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Journal of Neonatal-Perinatal Medicine 8 (2015) 393–402 393

DOI 10.3233/NPM-15915043
IOS Press

Original Research

Safety and efficacy of delayed umbilical cord


clamping in multiple and singleton premature
infants – A quality improvement study
C. Ruangkit, V. Moroney, S. Viswanathan and M. Bhola∗
Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children’s Hospital, University Hospitals,
Case Western Reserve University, Cleveland, Ohio, USA

Received 11 May 2015


Revised 28 July 2015
Accepted 10 August 2015

Abstract.
OBJECTIVES: To evaluate the safety and efficacy of a quality improvement (QI) program of delayed umbilical cord clamping
(DCC) in multiple and singleton preterm infants born at our center.
METHODS: After DCC protocol implementation, compliance and success rate were assessed. Clinical outcomes of selected
150 preterm infants <34 weeks gestation born in 2014 after protocol implementation (Epoch II) were compared to those of
preterm infants born in 2013 before protocol implementation (Epoch I).
RESULTS: Overall protocol compliance rate was 92% (246/267). DCC was successfully performed in 77% (205/267) after
protocol implementation. There were higher multiple births in Epoch II compared to Epoch I (27.3 vs. 15.3%, p < 0.01). At
birth, infants in Epoch II had significantly decreased need for intubation in delivery room (23.3 vs. 39.3%, p < 0.01), had higher
hematocrit (46.4 ± 7.3 vs. 44.0 ± 7.1%, p < 0.01) and less metabolic acidosis (base excess –4.1 ± 2.7 vs. –5.3 ± 4.2 mmol/L,
p < 0.01) compared to those born in Epoch I. During hospital stay, fewer infants in Epoch II received rescue surfactant therapy
(45.3 vs. 56.7%, p = 0.05), medical treatment for PDA (6.7 vs. 16.6%, p = 0.04%) and red blood cell transfusions (20.7 VS.
32.0%, p < 0.01) compared to Epoch I.
CONCLUSIONS: Protocol-guided practice of DCC for 30 seconds can be safely performed in multiple and singleton preterm
infants. In addition to higher initial hematocrit, infants in our QI project had lower need for delivery room resuscitation and less
metabolic acidosis at birth. We also observed decreased need for rescue surfactant therapy, medical treatment for PDA and red
blood cell transfusions after DCC protocol implementation.

Keywords: Delayed umbilical cord clamping (DCC), preterm infants, multiple births, quality improvement (QI)

1. Introduction

Currently there is no consensus for the clinical def-


∗ Corresponding
inition of delayed umbilical cord clamping (DCC)
author: Monika Bhola, M.D., Rainbow Babies &
Children’s Hospital, Division of Neonatology, 11100 Euclid Avenue,
in newborn infants. Wide variations in timing for
Cleveland, OH, USA. Tel.: +1 216 844 3387; Fax: +1 216 844 3380; cord clamping have been reported in clinical trials
E-mail: Monika.Bhola@uhhospitals.org. ranging from 30 seconds to several minutes or till

1934-5798/15/$35.00 © 2015 – IOS Press and the authors. All rights reserved
394 C. Ruangkit et al. / Delayed cord clamping in premature infants

cessation of cord pulsations [1]. Evidence from mul- anism were used during the entire process, including
tiple randomized control trials, systematic review and literature review, staff education, Plan-Do-Study-Act
meta-analyses suggest that DCC in preterm infants is (PDSA) cycle, data collection, and data safety mon-
associated with multiple favorable outcomes without itoring. Our patient population was preterm newborn
any significant increase in adverse outcomes [2, 3]. infants born at MacDonald Women’s Hospital Labor
DCC is endorsed by several international orga- and Delivery Unit (L&D) and subsequently admitted to
nizations including the World Health Organization the Neonatal Intensive Care Unit (NICU) at Rainbow
(2006, updated 2012) [4], the Society of Obstetricians Babies & Children’s Hospital (RB&C) in Cleveland,
and Gynecologists of Canada (2009) [5], the Interna- Ohio during 2013-2014. RB&C’s NICU holds a Level
tional Liaison Committee on Resuscitation (2010) [6], IV designation from the Ohio Department of Health.
and the European Association of Perinatal Medicine The NICU has a total of 82 beds with nearly 1,200
(2013) [7]. Additionally, in 2012 The American Col- admissions per year of predominantly inborn infants.
lege of Obstetricians and Gynecologists published The DCC protocol was drafted after extensive lit-
the committee’s opinion on the timing of umbili- erature review and approved by a multidisciplinary
cal cord clamping after birth, stating that “Evidence QI team comprising of representatives from neonatol-
exists to support delayed umbilical cord clamping (by ogy and obstetrics departments. All viable singleton or
30–60 seconds) in preterm infants, when feasible” [8]. multiple birth preterm infants born at <340/7 weeks’
This statement was later endorsed by the American gestation, for whom palliative care was not planned,
Academy of Pediatrics (AAP) in 2013 [9]. were evaluated by DCC protocol. We excluded infants
Despite strong evidence of its benefits, the prac- with 1) severe placental abruption, 2) hydrops if sec-
tice of DCC has not been widely adopted [10], ondary to anemia or congestive heart failure (CHF),
especially in multiple births. Concerns that impede 3) known twin to twin transfusion syndrome (TTTS)
the universal acceptance of DCC include possible and, 4) congenital anomalies that may hamper the per-
maternal-infant complications, such as maternal hem- formance of the DCC procedure (e.g., gastroschisis,
orrhage and delay in initiating infant resuscitation. omphalocele, spina bifida). In every eligible preterm
Nevertheless, these complications are not substantiated infant umbilical cord clamping was delayed for 30 sec-
by current evidence [10]. The lack of an established onds after birth to allow placental transfusion before
optimal procedure such as patient selection, optimal clamping and cutting the cord. The protocol checklist
DCC time [8], logistic difficulty to implement DCC in and procedure guideline are shown in Fig. 1. Prior to
clinical practice and obstetricians’ unawareness of the implementation of this protocol, the standard practice
benefits of the procedure are also major deterrents of at our institution consisted of clamping and cutting the
DCC procedure [11]. cord immediately after delivery. All neonatal resusci-
Despite the compelling evidence, DCC was not stan- tations were performed according to ILCOR guideline
dard practice at our center. So in 2013, as part of a (2010) [6]. Our center routinely administers 40%
hospital quality improvement (QI) initiative, we devel- inspired oxygen initially for resuscitation of preterm
oped and implemented a protocol for DCC in multiple infants following which oxygen is titrated to main-
and singleton premature infants born at our center, tain the infant’s oxygen saturation in recommended
an academic medical center and a tertiary-care hos- ranges. Before implementing the new protocol, exten-
pital. Data were collected prospectively as a QI study sive education of both neonatal and obstetric staff was
to evaluate the safety and effectiveness of the DCC conducted followed by a PDSA cycle of applying the
protocol. protocol to 20 cases of moderately premature infants,
gestational age 30–34 weeks, during October - Decem-
ber 2013. These infants were not included in our final
2. Materials and methods
analysis. The protocol was fully implemented from
The QI proposal was reviewed by the University January 1, 2014.
Hospitals Institutional Review Board (UH-IRB) which Compliance to the DCC protocol and success rate of
determined that this project did not qualify as human performing the DCC were used as process measures.
subject research because it was conducted as a QI We defined “Protocol Compliance” as completion of
application of a recommended practice, thus individual the checklist with the decision to perform or not
consent was not required. Key drivers for the QI mech- perform DCC determined by protocol. We defined
C. Ruangkit et al. / Delayed cord clamping in premature infants 395

the DCC protocol (Epoch II). To minimize gestational


age bias, infants born in each epoch were stratified into
three gestational age groups: ≤28 weeks, 29–31 weeks,
and 32–33 weeks. Gestational age cut points were
selected to yield similar numbers of patients among
the three gestational age groups based on the patients
born in 2013.
A power calculation was used to calculate the sample
size needed to evaluate the outcomes. Initial hematocrit
level on admission was used as a primary outcome that
reflects placental transfusion during DCC. Our data
from 2013 showed that the mean hematocrit on admis-
sion of all infants less than 34 weeks’ gestation was
44.7 ± 7.0%. Assuming a linear relationship between
hematocrit and gestational ages [12], 43 infants were
required to detect a 3% difference in hematocrit after
intervention at 0.05 alpha level and 80% power for a
two-sided test in each stratified gestational age group.
An additional 15%, or 7 subjects, were added to allow
for attrition. Therefore, 50 were selected as the total
number (N) of infants in each group, resulting in 150
infants in each Epoch and 300 infants in total.
To prevent selection bias, consecutive preterm
infants born in each year were stratified into three ges-
tational age groups until the total number of 50 infants
was obtained in each group. Patients were included
using the same inclusion and exclusion criteria men-
tioned earlier regardless of whether the protocol was
actually being followed or not. However, since the
Fig. 1. Protocol check list and procedure guideline for delayed clinical diagnosis of “severe placental abruption” can
umbilical cord clamping (DCC).
be subjective, for comparison purposes and to mini-
mize selection bias in our cohort, we ventured to place
“Successful Performance of DCC” as the infant receiv- an objective definition on this diagnosis. “Severe pla-
ing DCC for the complete duration of 30 seconds. cental abruption” was defined as significant degree of
Lack of documentation was interpreted as protocol anemia in infants (defined as infants’ initial hemat-
non-compliance. A protocol checklist was provided at ocrit ≤25% or red blood cell transfusion immediately
every eligible delivery for the resuscitation team leader after birth before the initial complete blood count on
to ensure completion. An audit was performed by the admission), in conjunction with a documented diag-
study team using a checklist and chart review. Updates nosis of placental abruption in the mother. All other
on compliance and results were presented at division patients with any placental abruption not meeting
QI meetings every 2-3 months to reinforce the practice, this criterion were included in our analysis, regard-
as well as to gain feedback. The protocol checklist and less of DCC performance. Finally, clinical outcomes
procedure guideline are shown in Fig. 1. between 150 infants in each epoch were analyzed and
For outcome measures and balancing measures, we compared.
enrolled the patients who were born between January Early termination of DCC was permissible at the
1 - December 31, 2013, when early (immediate) umbil- obstetrician’s discretion if the infant’s well being was
ical cord clamping was standard practice, as a historical a concern or if immediate resuscitation was deemed
control group (Epoch I) and compared them to a sim- necessary. Infants who underwent DCC for less than
ilar group of preterm infants who were born between 30 seconds were also included in the analysis as the
January 1 - December 31, 2014 after implementation of data were analyzed based on intention-to-treat.
396 C. Ruangkit et al. / Delayed cord clamping in premature infants

Data collected from maternal charts included moth- ated (compliance to protocol, DCC was performed but
ers’ demographics and clinical history and those from unsuccessful). As a result, DCC was successfully per-
the infants’ charts included infants’ demographics, formed in 77% (205/267) of all infants with gestational
resuscitation record, clinical data, laboratory data, co- ages less than 34 weeks after the implementation of this
morbidities or complications, discharge outcome, and study protocol (Fig. 2).
length of stay. Data on performance of DCC were col- During the 12-month period, DCC protocol compli-
lected using the protocol checklist and were confirmed ance rates ranged from 85–100% and DCC success rate
with maternal and infant chart review. ranged from 57–92% (Fig. 3). The protocol compliance
rate and success rate were similar between singletons
2.1. Statistical analysis and multiple gestations in all gestational age strata
(please refer to supplementary information).
Run charts were used to evaluate the overall perfor-
mance of our QI project including compliance to the 3.2. Outcomes
DCC protocol and the success rate of performing the
DCC over time. After consecutive patient enrollment and stratifica-
IBM SPSS version 20 was used for statistical tion process, 150 out of 267 (56.2%) viable infants,
analysis of outcomes measurement. A univariate anal- gestational age <34 weeks, born in 2014 (interven-
ysis was performed to identify significant differences tion group-Epoch II) were compared with 150 out
between the control group (Epoch I) and the QI inter- of 242 (62%) infants born in 2013 (historical control
vention group (Epoch II). Student’s t-test was used group-Epoch I). There were no significant differences
for parametric continuous variables and results were in demographic data between the two epochs, however,
presented as mean ± standard deviation, SD. For non- there were higher numbers of multiple births in Epoch
parametric continuous variables, Mann-Whitney U test II compared to Epoch I (27.3 vs. 15.3%, p < 0.01)
was used and results were specified accordingly wher- (Table 1). DCC was successfully performed in 111 of
ever it was used. The results were presented as median 150 infants (74%) in Epoch II, whereas no DCC was
(interquartile ranges). Two-tailed Fisher Exact tests or performed in Epoch I.
Pearson’s Chi-square tests were used for categorical Infants in Epoch II had a higher mean initial hema-
variables and results were presented as total number tocrit at birth (46.4 ± 7.3 vs. 44.0 ± 7.1%, p < 0.01)
(%). A p-value ≤0.05 was considered statistically sig- and had less metabolic acidosis (HCO3 23.4 ± 2.6 vs.
nificant. 22.6 ± 3.9 mmol/L, p = 0.05, base excess –4.1 ± 2.7
vs. –5.3 ± 4.2 mmol/L, p < 0.01) compared to Epoch
I. In the subgroup analysis, the differences in the mean
3. Results hematocrit were greatest in infants ≤28 weeks’ ges-
tation (p = 0.02), followed by infants 29–31 weeks’
3.1. Compliance gestation (p = 0.03), and least in infants 32-33 weeks’
gestation (p > 0.05) (Table 2). Polycythemia, defined
After DCC protocol implementation from January as hematocrit >65%, was not found in either Epoch.
1, 2014 to December 31, 2014, 267 infants [194 (73%) Significant degree of anemia (as defined earlier in
singleton, 73 (27%) multiple gestation], gestational Methods) was found only in infants whose mothers had
age less than 34 weeks, were born and admitted to diagnoses of severe placental abruption. Those infants
the NICU. In 21 patients (8%), DCC protocol evalua- did not receive DCC and were predetermined to be
tion was not performed or DCC checklist and guideline excluded as previously stated.
was not followed (non-compliance to protocol, DCC At birth, both groups required similar resuscitation,
was not performed). Of the remaining 246 patients albeit infants in Epoch II had a significantly decreased
(92%) who were evaluated for DCC, 28 patients met need for intubation in the delivery room (23.3 vs.
the exclusion criteria and were excluded from per- 39.3%, p < 0.01). However, there was no difference in
forming DCC (compliance to protocol, DCC was not Apgar scores at 1 or 5 minutes as well as vital signs
performed). DCC was then initiated in the remaining on admission to the NICU. Infants in Epoch II had a
218 patients and was abandoned before 30 seconds lower incidence of rescue surfactant therapy (45.3 vs.
in 13 of these 218 infants (6%) after it was initi- 56.7%, p = 0.05), medical treatment for PDA (6.7 vs.
C. Ruangkit et al. / Delayed cord clamping in premature infants 397

Fig. 2. Flow diagram depicting number of all infants born in 2014 as they pass through the study.

Fig. 3. Run chart showing monthly protocol compliance rates/DCC success rate (dashed line, left axis) and number of infant <34 weeks born
each month (solid line, right axis) in 2014.

16.6%, p < 0.01), and red blood cell transfusions (20.7 During this two-year period our NICU participated
vs. 32.0%, p = 0.04 when compared to those in Epoch in the “Transfusion of Prematures Trial (TOP Trial)”
I during their NICU stay. [13]. Similar numbers of infants were enrolled in
398 C. Ruangkit et al. / Delayed cord clamping in premature infants

Table 1
Demographics of preterm infants in Epoch I (2013) before DCC protocol implementation and Epoch II (2014) after DCC protocol
implementation
Epoch l (2013) Epoch ll (2014) P Value
N = 150 N = 150
Gestational age (weeks) 29.5 ± 3.1 29.6 ± 2.9 0.79
Birth weight (g) 1408 ± 537 1439 ± 510 0.62
Antenatal steroid (%) 144 (96.0) 145 (96.7) 0.76
Mode of delivery C/S (%) 86 (57.3) 89 (59.3) 0.73
Male gender (%) 85 (56.7) 75 (50.0) 0.25
African American (%) 105 (70.0) 102 (68.0) 0.71
Multiple gestation (%) 23 (15.3) 41 (27.3) 0.01
Placental abruption (%) 33 (22.0) 36 (24.0) 0.68

Table 2 period was greater than 90%, and approximately 77%


Laboratory findings on admission of preterm infants in Epoch I of infants with gestational age less than 34 weeks’
(2013) before DCC protocol implementation and Epoch II (2014)
after DCC protocol implementation successfully received DCC after the protocol imple-
mentation. Our safety and feasibility is similar to that
Epoch l (2013) Epoch ll (2014) P Value
N = 150 N = 150 demonstrated by Aziz et al. in 2013, who highlighted
Initial Hematocrit (%) 44.0 ± 7.1 46.4 ± 7.3 <0.01 that meticulous attention to education and reinforce-
Subgroup analysis ment was key to successful implementation of DCC
≤28 weeks (N = 50) [14]. Multiple gestation pregnancies were excluded in
Initial hematocrit (%) 39.6 ± 5.6 42.8 ± 7.2 0.02
most clinical trials of DCC (both term and preterm)
29–31 weeks (N = 50)
Initial hematocrit (%) 45.4 ± 5.9 48.1 ± 6.1 0.03 possibly because of logistical concerns and fear of twin
32-33 weeks (N = 50) to twin transfusion. However, several small random-
Initial hematocrit (%) 47.0 ± 7.6 48.3 ± 7.2 0.38 ized controlled trials have demonstrated that DCC in
Initial blood gas value
Number of sample (%) 137 (91.3) 137 (91.3) 1.00
preterm infants of multiple gestation is implementable
pH 7.24 ± 0.11 7.26 ± 0.11 0.13 and feasible [15, 16]. Despite limited data of DCC in
PCO2 (mmHg) 53.5 ± 15.8 53.1 ± 15.5 0.83 preterm infants of multiple births cited in the literature,
PO2 (mmHg) 84.2 ± 41.4 78.6 ± 36.5 0.24 we were able to safely perform DCC in our population
HCO3 (mmol/L) 22.6 ± 3.9 23.4 ± 2.6 0.05
Base excess (mmol/L) –5.3 ± 4.2 –4.1 ± 2.7 <0.01
of multiples (twins and triplets), which comprised over
Lactate (mmol/L) 2.6 ± 2.3 2.5 ± 2.1 0.58 25% of our preterm infants.

this study during each epoch and had similar rates 4.2. Outcomes
of randomization to high or low transfusion thresh-
old. Bilirubin in both groups reached peak levels at a Our observations of the clinical benefits of DCC
mean postnatal age of 1 week, with mean peak level were consistent with those previously reported in
lower in Epoch II compared to Epoch I (8.7 ± 2.7 vs. the literature. Findings of increase in hematocrit and
9.6 ± 3.1 mg/dl; p = 0.02). Other co-morbidities and decreased need for red blood cell transfusion were con-
discharge outcomes were similar between the two sistent with the systematic review and meta-analysis
groups (Table 3). [2, 3]. Similarly, we were also able to replicate the
findings of other authors in showing a reduction in
resuscitation effort in L&D [17], improved respiratory
4. Discussion status, and decreased need for surfactant [16]. How-
ever, contrary to previous clinical trials, we observed
4.1. Compliance other clinical benefits in our DCC cohort, including
decreased metabolic acidosis on the initial blood gas on
Our QI project has demonstrated that protocol- admission [16, 18], decreased need for medical inter-
guided DCC in singleton and multiple gestation vention for patent ductus arteriosus (PDA) [16, 18–20],
premature infants is feasible and safe. Overall com- and lower peak bilirubin in the DCC group [15, 16,
pliance rate with the protocol during the 12-month 21, 22]. Finally, we did not observe the findings of
C. Ruangkit et al. / Delayed cord clamping in premature infants 399

Table 3
Clinical outcomes of preterm infants in Epoch I (2013) before DCC protocol implementation and Epoch II (2014) after DCC protocol
implementation
Epoch l (2013) Epoch ll (2014) P Value
N = 150 N = 150
Apgar 1 mina 5 (2–8) 6 (2–8) 0.30
Apgar 5 mina 7 (5–8) 8 (6–9) 0.06
Apgar 5 min < 7 (%) 56 (37.3) 42 (28.0) 0.08
MAP (mmHg) 43 ± 9.8 43 ± 8.3 0.87
Heart rate (beat/min) 151 ± 17 157 ± 17 0.07
Admission temperature (◦ C) 36.7 ± 0.5 36.7 ± 0.5 0.79
Resuscitation performed
O2 Supplement (%) 125 (83.3) 127 (84.7) 0.75
CPAP (%) 118 (78.7) 120 (80.0) 0.78
PPV (%) 95 (63.3) 85 (56.7) 0.24
Intubation (%) 59 (39.3) 35 (23.3) <0.01
Chest compression (%) 1 (0.7) 0 (0) 1.00
Medication (%) 1 (0.7) 2 (1.3) 1.00
Clinical outcomes
Peak bilirubin (mg/dl) 9.6 ± 3.1 8.7 ± 2.7 0.02
Day peak bilirubin (day) 7.31 ± 7.5 7.63 ± 11.6 0.78
TOP trialb (%) 16 (10.7) 15 (10.0) 0.85
TOP trial high/lowb 8/8 8/7
Erythropoietin treatment (%) 26 (17.3) 22 (14.7) 0.53
Red blood cell transfusion (%) 48 (32.0) 31 (20.7) 0.03
Early-onset sepsis (EOS) (%) 1 (0.7) 2 (1.3) 0.89
Late-onset sepsis (LOS) (%) 6 (4.0) 4 (2.7) 0.75
Inotropic agents (first 72 hr) (%) 14 (9.3) 9 (6.0) 0.28
Surfactant treatment (%) 85 (56.7) 68 (45.3) 0.05
IVH (all grade) (%) 23 (15.3) 20 (13.3) 0.62
IVH (Grade I-II) (%) 17 (11.3) 15 (10.0) 0.71
IVH (Grade IIII-VI) (%) 6 (4.0) 5 (3.0) 0.76
PVL (%) 4 (2.7) 2 (1.3) 0.68
PDA medical treatment (%) 25 (16.7) 10 (6.7) <0.01
PDA surgical treatment (%) 6 (4.0) 8 (5.3) 0.58
ROP laser surgery (%) 4 (2.7) 4 (2.7) 1.00
NEC medical treatment (%) 4 (2.7) 6 (4.0) 0.75
NEC surgical treatment (%) 2 (1.3) 0 (0) 0.50
Moderate-severe BPDc (%) 34 (22.7) 31 (20.7) 0.67
Death before discharge (%) 6 (4.0) 6 (4.0) 1.00
Length of stay (day) 55.8 ± 46.5 47.9 ± 44.5 0.14
a Median (interquartile ranges). b Transfusion of prematures trial (TOP Trial) [13]. Randomization to; High – high transfusion threshold,

Low – low transfusion threshold. c Defined according to diagnostic criteria from NICHD/NHLBI/ORD Workshop [25]. Abbreviations:
MAP-Mean Arterial Pressure, CPAP-Continuous Positive Airway Pressure, PPV-Positive Pressure Ventilation, IVH-Intraventricular Hem-
orrhage, PVL-Periventricular Leucomalacia, PDA-Patent Ductus Arteriosus, ROP-Retinopathy of Prematurity, NEC-Necrotizing Enterocolitis,
BPD-Bronchopulmonary Dysplasia.

other authors that showed higher mean arterial blood infants ≤28 weeks’ gestation, followed by 29–31
pressure (MAP) at birth [21], decreased necrotizing weeks’ gestation, both with statistical significance.
enterocolitis (NEC) [3], intraventricular hemorrhage However, in infants 32-33 weeks’ gestation the differ-
(IVH) [2, 3] or late onset sepsis (LOS) [22]. We specu- ence in hematocrit did not reach statistical significance.
late that the improved intravascular volume associated Other authors have also found a trend towards higher
with DCC may be the reason for less metabolic acidosis hematocrit values associated with DCC in the lower
and decreased need for respiratory support at birth. gestation (26–29 week) [15]. A possible explanation
Although there were significant differences in the for this phenomenon could be that nature shifts placen-
mean hematocrit level between the two epochs, in tal blood towards the fetus during the third trimester.
the subgroup analysis the difference was greatest in We speculate that, in order to achieve significant dif-
400 C. Ruangkit et al. / Delayed cord clamping in premature infants

ferences in hematocrit values in infants of higher of DCC, or position of the infants relative to the pla-
gestation and larger size, longer duration of DCC may centa. Multi-center randomized controlled trials will
be required. be needed to study the other possible benefits of
We found no deleterious outcomes in any of our DCC that were not found or inconsistently reported
balancing measures including Apgar score, infants’ in previous trials. Research on potential long term out-
vital signs on admission (especially rate of hypother- come benefits of DCC in this patient population, such
mia), peak bilirubin level, anemia or polycythemia, all as hematological and neurodevelopmental outcome
consistent with the existing literature [2, 3]. Despite after hospital discharge, is also needed. Moreover,
concerns for possible placental twin to twin transfu- other techniques to facilitate placental transfusion to
sion associated with DCC in multiple gestation, none improve infants’ blood volume such as umbilical cord
of our preterm infants of multiple gestation had differ- milking [23] or reducing iatrogenic blood use by using
ences in initial hematocrit >15% at birth. Kugelman cord blood for admissional blood work [24] should be
et al. in 2007 reported similar findings in his cohort thoroughly investigated and considered for routine use
of nine infants of multiple gestation where no signs in clinical practice.
of twin to twin transfusion syndrome were found after
DCC [16].
The findings in our study need to be interpreted with 5. Conclusions
caution as these are part of a quality assurance project.
The goals of our study were not to prove or refute the We were able to demonstrate at our center that
benefits of DCC already reported in literature, but to meticulous adherence to protocol-guided practice of
evaluate the safety and efficacy of our QI program. delayed umbilical cord clamping for 30 seconds can
This QI study has significant limitations of be safely performed not just in preterm singletons but
unblinded, pre- and post-intervention study without also preterm infants of multiple gestation. In addition
true randomization as well as a single-center expe- to higher initial hematocrit as previously demonstrated
rience. We have tried to reduce bias by recruiting in the literature, infants in our QI project had decreased
consecutive births, stratifying patients by gestation need for delivery room resuscitation and less metabolic
age, and using intention to treat analysis. Some of our acidosis at birth without significant adverse outcomes.
significant observations, such as lower rates of intuba- We also observed a decreased need for rescue sur-
tion, surfactant treatment, medical treatment of PDA, factant therapy, medical treatment for PDA, and red
or number of blood transfusions, could be a reflection blood cell transfusions after protocol implementation.
of change in practice over time, or individual physi- However, the observed characteristics may also be the
cian preference. To address this we made every effort result of variations in clinical practices and other QI
to minimize bias by choosing our control from the year measures.
preceding our QI year. To the best of our knowledge,
there were no significant practice changes from 2013 Acknowledgments
to 2014 in our NICU.
Our single center success with this QI project can The authors would like to thank the multi-
largely be attributed to rigorous adherence to the pro- disciplinary QI team contributors and staffs from
tocol, education of staff as well as team efforts between MacDonald Women’s Hospital L&D as well as RB&C
obstetrics and the neonatal unit. The practice may be NICU for their hard work in improving patient care and
difficult to adopt in other medical facilities with dis- making this project possible. We are grateful to Dr.
parate resources and environment. Kristin Voos for reviewing our manuscript and provid-
We hope our report can provide a framework for ing valuable suggestions as well as Carolyn D. Grier
further QI work in a similar fashion. These study find- for helping prepare this manuscript.
ings from our unique patient population that included This work was supported by the Fellowship
a high number of multiples deliveries may provide Research Award Program (FRAP) in Pediatrics
safety information on DCC, especially in multiples. established by the Office of the Fellowship Direc-
Since there is no general consensus guideline on DCC, tors/Pediatric Education Department at Rainbow
further research will be needed to answer unresolved Babies & Children’s Hospital and the Rainbow Babies
questions such as optimal patient selection, duration & Children’s Foundation.
C. Ruangkit et al. / Delayed cord clamping in premature infants 401

Conflict of interest [13] Eunice Kennedy Shriver National Institute of Child Health
and Human Development (NICHD); National Heart, Lung,
and Blood Institute (NHLBI). Transfusion of Prematures
The authors declare no conflict of interest. Trial (TOP) In: ClinicalTrials.gov [Internet]. Bethesda
(MD): National Library of Medicine (US). 2000- [cited
2015 Mar 1]. Available from: https://clinicaltrials.gov/
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Supplementary information
Protocol compliance and DCC success rate of all singletons and multiples born in 2014 stratified by gestational age
Gestational age (weeks) Compliance rate (%) Success rate (%)
Singletons Multiples Singletons Multiples
≤28 47/53 (88.7) 19/19 (100.0) 38/53 (71.7) 15/19 (78.9)
29–31 62/64 (96.9) 30/34 (88.2) 53/64 (82.8) 28/34 (82.4)
32-33 69/77 (89.6) 19/20 (95.0) 56/77 (72.7) 15/20 (75.0)
Total 178/194 (91.8) 68/73 (93.2) 147/194 (75.8) 58/73 (79.5)
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