454 - Motherside Assessment of Neonates with Intact Cord: MANIC QI to promote delayed cord clamping for infants <32 weeks gestation

Publication Number: 1436.454

Ari Esrig, University of Virginia School of Medicine, charlottesville, VA, United States; Nicholas Heitkamp, University of Virginia School of Medicine, Crozet, VA, United States; Karen Fairchild, University of Virginia School of Medicine, Charlottesville, VA, United States

Background: Delayed cord clamping (DCC) increases survival of preterm infants as shown in a large meta-analysis of randomized trials. Despite this, most preterm infants do not receive the benefit of DCC because the obstetrics (OB) team wants to quickly hand the baby to the neonatology (NICU) team. In the VentFirst trial of infants < 29 weeks gestational age (GA), led by University of Virginia (UVA), a standardized script was used, encouraging the OB team to stimulate the baby. With stimulation, 52% of enrolled infants were breathing well by 30 seconds (sec), and median CC time for control infants was 60 sec. Since completion of the trial, we noticed a decrease in CC times for preterm infants at UVA, with review of infants < 32 weeks GA showing mean CC 36 sec.

Objective: In the MANIC (Motherside Assessment of Neonates with Intact Cord) QI initiative, we designated a "Cord Coordinator" (NICU fellow) to encourage 60 sec of DCC for infants < 32w GA. The SMART aim was to increase mean CC time of < 32w GA infants by at least 35% by October 2025.

Design/Methods: A waiver from UVA IRB was granted. Baseline CC seconds after birth was obtained from medical records for all inborn infants < 32w GA 2022-2024. Stakeholder analysis, key driver diagram, and process maps were performed. PDSA Cycle 1 (May-Oct 2025) included education of the NICU and OB teams and training neonatology fellows to serve as "Cord Coordinators" near the mother, advocating for 1 minute of DCC if no contraindications, and encouraging the OB team to stimulate the baby. CC time before and during PDSA 1 were compared using QIMacros software. As a balancing measure, we assessed NICU admission temperature.

Results: In the baseline period, there were 376 inborn < 32w GA infants (median GA 28.7w), and in PDSA 1 there were 64 infants (median GA 28.5w). Demographics are summarized in Table 1. The mean DCC time increased from 36 sec at baseline to 45 sec during PDSA 1, a 35% improvement which matched our SMART aim (Figure 1). Mean NICU admission temperature was normal and similar in the two time periods (Table 1).

Conclusion(s): In the MANIC QI first PDSA cycle, average CC duration for infants < 32w GA increased by 35%, demonstrating a positive impact of a NICU team member serving as a Cord Coordinator. In the next PDSA cycle (Nov 2025-April 2026) we will reeducate providers about the 60 sec goal CC time, which represents another 35% increase over PDSA 1 time. In addition to collecting CC times, we will record reasons for immediate or early CC and will begin to evaluate short-term infant outcomes such as hematocrit and need for blood pressure support.

Figure 1: Mean cord clamping seconds for infants <32 weeks gestation, baseline and PDSA 1.
Statistical process control chart showing mean cord clamping seconds after birth (blue) with upper and lower control limits (red dashed lines, ±3 SD) before and during MANIC PDSA cycle 1. CC times are averaged over every five infants. Baseline data from January 2022 - April 2025 (n = 376) and PDSA 1 from May-October 2025 (n = 64) are shown. Mean CC increased from 36 to 45 seconds (35% increase).


Table 1: Clinical Variables in Baseline and PDSA 1 Cohorts.
Continuous variables are presented as median (interquartile range), and categorical variables as n (%).