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Delayed Umbilical Cord Clamping

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by

Hannah Reed

on 3 December 2013

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Transcript of Delayed Umbilical Cord Clamping

Delayed Umbilical Cord Clamping
Step One: Catalyst and Asking
Setting & Significance
Is the question relevant? For what setting?
The World Health Organization recommends delayed cord clamping of 1-3 minutes
Current practice leaves the issue of cord clamping to individual providers
Sharp Mary Birch Clinical Trial
Background
Umbilical cord clamping and cutting is one of the oldest medical interventions amongst humanity (Hutton & Hassan 2007)
Optimal timing of clamping has always been controversial, differing from country to country (Hutton & Hassan 2007)
The topic has been more recently studied in both low income countries and high income countries. (Andersson, Hellstom-Westas, Andersson, & Domellof, 2011).
Appraising
Acquiring
Databases used:
EBSCO Host, CINAHL, Trip, & PubMed
Of vaginally delivered newborns, does a delay in cord clamping of 1-3 minutes as compared to immediate clamping result in improved neonatal well being as evidenced by increased blood volume and decreased anemia?
P:Vaginally delivered newborns
I: Delayed cord clamping
C: Immediate cord clamping
O: Improved neonatal well-being
PICO
Search terms:
"Delayed Cord clamping"
"Umbilical cord clamping"
"Delayed verse immediate cord clamping"
Sources of Evidence:
5 single studies
2 Literature reviews
1 Systematic review
Applying
Increased Blood Volume
Early clamping deprives the baby of 50-100ml of blood, causing other organs to compensate resulting in complications such as respiratory distress syndrome (Bluff 2005).
During the first four days of life, DCC infants showed increased superior vena cava blood flow (Sommers et al., 2012)
Improved blood volume reduces the risk of mental impairment and bleeding in the brain from lack of oxygen to the brain (Cook, 2007).
Within 24 hours after birth, significant increase in red blood cells (p=.04) (Strauss et al. 2008).
Decreased Anemia
Multiple studies revealed Improved iron level and reduced deficiency
Decreased neonatal anemia at 2 days of age (Andersson, Hellstom-Westas, Andersson, & Domellof, 2011).
At 4 months of age, DCC babies had 45% higher mean ferritin concentration (p<.001) and lower prevalence of iron deficiency (p=.01) (Andersson, Hellstom-Westas, Andersson, & Domellof, 2011).
Baseline Assessment
Staff nurses at Sharp Mary Birch were queried regarding current practice and cord clamping policies.
The results showed the time of clamping varies, with no established policies.
Description of Proposed Project
The desired plan is to implement an institutional policy where delayed cord clamping of 1-3 minutes is the norm
Stakeholders will be addressed and involved in the implementation progress, beginning with an educational meeting to introduce the proposed change and present the evidence.
Staff will then be trained in the procedure of DCC and change progress will be consistently evaluated
Patients will be informed of new DCC procedure. Only patients who give informed consent and are not high risk will undergo DCC
Project Plan
Cost/Benefit
Training
-85 registered nurses for 8 hours total: $30,770.00
-10 obstetricians for 4 hours total: $4, 248.80
-5 midwives for 4 hours total: $1, 087.20

Total Cost
-Training: $36,106.00
-50 Timers: $500.00
Analyzing
Outcomes
The research evidence strongly supports this practice change
The goal is to achieve successful interdisciplinary collaboration
Implementing DCC will result in consistent benefits to newborn well-being, specifically regarding an increase in blood volume and decrease in anemia
Lessons Learned
-Team collaboration through delegation, communication, and utilization of each peer's individual strengths
-Types of leadership styles among group members
-Researching through databases to find strong, high levels of evidence
-How to write evidence based research papers through catalyst identification, acquiring, appraising, applying, and analyzing research
-The need for interdisciplinary team member involvement in order to implement a safe, quality, and effective change
-Budgeting, costs, time, and coordination in implementing change



Potential Complications
* In all of the research, the potential for adverse affects were statistically insignificant.
Polycythemia
Hyperbilirubinemia
Tachypnea & Grunting
NICU admission

Data Collection Plan
During the
unfreezing
stage, input from the stakeholders will be collected via email questionnaire
During the
movement
phase, L&D nurses will maintain thorough documentation of DCC procedure, including the timing of cord clamping
Follow up neonatal blood counts will be analyzed to determine effectiveness of DCC.
Upon evaluation, if lab results and neonatal outcomes are consistently positive, DCC will become an official part of institutional policy and procedure during the
refreezing
stage
References
Andersson, O., Hellstrom-Westas, L., Andersson, D., & Domellof, M. (2011). Effect of delayed versus early umbilical cord
clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ,343, doi: 10.1136/bmj.d7157
Blouin, B., Penny, M. E., Casapia, M., Aguilar, E., Silva, H., Joseph, S. A., & ... Gyorkos, T. W. (2011). Effect of a two-
component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon. Revista Panamericana De Salud Publica,29(5), 322-328.
Bluff, L. (2005). Early versus delayed cord clamping. International Journal Of Childbirth Education, 20(4), 16-21.
Cook, E. (2007). Delayed cord clamping or immediate cord clamping?: a literature review. British Journal Of
Midwifery,15(9), 562.
Hassan, E. S. (2007). Late vs early clamping of the umbilical cord in full-term neonates: systematic review and
meta-analysis of controlled trials. JAMA: The Journal of the American Medical Association, 297(11), 1241-1252. doi:10.1001/jama.297.11.1241.
Katheria, A. (2013, October 6). The PREMOD trial: a randomized controlled trial of umbilical cord milking vs. delayed
cord clamping in premature infants. In Clinicaltrials.gov. Retrieved November 3, 2013, from http://clinicaltrials.gov/ct2/show/NCT01866982?term =%22delayed+cord+clamping%22+AND+%22Sharp+Mary+Birch%22&rank=1
Marquis, B. L. & Huston, C. J. (2012). Leadership roles and management functions in nursing: Theory and application.
Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins.
Sommers R., Stonestreet, B. S., Oh, W., Laptook, A., Yanowitz, T. D., Raker, C., & Mercer, J. (2012). Hemodynamic
effects of delayed cord clamping in premature infants. Pediatrics.
U.S. Bureau of Labor Statistics (2013, March 29). Occupational employment statistics. Retrieved from http:/
/www.bls.gov/oes/current/oes_stru.htm#31-0000
Unfreezing
Month 1
Movement
Month 2-6
Refreezing
After 6 months
-Short study of average timing of current cord clamping practices at facility
-Meetings with lead obstetricians/nurse midwives
-Seminar for nurses and stakeholders
-Questionnaire

-Defining goal of fully implementing change of delayed cord clamping
of 1-3 minutes in 6 months
-"How to" training for nurses (3 hours a week for 4 weeks) that includes:
-Education for patients and opportunity to refuse
-Guidelines for high-risk delivery
-Implementation of timer
-Guidelines for documentation
-Change fully implemented month 3-6
-Review meeting/in-service for 1 hour every month





-Making system the norm
-Charge nurse/midwife examining each nurse during practice
-Survey/evaluation for nurses and physicians on new practice
-Evaluation on effects on neonates- is this practice helpful?
Questioning the ritual practice of immediate cord clamping
Why do we clamp immediately? Is immediate cord clamping evidence based?
Catalyst
Road Map
Catalyst and Asking
Acquiring
Appraising
Applying
Analyzing
Lessons learned
Lindsey Miller. Hannah Reed. Elise Zamora. Devyn Bontempo. Taylor Ambrose.
Adina Vogler.
Questions
1. How is this going to be a nursing intervention?

2. DCC shows that a baby receives more iron. Why is this important?

3. What education will be provided for the patients?

4. How reliable is the evidence?
Fall 2013
NSG 470: Leadership and Management
Delayed Cord Clamping: An Evidenced Based Project
Full transcript