TOP 27 - Optimizing Cord Management at Birth: A Multidisciplinary Quality Improvement Initiative.

Publication Number: 3755.TOP 27

Aleksandra M. Hibner, University of California, San Diego School of Medicine, Phoenix, AZ, United States; Kayla Schmittau, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA, United States; Regina Prairie, University of California, San Diego School of Medicine, San Diego, CA, United States; Kristen Schaffer, University of California, San Diego School of Medicine, San Diego, CA, United States; Henry Lee, University of California, San Diego School of Medicine, La Jolla, CA, United States; Katherine Weiss, University of California, San Diego School of Medicine, San Diego, CA, United States

Background: Deferred cord clamping (DCC) improves neonatal outcomes by optimizing placental transfusion, enhancing blood volume, iron stores, and cardiorespiratory transition. Current guidelines recommend DCC ≥60 seconds for most newborns, with a meta-analysis indicating that longer duration, up to 120 seconds, may be optimal for preterm infants. Cord milking may be indicated in non-vigorous infants ≥35 weeks. Despite strong evidence, implementation gaps persist. At UCSD Health Level 3 NICU, a tertiary academic center, approximately forty infants < 30 weeks are delivered annually. Baseline data (April 2024-June 2025) revealed suboptimal DCC compliance: only 8% of infants < 30 weeks achieved >90 seconds, 49% of infants 30-34 6/7 weeks achieved ≥60 seconds, and 22% of non-vigorous infants ≥35 weeks received cord milking.

Objective: Primary objective: To increase DCC >90 seconds in infants < 30 weeks' gestation from 8% to 25% within six months (July-December 2025). Secondary objectives included increasing DCC ≥60 seconds in infants 30-34 6/7 weeks (from 49% to 59%) and implementing cord milking in non-vigorous infants ≥35 weeks' gestation (from 22% to 35%).

Design/Methods: A multidisciplinary quality improvement team used the Plan-Do-Study-Act (PDSA) methodology. Key drivers were identified through process mapping and fishbone analysis (Fig. 1). The main interventions included: (1) standardized DCC protocols with trolley-assisted bedside resuscitation that enabled ventilatory support, including continuous positive airway pressure (CPAP) and assisted ventilation as needed, on the intact cord (Fig. 2); (2) direct involvement of neonatal providers during initial stabilization; and (3) structured team prebriefing and communication. Baseline data were collected from April 2024 to June 2025 (Fig. 3). Statistical process control charts tracked monthly performance for the primary outcome (DCC >90 seconds in infants < 30 weeks) and secondary outcomes (DCC ≥60 seconds in 30-34 6/7 weeks; cord milking in non-vigorous infants ≥35 weeks). Process measures included protocol adherence, trolley use, and provider engagement. Balancing measures involved admission hypothermia, intubation rates, maternal blood loss, uterotonic use, and operative time. Ongoing PDSA cycles focus on enhancing data collection, refining teams' prebriefing protocols, and developing strategies for complex clinical scenarios, including short cords and dichorionic-diamniotic twins. This project was exempt from IRB review by the UCSD ACQUIRE Committee.

Figure 1. Key Driver Diagram.


Figure 2. The resuscitation trolley facilitates early respiratory support at the maternal bedside while optimizing placental transfusion during deferred cord clamping. Adapted from: Katheria A, Lee HC, Knol R, et al. J Perinatol. 2021;41(7):1540-1548.


Figure 3. Baseline Data April 2024 - June 2025, UCSD.