor, dystocia, etc.), offering a direct step-by-step approach to management, procedure, and technique. This book can be purchased at http://www.amazon.com 5

Check out these websites! MothersAdvocate.org, a not-for-profit service of InJoy Birth and Parenting Education, is dedicated to helping expectant mothers have the healthiest, safest, most satisfying birth possible. This user-friendly website features free, professionally-produced online video clips, a printable booklet, helpful handouts, and more. The Academic Health Council-Champlain Region (AHC) (www.ahc-cas.ca/) is a partnership between the University of Ottawa, Algonquin College, La Cité Collégiale and the Champlain s region s Local Health Integration Network (LHIN). Their main area of focus has been to lead, facilitate and sustain collaborative education, practice and research within the region. It is a one-stop resource for health service providers, management and educators to create, integrate, and improve interprofessional learning opportunities. KidCareCanada Society (http://kidcarecanada.org/) translate current research and applies technology to produce appealing educational resources for new and expectant parents so that they can give their baby the best possible start in life. Health Nexus (www.healthnexus.ca) is a bilingual organization that supports individuals, organizations and communities to strengthen their capacity to promote health. Visit their new site! What s new? Simpler navigation Social media integration- Clean modern look Find information fast. Evidence Updates (http://plus.mcmaster.ca/evidenceupdates/). BMJ Group and McMaster University's Health Information Research Unit are collaborating to provide health care providers access to current best evidence from research, tailored to their own health care interests, to support evidence-based clinical decisions. This service is unique: all citations are pre-rated for quality by research staff, and then rated for clinical relevance and interest by at least 3 members of a worldwide panel of practicing physicians. This website provides: A searchable database of the best evidence from the medical literature An email alerting system Links to selected evidence-based resources Come join CMNRP on the last Wednesday of the month from 2 to 3 pm To register your site for these sessions please contact scheduling@otn.ca or your site coordinator. For further registration inquiries and technical difficulties, please contact: 1-866-454-6861. The 2012-2013 Schedule and archived sessions are available on the CMNRP website: http://www.cmnrp.ca/en/cmnrp/the_learning_caf_p553.html 6

Preliminary Program Day 1-Thursday May 30 Day 2-Friday May 31 Strategies to reduce cesarean sections Midwifery-led Birth Centres in Ontario New options for families Mother-Baby Dyad Care: Dispelling the myths Supporting moms on methadone and their babies Pulling it all together: Supporting families experiencing postpartum depression Supporting breastfeeding: What happens after discharge? Obstetrical mystery case Umbilical cord derived stem cells: A potential breakthrough in perinatal medicine I m not early, I m late. What s the fuss? Partners in care: How pathology can help parents & healthcare providers make decisions Promoting safe sleep for infants: A RNAO best practice guideline Formula supplementation Benign or not? Family integrated care: An innovative model of care End of life care in the NICU: Can information technology-based tools improve shared decision making? Newborn mystery case 7

Interesting Articles D Souza, R., & Arulkumaran, S. (2013). To C or not to C? Caesarean delivery upon maternal request: A review of facts, figures and guidelines. Journal of Perinatal Medicine, 41(1), 5-15. doi: 10.1515/jpm-2012-0049. The last few decades have seen an unrelenting rise in caesarean section (CS) rates. In addition to an increase in numbers of CS performed worldwide, there has also been a change in the indications for CS, a reflection of changing times. A new dilemma facing obstetricians is the increasing demand for CS in the absence of any medical indication (caesarean delivery on maternal request CDMR). CDMR has generated enormous interest both in the media and among health-care providers, and many national and international bodies have now issued guidelines on the topic. This article explores the factors responsible for the increase in CDMR. Dugas, M., Shorten, A., Dube, E., Wassef, M., Bujold, E., & Chaillet, N. (2012). Decision aid tools to support women's decision making in pregnancy and birth: A systematic review and meta-analysis. Social Science & Medicine, 74(12), 1968-1978. Decision aid tools can assist health professionals to provide information and counseling about choices during pregnancy and support women in shared decision making. The choice of a specific tool should depend on resources available to support their use as well as the specific decisions being faced by women, their health care setting and providers. Peterson, W. E., Davies, B., Rashotte, J., Salvador, A., & Trepanier, M.-J. (2012). Hospitalbased perinatal nurses identify the need to improve nursing care of adolescent mothers. Journal of Obstetric, Gynecologic & Neonatal Nursing, 41(3), 358-368. A minority of perinatal nurses have expertise in adolescent mother-friendly care. There is a need for perinatal unit-level interventions to support the development of nurses' skills in caring for adolescent mothers and their knowledge of community-based resources. Peer mentoring and self-reflective practice are promising strategies. Grohmann, B., Brazeau-Gravelle, P., Momoli, F., Moreau, K., Zhang, T., & Keely, E. (2012). Obstetric health-care providers perceptions of communicating gestation weight gain recommendation to overweight/obese pregnant women. Obstetric Medicine, 5, 161-165. doi: 10.1258/om.2012.120003. Gestational weight gain (GWG) is a major risk factor of poor pregnancy outcomes. Obese pregnant women frequently report bias and discrimination when dealing with healthcare providers (HCPs). Effective communication of GWG recommendations may impact risks. The objectives of this study were to identify perceptions of HCPs in communicating GWG recommendations and to identify potential gaps/opportunities that could be addressed in the development of appropriate materials/programmes. Conclusions: HCPs believe they are providing GWG recommendations in an effective and empathetic manner. While an underlying current of bias/ discrimination remains, there is recognition of the importance of more training and access to appropriate tools. Severe Combined Immune Deficiencies screening to begin in Ontario in April 2013 Newborn Screening Ontario (NSO) is pleased to announce that the Government of Ontario has accepted the recommendation from the Newborn and Childhood Screening Subcommittee to add Severe Combined Immune Deficiencies (SCID) to Ontario s newborn screening panel. This recommendation was endorsed by the Provincial Council on Maternal and Child Health (PCMCH) and Newborn Screening Ontario (NSO), and NSO is targeting April 22, 2013, to begin screening. Based on direct communications with other jurisdictions already screening for SCID, they estimate that approximately 52 infants will screen positive each year, and about 5-10 will have SCID. For more information, please visit the Newborn Screening Ontario s website at: http://www.newbornscreening.on.ca. 8

Upcoming CMNRP Workshops Breastfeeding Fundamentals April 26, 2013 in Ottawa Fetal Health Surveillance in Labour Fundamentals April 18 & May 28, 2013 in Ottawa Fetal Health Surveillance in Labour Instructor April 19, 2013 in Ottawa Neonatal Resuscitation Program Provider April 25 & June 6, 2013 in Ottawa April 29, 2013 in Kingston Labour Support June 11, 2013 in Ottawa May 7, 2013 in Kingston * All workshops are open to interprofessional perinatal care providers. Registration form on the CMNRP website: http://www.cmnrp.ca/en/cmnrp/ Workshops_p550.html For more information, please contact Ariane Cloutier at 613-737-2660 ext. 2660 or by email acloutier@cmnrp.ca Contact us Healthy babies Healthy Children Protocol (2012) As part of the government s overall commitment to quality healthy child development programs and services, the Ministry of Children and Youth Services (MCYS) developed the new Healthy Baby Healthy Children (HBHC) Protocol (2012) in partnership with the Ministry of Health and Long- Term Care (MOHLTC). Of particular interest to hospitals, midwifery services and community partners, the new Protocol: 1. Requires all public health units to use the new HBHC Screen at the prenatal, postpartum and early childhood periods. This evidenceinformed tool replaces the current Larson (prenatal) and Parkyn (postpartum) screens. 2. Allows flexibility for public health units to select, in collaboration with hospitals and other health care partners, an HBHC Screening Liaison Model that works best for their community. 3. With the introduction of the new screening process, effective partnerships among public health units, hospitals, midwives and other health care partners continue to be integral to the continuity of care for women and their families. The new protocol is available on the Ontario Public Health Standards website at: http:// www.health.gov.on.ca/en/pro/programs/ publichealth/oph_standards/docs/hbhc.pdf Champlain Maternal Newborn Regional Program (CMNRP) 2305 St-Laurent Blvd. Ottawa ON K1G 4J8 Tel: 613-737-2660 Fax: 613-738-3633 E-mail: cmnrpinfo@cmrnp.ca 9