Variability in guidelines

Guidelines varied widely in terms of technique and nature of recommendations (see table 1). Sites varied in the extent to which staff were aware of, and reported adherence to, guidelines. No two sites were practicing placental transfusion in the same way. No site had guidance for, or reported a practice of ‘resuscitation’, airway or breathing support of very preterm infants with cord intact, although one Guidelines described DCC as ‘part of the resuscitation process’ (Site 3)

Intraunit variation in reported practice was most marked where neither DCC nor CM were supported by guidelines. Reported positions for DCC varied from above, or level with, the placenta to 6–20 cm below, avoiding tension in the cord, and were based on practicality rather than evidence: for example, placement on mothers’ legs at section. Reported positions for CM were similar. Some clinicians practised DCC, CM or both techniques as a matter of routine, others only when they remembered, and often in ignorance of what colleagues were doing. Interviewees spoke of the need for a local clinical champion to move practice forward.

Placental transfusion practices were most commonly led by neonatologists or paediatricians; however, the most successful sites had also engaged the support of senior obstetricians. Lesser engagement across professions was associated with incomplete implementation. One site had introduced a requirement to state in the infant's notes why DCC had not been implemented in any given case, and this was believed to have helped to normalise the practice. Elsewhere, recording of DCC and CM was ad hoc rather than systematised.

CM was the preferred practice in two sites (table 1); elsewhere, it was viewed as a second-line therapy. In choosing CM over DCC, one person commented that the decision might be influenced by anxiety about health of the baby; others reported using both techniques in a single delivery, starting with delay, followed by CM. CM was more likely than DCC to be seen as an obstetric intervention—undertaken without negotiation or remark, whereas DCC required coordination of the delivery team as a whole.

The exact nature of the intervention varied by site (see table 1): sites where CM was regularly practised had more specific content in their guidelines; at others, personal preferences and perceptions of the baby's condition were stronger influences.

Assessment of eligibility

Participants agreed that most babies do not need immediate resuscitation; determining the need for resuscitation was the major challenge. Some questioned the need for immediate resuscitation, and the guideline for one site (Site 3) stated that the ‘thirty second (delay) should be viewed as part of the infant's resuscitation not a hindrance to it’ (emphasis in original). Most agreed with the paediatrician who said, ‘If the baby came out pink, beginning to wriggle and beginning to make a respiratory effort… delayed cord clamping would be fine.’ For other babies, decision making was less clear-cut and rested on largely subjective judgements of a combination of indications that included colour, tone, heart rate and breathing. No one was prepared to nominate a sole determining factor.

Individuals varied in the extent to which they were persuaded of the benefits of DCC or CM as balanced against potential risks, and described differing possible responses to similar situations: for example, with a baby that was ‘white and floppy’, one clinician would ‘not want to be wasting time’ and opt for immediate clamping, while another would ‘try and get some blood back into the baby’.

Competing priorities: anxiety about timing

The most commonly expressed obstetric concern was maternal bleeding at caesarean section, with less experienced obstetricians reportedly more concerned about delay.

Unless the mother's condition was cause for concern, the onus of decision making rested with the neonatologist or paediatrician, and it could take confidence and courage in the face of one's own and others’ anxiety to persist with the full recommended delay. As one neonatologist commented, ‘I would hold my nerve for a full 30 s’. Clinicians with more experience were reported to be more likely to defer clamping and wait the full 30 s.

In the absence of guidelines, delays of 10–30 s were reported, reflecting a cautious approach to risk in ignorance of optimal duration and sensitivity to the emotional tolerance of team members. Three people said they would delay clamping as long as they could feel pulsating of the cord. Responsibility for exact timing generally rested with the neonatal team. Anxieties lessened over time and engaging in concurrent activities, such as drying the baby or using the delay to assess the baby's condition, were helpful in managing anxiety.

Persisting uncertainty

In addition to uncertainties about eligibilty, positioning of the baby and duration of delay, there were inconsistencies in the sequence of administration of uterotonic drugs—between sites, practitioners and contexts. When given before cutting of the cord, reported timing varied from crowning, to delivery of the anterior shoulder or body. Few considered the timing of uterotonics administration relevant to DCC. Policies mandating uterotonic administration after cord clamping had been introduced at sites where DCC was routine practice for preterm birth (n=3). However, even here, practice was inconsistent and reportedly varied by mode of delivery, with uterotonics administered after clamping at section, but before in vaginal deliveries. The most uniform practice was reported at the site where DCC had been practised the longest time, and policy and practice were guided by a clear understanding that uterine contraction induced by drugs would restrict placental transfusion. Elsewhere, responsibility for the decision was considered to be solely that of the midwife or obstetrician, and members of the neonatal team were unable to say at what point the drug was given. Timing of administration was not considered relevant to CM.