Knowledge and Practice of Umbilical Cord Clamping among Maternity Care Providers

Introduction

Early umbilical cord clamping (ECC) practice is a routine care performed worldwide. Delayed cord clamping (DCC) facilitates the transition of additional blood from the mother to the neonate until around 2-3 min post-birth or after the stoppage of the cord pulse. Accordingly, this practice reduces the risk of iron deficiency anemia during the infancy. In the term newborns, DCC is associated with a higher early hemoglobin concentration, improved ferritin levels, increased iron stores, and decreased risk of iron deficiency anemia in the infancy. This practice even results in the improvement of long-term neurodevelopment (1-3).

Even with the well-documented benefits of DCC, the majority of the maternity care providers still perform ECC, and they follow different cord clamping timing. Regarding the growing evidence showing that DCC increases early hemoglobin concentrations and iron stores in the newborns, a more liberal approach is to delay the clamping of the umbilical cord in the healthy neonates.

The systematic reviews and meta-analyses of randomized controlled trials investigating the effect of umbilical cord clamping timing by the Cochrane Collaboration have concluded that DCC is beneficial in terms of elevating early hemoglobin concentrations and iron stores in the newborn. Therefore, they have recommended a substantial approach to delay the clamping of the umbilical cord in the healthy term neonates as long as the access to treatment for jaundice requiring phototherapy is available (4).

The results of these meta-analyses suggested that enhanced placental transfusion by DCC at birth provides better outcomes for the preterm neonates, the most notable of which include reductions in overall mortality, lower risk of intraventricular hemorrhage, decreased blood transfusion incidence, and lower risk of necrotizing enterocolitis (5-7).The DCC in the very preterm newborns has been reported to be safe, feasible, and effective with no adverse consequences (8).

As indicated by a large number of studies, DCC has undisputable benefits (4, 9, 10).The DCC translates into a physiologic ‘placental transfusion’ of up to a 30 mL/kg of blood to the neonate, and a 40-60% increase in the red cell volume(4, 10, 11). The ECC is an intervention depriving a neonate from up to 30% of its circulatory blood volume at the most critical few minutes of his/her entire life, leading to a potential for iatrogenic hypoxia, hypovolemia, anemia, and low iron stores (9).

In response to the studies conducted over the past decade on the importance of
the individual components of the active management of the third stage of labor, leading international organizations, including the World Health Organization (WHO) (12), International Federation of Gynecologists and Obstetricians, and International Confederation of Midwives (13) have redefined the criteria, which exclude the practice of ECC.

Late cord clamping (performed 1-3 min after birth) is recommended for all births while initiating simultaneous essential newborn care (12). The WHO confirms this practice in
their “Recommendations on Basic Newborn Resuscitation”, indicating that “in newly-born term or preterm babies who do not require positive pressure ventilation, the cord should not be clamped earlier than 1 min after birth” (12).

In this regard, in the same document, the ideal timing of “around 3 min” has been considered as the “lower limit”. Finally, in a statement released by the Royal College of Obstetricians and Gynecologists in 2013 (14)in response to new evidence from the Cochrane Review on the timing of cord clamping, it was recommended that the umbilical cord should not be clamped earlier than necessary, based on the clinical assessment of the situation (14).

For the healthy women with term neonates, the National Institute for Health and Care Excellence recommends not to clamp the cord in the first 60 sec, except when there are concerns about the cord integrity or neonatal heart rate.Despite the new well-established scientific evidence, the practice of ECC is a standard care routine that stubbornly persists in many countries worldwide (2).

There are many reasons accounting for the implementation of ECC, such as a desire to speed up the third stage of labor and get the mother and newborn out of the delivery room, presence of a neonatologist or pediatrician who is anxious to attend to the neonate, a desire to place the newborn in an immediate skin-to-skin contact, need for neonatal resuscitation, incidence of nuchal cord, fear of hyperbilirubinemia and/or polycythemia with DCC, and need for cord blood gases, cord blood banking, or a blood group specimen in the newborns of rhesus negative mothers (2, 9).

A number of the recent studies have reported about the national and international surveys to identify cord clamping practices of obstetricians, family physicians, and midwives (15-19). Their findings were indicative of a wide variation in cord clamping practice and lack of awareness of the benefits of DCC Moreover, they reported that DCC is perceived as a difficult practice. Therefore, they made some recommendations highlighting the need for the establishment of an institutional policy and clear national guidelines.

The Micronutrient Status Survey revealed that the infants under the age of 12 months had a high prevalence rate of anemia (90.7%). The Oman Ministry of Health Department of Nutrition recommends to consider anemia as a high priority and execute interventional strategies targeting the infants under the age of nine months (20). According to the Oman World Health Survey, the prevalence of anemia in pregnant women is 61% (21).The neonates born to iron-deficient mothers are at an even greater risk of iron deficiency and more likely to benefit from DCC (10).

Guidelines on the optimal timing of cord clamping would help decrease the incidence of serious preterm morbidities and address the high prevalence of anemia in all infants across Oman. This change in policy and practice is evidence-based, cost-effective, safe, and simple, and yet could significantly affect the national disease burden.

With this background in mind, the current study aimed to identify the current cord clamping practices of maternity care providers in Oman and their perceptions on the risks and benefits of this practice to the neonate and mother. The results of this study would provide baseline data for further research and policy development at the institutional and national levels.

The objectives of the study were as follows:

• To assess the knowledge on the timing of umbilical cord clamping for term and preterm neonates
• To identify the current umbilical cord clamping practices for term and preterm newborns
• To assess the perceptions of the risks and benefits of both ECC and DDC
• To determine the factors influencing clinical decision making on cord clamping practices

Materials and Methods

This non-experimental descriptive study was conducted nationally across Oman. The study population corresponded to a group of maternity care providers, namely midwives, obstetrician/gynecologists, and physicians, who voluntarily responded to the email invitations to complete an online monkey survey. Theconvenience sampling technique was performed based on the survey responses.

Formal approval was obtained from the Research and Ethics Committee of the College. In addition, permission was obtained to access the email database of the Oman Society of Obstetricians and Gynecologists. The sample size was estimated using the following formula:

Sample size =Z² x p (1-p)

                                 d²

where Z is the value from the standard normal distribution showing the desired confidence level of 95% (Z score=1.96), p is the expected proportion, and d is absolute error/precision in percentage, put into decimal form.

Out of the 450 members registered in the Oman Society of Obstetricians and Gynecologists, 175 maternity care providers responded to the survey. The exclusion criteria included: 1) inability to speak English, 2) lack of active involvement in providing intrapartum care in the past 12 months, and 3) non-responding to the survey.

Research instruments

A revised version of an online survey software (i.e., Survey Monkey) was employed after obtaining permission from Stoll and Hutton (2012), who conducted a similar survey in Canada (17). The questions were revised following a review of the most recent literature and based on the variation in maternity care services in Oman. The questionnaire consists of 25 single and multiple response questions inquiring the maternity care providers’ knowledge and practices on cord clamping in the country for the term and preterm neonates.

The participants were required to choose from a list of options and, when applicable, they could choose as many options as apply. The few open-ended questions allowed the participants to elaborate on their answers/opinions. The survey was piloted and found to be feasible and valid. The reliability coefficient of this instrument was estimated as 0.75. The completion of the survey took 10-15 min for each participant.

Ethical Considerations

Formal approval was obtained from the Research and Ethics Committee of the College. Furthermore, a permission was obtained from the president of the Oman Society of Obstetricians and Gynecologists to access the email database through the heads of the department of the ministry of health and private hospitals in Oman. The midwives were accessed after taking a permission from the Director of Nursing Services who encouraged their staff to participate in the project. The participation in the survey was quit voluntary. In addition, the subjects were assured about the confidentiality of their information. Moreover, the data were collected anonymously and stored on a password protected computer. Additionally, the online completed questionnaires were automatically imported into a spreadsheet and not linked to the email address.

Data Collection

In order to collect the data, several emails were sent to the members of the Oman Society of Obstetricians and Gynecologists. Due to receiving inadequate email responses (i.e., as few as 25 emails) even after two reminders, the researchers directly contacted the members through the heads of departments and asked them to fill out the questionnaire. Therefore, 150 participants volunteered and completed the questionnaire at their convenience. The data were analyzed using descriptive statistics, such as percentage and mean.

Results

According to the results, 106 (60.6%) and 55 (31.4%) participants were obstetricians and midwives, respectively, and the rest were maternal-fetal specialists and general practitioners. All the participants were involved in intrapartum care delivery. The majority of the participants (75.5%) were within the age group of 30-49 years, and 81.2% of them had more than five years of intrapartum experience. Most of the participants (91.3%) were practicing at governmental and university sectors of Oman during the research period. Figures 1 and 2 present the main five countries in which the maternity care providers received their basic and post-basic professional training.

The exploration of the participants’ knowledge regarding the umbilical cord clamping revealed that 87.4% and 89.6% of the subjects regarded the ECC timing for the term and preterm neonates to be below 1 min. Furthermore, 50% of the participants reported that the timing of DCC is below 2 min of birth for both term and preterm newborns. In terms of DCC, 30% and 34% of the participants considered the timing of this practice to be 2-3 min for the healthy and preterm term newborns, respectively. In addition, 20% of the subjects perceived that DCC timing is after the cessation of the cord pulse.

As displayed in Table 1, 70% and 11.4% of the maternity care providers clamped the cord of a normally born term neonate within 1 and 2-3 min of delivery, respectively. Furthermore, 4%

              Figure 1. Distribution the participants in terms of the countries in which they received basic training

            Figure 2. Distribution the participants in terms of the countries in which they received post-basic training

Table 1. Maternity care providers’ timing of cord clamping practice

SVD: spontaneous vaginal delivery

of them waited for the cord to stop pulsation, and then cut the cord. In terms of the healthy preterm newborns, 72.6%, 7%, and 2.8% of the participants performed this practice below 1 min of birth, within 2-3 min of delivery, and after the cord pulse stoppage, respectively. Out of the subjects performing cesarean sections (71%), 2%, 15%, and 83% of the participants clamped the cord after the cessation of the cord pulse, within 1-3 min of delivery, and below 1 min of birth, respectively. The results also indicated that 67.4% of the participants were not practicing cord stripping.

The most frequently listed perceived benefits of ECC practice were decreased incidence of postpartum hemorrhage, part of active management of the third stage of labor, and facilitation of the initiation of routine newborn care in a timely manner, resuscitation if needed, and cord blood collection for routine testing (Table 2). In the investigation of the circumstances where immediate cord clamping is preferred, most of the participants (63%) reported the need for neonatal resuscitation, twin delivery, tight nuchal cord, stem cells collection, routine blood works, prevention of postpartum hemorrhage, cesarean section, or any other required medical intervention as the reasons for the adoption of ECC.

As stated by more than 50% of the maternity health care providers, the most important benefits of DCC were the facilitation of the physiologic transitioning of the newborn, increase in neonatal iron stores, reduced risk of infant anemia, and decreased need for transfusions in the preterm neonates. It is notable that 13% of the participants marked no benefits for DCC (Table 3). Most of the maternity care providers (90%) rated polycythemia and jaundice as the highest associated risks of DCC.

 Table 2. Benefits associated with early cord clamping

 Table 3. Benefits associated with delayed cord clamping