Studies have demonstrated that delaying clamping of the umbilical cord by as little as a minute after birth can help assure a safer landing for newborns, whose passage from womb to world is sudden, traumatic, and physiologically transformative.
Neonatologist Scott O. Guthrie, M.D., who has devoted much of his practice to improving outcomes for the tiniest of babies, is now a leader in a mission to improve cord-clamping strategies in Tennessee, particularly for preterm infants, who face greater hazards during the circulatory and respiratory transition of birth.
“It can be challenging because many obstetricians and their teams have a well-worn pattern of racing to get the newborn from delivery to the warmer.”
When research in the early 2010s showed that a 60-second delay in cord clamping reduced morbidities such as intraventricular hemorrhage (IVH), guidance from the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists’ shifted accordingly. Yet in Tennessee, only a small proportion of newborns were beneficiaries of this recommended measure, Guthrie says.
Guthrie has set an ambitious aim of a 60-second delay implemented in 90 percent of the more than 80,000 births each year in the state.
“Preterm infant mortality can be reduced by 30 percent through this one action alone,” he said. “My tagline is: ‘This is the easiest thing you can do to make a big difference.’ Yet it can be challenging because many obstetricians and their teams have a well-worn pattern of racing to get the newborn from delivery to the warmer so they can examine the infant.”
Maintaining Placental Flow
Among the chief benefits of delayed cord clamping in full-term infants is increased hemoglobin levels at birth and improved iron stores during the first several months of life, which may impact developmental outcomes.
In preterm infants, the benefits multiply, largely because the delay also may protect against severe intraventricular hemorrhage, which often stems from treating hypotension, elevating risks up to two- or threefold in the more severe cases.
“By maintaining the placental blood flow during the transition to breathing, the infant is essentially getting a transfusion while they transition to using their lungs.”
“The incidence of IVH at 30 weeks is about 2 percent, but about 35 percent at 23 weeks. Risk essentially doubles for every two weeks of increasing prematurity,” Guthrie said.
In preterm babies, about half of their placental-fetal blood volume is in the placenta at any given point.
Accordingly, studies show delayed clamping reduces the need for blood transfusions, reduces rates of necrotizing enterocolitis, and trends toward a lower incidence of late onset sepsis, as well as fewer NICU admissions, Guthrie says.
With no differences in APGAR scores reported, these benefits accrue without a countervailing downside, and Guthrie says contraindications for delayed clamping are few and rarely encountered.
“When a newborn takes those first breaths, they’re having to open all those alveoli and also beginning to perfuse the area,” Guthrie said. “By maintaining the placental blood flow during the transition to breathing, the infant is essentially getting a transfusion while they transition to using their lungs.”
Despite improvements in recent years, Tennessee has high preterm birth rates and high infant mortality rates relative to the national average. To reach a nationally established goal of five deaths per 1,000 live births by 2030, Tennessee needs to reduce its current infant mortality rate by about 25 percent.
Working with the Tennessee Initiative for Perinatal Quality Care (TIPQC) to pursue this goal, Guthrie recently completed his term as the infant medical director, where he oversaw the Optimal Cord Clamping Project.
Guthrie worked with TIPQC to launch the initiative with five pilot teams in January 2022, developing a toolkit and detailed educational instructions, and scheduling monthly huddles with the participating sites. In May 2022, the project expanded to 22 additional teams.
By its close in June of 2023, 61,642 newborns had undergone delayed cord clamping, representing 82 percent of the total live births among the participating teams and more than 75 percent of the yearly births in Tennessee.
In the pilot, the percentage of births with delayed cord clamping rose by 72 percent, and in the expansion group, delayed cord clamping improved by 14 percent to 86.3 percent in March 2023.
“This would likely have been an even more dramatic increase, but by the time we expanded, many hospitals had already made the transition,” Guthrie said. “While we haven’t yet sustained our overall goal of 90 percent, we are very close.”
Next steps for Guthrie and TIPQC leaders include accruing data on mortality and other outcomes from the expanding practice.
“A large California hospital found that every 10 percent increase in the rate of delayed cord clamping among preterm infants was associated with a 4 percent lower hospital mortality rate,” Guthrie said.
“This level of improvement is intuitive, but we need to quantify our results in Tennessee to promote change in all the remaining pockets where the old practice still prevails.”
He is also working with TIPQC to develop the Tennessee Tiniest Babies Project. This project is specifically focused on mortality and morbidity in Tennessee’s smallest citizens. The first bundle is aimed at severe IVH reduction and will specifically track rates of delayed cord clamping in all infants born earlier than 30-weeks’ gestation.