How to Engage Your Team to Implement Delayed Cord Clamping

Transcription

1 In Practice How to Engage Your Team to Implement Delayed Cord Clamping I REBECCA L. GAMS KIMBERLY K. POPP JULIANNE CRAMER In 1801, Erasmus Darwin, a respected English physician, philosopher, and physiologist, stressed the importance of delaying the clamping of the umbilical cord as a provision for maternal and neonatal health. In one of his THOMAS N. GEORGE PHILLIP N. RAUK SAMANTHA A. SOMMERNESS JANE A. SUBLETTE writings titled Zoonomia; or, the Laws of Organic Life (Darwin, 1801), Darwin wrote Another thing very injurious to the child is the cutting (of) the navel-string too soon; which should always be left till the child has not only Photo Pixelistanbul / istockphoto.com Abstract This article describes how a health care team changed practice by implementing delayed cord clamping as standard practice. After administration of a survey to assess clinicians knowledge and to discover barriers to this proposed practice change, members of a multidisciplinary committee used the results to create a guideline for delayed cord clamping and a plan for successful implementation. Integral to embedding and sustaining changes in practice was development of the Delivery Room Brief and Debrief Tool and inclusion of the process into nursing guidelines and the electronic health record. Through the use of these tools and teamwork, delayed cord clamping was implemented as standardized practice across six hospitals within this health care system. Keywords change management delayed cord clamping implementation protocol shared vision nwhjournal.org 2017, AWHONN 489

2 In Practice Rebecca L. Gams, MS, APRN, WHNP-BC, is the obstetric Advanced Practice Nurse Leader at the University of Minnesota Medical Center and University of Minnesota Masonic Children s Hospital in Minneapolis, MN. Kimberly K. Popp, MA, RN, is the NICU Patient Care Supervisor at University of Minnesota Masonic Children s Hospital in Minneapolis, MN. Julianne Cramer, MA, APRN, NNP, is the neonatal Advanced Practice Nurse Leader at University of Minnesota Masonic Children s Hospital in Minneapolis, MN. Thomas N. George, MD, FAAP, is a professor of pediatrics, Director of Clinical Services in the Division of Neonatology, and the Medical Director of the NICU at the University of Minnesota Masonic Children s Hospital in Minneapolis, MN. (continued) repeatedly breathed, but till pulsation in the cord ceases. As otherwise the child is much weaker than ought to be; a part of the blood being left in the placenta which ought have been in the child. (p. 133) Assessment of current practice and review of current literature around delayed cord clamping, coupled with the drive to improve outcomes, heightened our team s attention to changing the current practice of cord clamping The timing of when to clamp the umbilical cord has been a point of debate for centuries. As births moved to the hospital setting, concern about polycythemia and hyperbilirubinemia (Leslie, 2015; Mercer & Erickson-Owens, 2012) and maternal hemorrhage (Callahan, 2017) developed and advancements in neonatal resuscitation accelerated (Callahan, 2017), and immediate cord clamping became routine practice, and this is still ingrained in the culture of many labor and delivery units today. Background The act of immediate cord clamping is performed as soon as a newborn is born, whereas delayed cord clamping provides continued placental exchange over a variable period of time after birth. The recommended specific times of delay differ in the literature but are dependent on gestational age (Hutton & Hassan, 2007), signs of vigor (American Heart Association & American Academy of Pediatrics, 2015), position of the newborn in relation to the placenta (Farrar et al., 2011), volume of blood transfused over time (Boere et al., 2015), and concerns for maternal hemorrhage (McDonald, Middleton, Dowswell, & Morris, 2013). Hooper et al. (2015) suggested that timing cord clamping based on the respiratory function of the newborn at the time of birth may offer more clinical benefit than setting specific yet arbitrary time frames. The Neonatal Resuscitation Program (American Heart Association & Academy of Pediatrics, 2015) and the American College of Obstetricians and Gynecologists (ACOG, 2017) recommend that without concerns for compromised placental circulation, delayed cord clamping should occur for at least 30 to 60 seconds for most vigorous term and preterm newborns (Raju & Singhal, 2012). Delayed cord clamping provides increased initial blood volume that favors improved hemoglobin levels (Ultee, van der Deure, Swart, Lasham, & van Baar, 2008); cardiopulmonary adaptation (Bhatt et al., 2013); cerebral and gastrointestinal blood flow; and iron stores, which decrease the risk of newborn anemia (ACOG, 2017; Andersson, Domellöf, Andersson, & Hellström-Westas, 2014; Blouin et al., 2013; Eichenbaum-Pikser & Zasloff, 2009; Georgieff, 2011). In preterm newborns, it further decreases the need for treatment of hypotension and hypovolemia with blood transfusions and inotropes, thereby improving cardiovascular stability; delayed cord clamping also leads to a decreased incidence of intraventricular hemorrhage and late-onset sepsis (Arca, Bolet, Palacio, & Carbonell-Estrany, 2010; Ghavam et al., 2014). The practice does not increase a woman s risk of bleeding (Leslie, 2015; McDonald et al., 2013), and it facilitates immediate skin-to-skin contact, which enhances extrauterine transition and bonding for the mother and newborn. A Cochrane Review from 2013 highlighted a nonpublished study suggesting that delayed cord clamping increased the rates of term newborns requiring phototherapy for hyperbilirubinemia (McDonald et al., 2013); however, no other studies conducted since 1980 support this finding (Mercer & Erickson-Owens, 2012). Current Practice Leading to Research Question Assessment of current practice and review of current literature around delayed cord clamping, coupled with the drive to improve outcomes, heightened our team s attention to changing the current practice of cord clamping. Investigation of existing practice showed lack of standardized guidelines and lack of adherence to the mission of evidence-based practice. Furthermore, the variation in practice among providers created confusion for the nursing staff and inconsistent care among births. The team hypothesized that with an understanding of why variation existed, a process 490 Nursing for Women s Health Volume 21 Issue 6

3 In Practice Photo tatyana_tomsickova / istockphoto.com that supported, encouraged, and standardized the consistent practice of delayed cord clamping would be attainable. The guiding question driving the investigation was What barriers exist in standardizing the best practice in cord clamping within the health system despite delayed cord clamping gaining increased support in the literature? This question was presented to an internal multidisciplinary perinatal committee called Zero Birth Injury (ZBI) in an effort to gain support and build a shared vision. Infrastructure to Support Change ZBI is a system-wide organizational mothers and children s quality and safety committee. The aim of ZBI is to improve maternal and neonatal outcomes and women s experiences while reducing cost and liability through implementation and sustainment of evidence-based clinical guidelines, standardized clinical practice, teamwork, and communication throughout the health system (Kozhimannil et al., 2013; Sommerness et al., 2017). Membership includes obstetricians, neonatologists, pediatricians, certified nurse-midwives (CNMs), advanced practice registered nurses in obstetrics and neonatology, quality improvement and patient safety representatives, nursing leaders, and administrators. Information about delayed cord clamping best practices was presented at monthly ZBI meetings followed by an electronic survey sent to team members in the health care system. Multidisciplinary team review, presentations, discussions, and subsequent endorsement of evidence in the literature were integral to success This multisite survey was an initial step in the change process that increased awareness, identified barriers, and illustrated the amount of delayed cord clamping in current practice. Survey In July 2012, the survey was introduced at the ZBI meeting. After the meeting, the 10-question online survey was sent to all neonatologists, neonatal nurse practitioners, obstetricians, CNMs, birthing room nurses, and NICU nurses at all six hospitals that made up the health care system. Surveys were sent to 900 nurses and providers, with a completed response rate of 13%. Of the 10 questions, the following questions and responses were most pertinent to affecting change. The results were shared with ZBI in September 2012 and were as follows: 1. What is your familiarity with delayed cord clamping? Results indicated that 12.8% of nurses had never heard of delayed cord clamping and most had never witnessed it. Most providers surveyed had heard of delayed cord clamping but had never witnessed or performed it. Of the birth providers, only the CNMs routinely performed (continued) Phillip N. Rauk, MD, is a professor in the Department of Obstetrics, Gynecology and Women s Health at the University of Minnesota School of Medicine in Minneapolis, MN. Samantha A. Sommerness, DNP, APRN, CNM, is a clinical assistant professor in the Child and Family Health Co-Operative Unit in the School of Nursing at the University of Minnesota in Minneapolis, MN. Jane A. Sublette, MS, APRN, CNM, WHNP-BC, is the obstetric, pediatric and neonatal Advanced Practice Nurse Leader at Fairview Ridges Hospital in Burnsville, MN. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: bgams1@fairview.org. December 2017 Nursing for Women s Health 491

4 delayed cord clamping. The results of this question confirmed the variation in care provided among birth providers (see Figure 1). 2. In your opinion, which of the following are maternal/fetal barriers to using delayed cord clamping? Delayed resuscitation was the primary barrier identified, followed by concerns for increased risk of neonatal hyperbilirubin-emia, elevated hematocrit levels, and general anesthesia affecting the newborn. Many respondents selected other and listed the following additional concerns: Physicians reluctant to wait the required time Figure 1. Familiarity With Delayed Cord Clamping by Profession: Weighted Average of Responses Certi ied Nurse-Midwife (n = 10) Family Practice Physician (n = 4) Neonatal Nurse Practitioner (n = 2) Neonatologist (n = 5) Obstetrician (n = 12) Registered Nurse (n = 84) All Responses (n = 117) 0 1 >1 2 >2 3 >3 4 >4 5 Weighted Average Women desiring and hospitals promoting skin-to-skin contact Newborn must be at the perineum, and placement on maternal abdomen could compress the cord and cause a pressure gradient that reduces the benefit The practitioner s convenience NICU/newborn team anxiety for newborn well-being Sterility in cesarean births (see Figure 2) 3. Which of the following are your personal/professional barriers to using delayed cord clamping? The top five barriers were related to lack of knowledge of the procedure and the newborn benefits. No responses indicated that it was inappropriate (see Figure 3). 4. Do you believe there is a need for an evidence-based delayed cord clamping protocol at your facility that includes patient selection, gestational age assessment, communication plans prior to birth and parent education? Results showed that 90.27% agreed with the need Figure 2. Perceived Maternal and Fetal Barriers to Performing Delayed Cord Clamping Delayed infant resuscitation Increased jaundice requiring phototherapy None of the above Use of general anesthesia Higher infant hemoglobin Infant hypothermia Infant hypervolemia Other responses Increased risk of infant respiratory distress Placental retraction Lower maternal ferritin level at delivery Increased risk of maternal blood transfusion Increased risk of postpartum hemorrhage Number of respondents 492 Nursing for Women s Health Volume 21 Issue 6

5 for a protocol, 7.96% disagreed, and 1.77% selected other. Other text comments included the following: As NICU RNs, we do not manage the cutting of the cord Unclear of benefits and risks (see Figure 4) The results of the survey were reported to ZBI, which in turn encouraged and supported guideline development and implementation. Literature Review In a literature review conducted on umbilical cord clamping, the main focus was on best practice. The literature supported that delayed cord clamping is beneficial for term and preterm newborns and is not harmful to women. Literature was revisited multiple times for the development of evidence-based system guidelines and to address concerns that arose through the implementation process. Change Process Interviews Two representatives from the quality and patient safety department, with experience in change management, were interviewed to identify effective strategies for changing culture; their key recommendations are listed in Box 1. In addition, they recommended the Change Acceleration Process (CAP) Model (General Electric Company, 2006) as the best model to support this project. The CAP Model illustrates how individuals and organizations transform from current state through transitional state and to an improved state by focusing on five areas: Creating a Shared Need, Shaping a Vision, Mobilizing Commitment, Making Change Last, and Monitoring Progress. Triangulation The process of triangulation was used to create an unbiased approach by incorporating the three strategies inherent to the method: surveying staff, reviewing the literature, and conducting expert interviews. Triangulation uses a variety of sources and methods to collect data. When defining triangulation, Maxwell (2005) states, This strategy reduces the risk that your conclusions will reflect only the systematic biases or limitations of a specific source or method and allows you to gain a broader and more secure understanding of the issues you are investigating (pp ; see Figure 5). It was evident that if the knowledge gaps and barriers were identified and addressed, implementation of delayed cord clamping could be successful Addressing Concerns Findings during triangulation were presented to ZBI committee members, and their concerns were addressed before Figure 3. Perceived Personal and Professional Barriers to Performing Delayed Cord Clamping Unknown criteria for patient selection Unfamiliar with DCC procedure Unknown bene its of DCC Providers at my hospital not familiar with DCC Nurses at my hospital not familiar with DCC Other responses Hospital does not have guidelines that support DCC None, I currently use DCC Infant should be placed on warmer Not appropriate for my patients Number of respondents Note. DCC = delayed cord clamping. December 2017 Nursing for Women s Health 493

6 Figure 4. Assessing Need for Standardized Evidence-Based Protocol implementation. Several members were specifically concerned about how delayed cord clamping would affect other birth practices. Obstetricians voiced concerns regarding the increased risk of hyperbilirubinemia necessitating the need for phototherapy treatment, delayed discharge, and readmission. Neonatology was able to address these concerns by reviewing the evidence supporting the benefits to the newborn and Do you believe there is a need for an evidence-based delayed cord clamping protocol at your facility? Figure 5. Triangulation of Data Collection Literature Review Focus #1: Best Practice? Survey Focus #2: Barriers Interviews Focus #3: Change Process highlighting lack of literature support for increased need for phototherapy. Placement of the newborn during delayed cord clamping was heavily discussed for vaginal and cesarean births. The literature recommended positioning the newborn within 10 cm above or below the level of the placenta. Some providers who use stirrups were unable to envision themselves holding wet babies midair for a time frame. This concern was heightened at hospitals that had not fully implemented the practice of placing newborns skin to skin with the mother immediately after birth. Once the team recommended that all newborns at all six hospitals would be immediately placed on the mother s abdomen, chest, or thighs during a cesarean birth for drying and stimulation (Leslie, 2015; Mercer & Erickson- Owens, 2014; Vain et al., 2014), the conversations became more positive about abilities to change individual practice. Coggins and Mercer (2009, p. 138) state, Immediately placing the newborn skin-to-skin on the maternal abdomen is a good way to start incorporating delayed cord clamping. This ultimately facilitated a secondary practice change of routinely placing newborns skin to skin at all hospitals. The challenge of implementing delayed cord clamping in the operating room was also addressed, because surgeons were not accustomed to drying for a set period of time while performing delayed cord clamping. To address this, the recommendation was to increase the number of sterile towels or blankets available and to place of newborn onto the mother s thighs or near the incision. Because the nurse was already responsible for monitoring the time, the nurse announces the time to the surgical team at 30 and 60 seconds. Questions arose regarding a family s ability to bank cord blood in conjunction with delayed cord clamping. A Red Cross representative, an expert in cord blood banking, was invited to attend meetings to speak to this concern. She referenced the limited literature at that time and stated that it was her experience that although the volume of blood collected was often less, the concentration of cells per milliliter was frequently greater. She further reinforced the benefits for newborns who receive delayed cord clamping after birth. This is supported by the recent ACOG Committee Opinion that delayed cord clamping may lower the volumes of blood collected for the purposes of banking, 494 Nursing for Women s Health Volume 21 Issue 6

7 Box 1. Key Recommendations for Change Management From Representatives of the Quality and Patient Safety Department Develop passion for topic Involve key stakeholders to create a shared mental model Engage and hook people Dedicate champions for project management Engage resistors early on Develop a subcommittee Address difficult questions up front Provide clear and organized data Create and stick to a time line Be patient, because the process of change management takes longer than most people realize particularly when longer delay times are used (Allen, 2016; ACOG, 2017). Parents considering cord blood collection must be fully informed about the risks and benefits of delayed cord clamping and the potential for smaller volumes yielded should cord blood banking be desired. The final significant concern was the management of unanticipated nonvigorous newborns after birth. Recommendations for such an event were incorporated into our guideline for management of the third stage of labor that included delayed cord clamping. Incorporating Delayed Cord Clamping Into Third Stage of Labor Guideline Development A subgroup of ZBI members developed a guideline for management of the third stage of labor that included delayed cord clamping in May The Third Stage of Labor guideline covers assessment of risks for obstetric hemorrhage, the use of uterotonics for the management of hemorrhage, placement of the newborn skin to skin, and cord gas and cord blood collection. The guideline also includes delayed cord clamping newborn exclusion criteria, step-by-step instructions, and timing based on gestational age and positioning. At this same meeting, NICU providers presented information about the benefits of delayed cord clamping for the low-birth-weight preterm newborn. After this presentation, all gestational ages were included in the delayed cord clamping guideline. Delivery Room Brief and Debrief Tool During the work to implement delayed cord clamping, the need for a standardized communication tool became apparent. Because errors in communication can account for up to 70% of errors in the health care setting (Institute of Medicine, 2000), a communication tool was developed to structure information exchange and provide a space to have any team member raise questions and concerns. This Delivery Room Brief and Debrief Tool, implemented in December 2014, involved four structured points in time of communication. The tool ensures that all team members, including the woman and her support person(s), have a shared mental model, which is important to mitigate the risk of confusion or communication errors (see Figure 6). The tool includes gestational age and anticipated condition of the newborn, thus facilitating a team decision for the timing of cord clamping. This tool, along with the guideline for the third stage of labor, incorporates immediate evaluation of newborn vigor in accordance with Neonatal Resuscitation Program guidelines (American Heart Association & American Academy of Pediatrics, 2015) and standardizes language. For example, if a newborn s presentation is nonvigorous, any team member can state, The resuscitation team needs to assess the newborn. Please clamp and cut the cord now. This signifies to everyone in the room in a clear, nonthreatening manner that there is a change in plans, and the cord is immediately clamped and cut. The statement also allows the woman and her support person(s) to understand that there is a change in the plan of care and that the resuscitation team will manage the situation. Calm communication between team members is imperative at this critical time, because changes in status and plan of care can be a great source of stress and discomfort, particularly to the woman and family. Education and Implications for Nursing Practice A learning module was developed and assigned through an online learning system. This facilitated tracking of completed education for every labor and delivery nurse, approximately 300, in November Guidelines outlining a step-by-step approach for the timing of cord clamping and the Delivery Room Brief and Debrief Tool were posted in every labor unit and were included in orientation materials for onboarding labor and delivery nurses. A poster describing the benefits, step-by-step approach, and exclusion criteria of delayed cord clamping was prominently displayed on labor and delivery units and NICUs within the system. December 2017 Nursing for Women s Health 495

8 Figure 6. Delivery Room Brief and Debrief Tool Birth Brief, Provider Lead Delivery Room Baby Debrief, Provider/2nd RN Lead *Initiate between 8 10 cm or after the initial count* Introductions include mother and support persons. RN: PPH (QBL process) and shoulder dystocia risk factors Concerns for fetal heart tones or maternal well-being Delivering Provider: Plan for mode of delivery Anticipated needs for newborn resuscitation team Concerns for risk factors (PPH, shoulder dystocia) Timing for oxytocin infusion or injection Timing for cord clamping and skin to skin Specimen collection (cord gases or placenta disposition) Baby Brief, Provider Lead *After resuscitation team/second RN enters the room* Delivering Provider (RN may update also): Maternal and fetal indications for resuscitation team Plan for resuscitation or routine care FHR status, ROM and color, and gestational age Timing for cord clamping and skin to skin Maternal medication (insulin/ssri/street drugs) Meds during labor (antibiotics/narcotics) Expected anomalies Need for other specimen collection *Before resuscitation team/second RN leaves* NICU Team or 2nd RN: Resuscitation steps performed Apgar scores Next steps for care of the neonate Birth Debrief, Provider Lead *Initiate after the count is complete* Delivering Provider: Verify closing count/packed items QBL Procedure performed (VE/Shoulder dystocia) Post-delivery diagnosis Specimen/gases verification Type of episiotomy or tear What went well, what could go better? Key concerns for recovery Copyright 2016 Fairview Health Services. All rights reserved. Note. FHR = fetal heart rate; PPH = postpartum hemorrhage; QBL = quantified blood loss; RN = registered nurse; ROM = rupture of membranes; SSRI = selective serotonin reuptake inhibitor; VE = vacuum extractor. In addition, educational information was shared with approximately 200 NICU staff (neonatologists, residents, neonatal nurse practitioners, and nurses) who attend births. Project implementation would not have been possible without the support of the delivery room nurses, who are knowledgeable about bedside workflow. Although labor and delivery nurses are not responsible for clamping and cutting the umbilical cord, they are responsible for the initial assessment and steps of newborn resuscitation. Labor and delivery nurses facilitate the placement of a newborn skin to skin with his/her mother. Their assessments reassure a mother and the obstetric provider that the newborn is vigorous and undergoing normal transition. Labor and delivery nurses also drive initiation and completion of the brief and debrief. Implications for Multidisciplinary and Multisite Implementation Without a combined neonatal and obstetric team approach, a shared mental model, and the ZBI infrastructure, implementation would have been extremely challenging, especially across multiple hospital sites. Multidisciplinary team review, presentations, discussions, and subsequent endorsement of evidence in the literature were integral to success. Based on the results of the survey, it was evident that if the knowledge gaps and barriers were identified and addressed, implementation of delayed cord clamping could be successful. Through the existing ZBI infrastructure, guidelines for delayed cord clamping and the Delivery Room Brief and Debrief Tool were distributed to obstetric and neonatal team members at each hospital within the system for widespread implementation. The shared electronic medical record was also adapted to reinforce the permanence of the practice and facilitate 496 Nursing for Women s Health Volume 21 Issue 6

9 data collection. A field in the medical record was added to indicate whether immediate or delayed cord clamping was performed at the birth. Questions regarding implementation or requiring clarification were addressed at each site by local champions. resource-rich environment for pregnant women, and therefore the benefit to the newborn would be marginal. By providing additional references supporting the benefits for term newborns (Leslie, 2015) and encouragement from delivery room neonatal nurse practitioners during the handoff brief at high-risk term births, hesitant obstetric providers began to provide delayed cord clamping routinely to newborns of all gestational ages. The surgical technicians were overlooked and not initially included in the education and communication process of delayed cord clamping in the operating room. As a result, they were unaware of placement of the newborn on the mother for a longer time frame and providing warm sterile blankets or towels during the initial implementation period. Personal communication and s were quickly developed to educate the surgical technicians on this change in practice. A robust data collection process and involvement of patient quality and safety staff on the team were limited. Mobilizing the resources to collect data initially was challenging because of competition with other strategic initiatives that required use of these limited resources. Monitoring by the NICU and quality and patient safety teams showed no increase in readmissions for hyperbilirubinemia or an increase in phototherapy use for treatment of jaundice at less than 34 weeks gestation meeting criteria for timing. Immediate cord clamping was noted in cases of abnormal placentation, fetal anomalies, multiple gestations, and immediate need for resuscitation. Births that did not include any documentation of delayed cord clamping were considered as having immediate cord clamping for the purpose of this analysis. Conclusion In addition to engagement, teamwork, and a shared mental model, these five strategic tactics can help make delayed cord clamping as a change in practice at any hospital possible: Discover the barriers of delayed cord clamping Educate all team members Lasting impact and sustained improvement through a change management model Address attitudes, issues, and concerns that continue to develop among team members You can make the difference Recommendations and guidelines that drive the process change are supported by evidence in the literature. Leadership comes in all forms, and nurses are in a strategic position to lead changes in practice to improve outcomes at the hospital and system levels. NWH Leadership comes in all forms, and nurses are in a strategic position to lead changes in practice to improve outcomes at the hospital and system levels Challenges With Multidisciplinary and Multisite Implementation Varying cultures (academic vs. community hospital setting), resources (number of births and staff), and workflow processes (variation in the types of providers and provider preferences) proved to be significant challenges of implementing delayed cord clamping at the hospitals. Because of the lack of systematic communication and online learning for providers, dissemination of the delayed cord clamping guideline and tracking for hundreds of providers was difficult to ensure. Each site was responsible for disseminating the information and for holding their health care team members accountable for implementation. Ongoing work to standardize the online communication and education processes for providers across all the hospitals continues. Obstetric providers verbalized a greater inclination to provide delayed cord clamping for preterm newborns than term newborns. This was likely because of the preponderance of evidence to support delayed cord clamping in preterm newborns coupled with strong NICU medical leadership and avocation of the practice to reduce morbidity for preterm newborns. Furthermore, benefits for term newborns may not have been assessed as being as advantageous. One conjecture is that the United States is considered a in healthy term newborns who experienced delayed cord clamping. Data from October through December 2016 at the academic health center showed a compliance rate of 85% for delayed cord clamping for births at greater than or equal to 34 weeks gestation meeting criteria for timing and 65% for births References Allen, D., Scrivens, N., Lawless, T., Mostert, K., Oppenheimer, L., Walker, M.,... Elmoazzen, H. (2016). Delayed clamping of the umbilical cord after delivery and implications for public cord clamping. Transfusion, 56, doi:10.111/trf American College of Obstetricians and Gynecologists. (2017). ACOG Committee opinion no. 684: Delayed umbilical cord clamping after birth. Obstetrics & Gynecology, 129(1), doi: /aog December 2017 Nursing for Women s Health 497

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Effect of timing of umbilical cord clamping of term infants on mother and baby outcomes. Cochrane Database of Systematic Reviews, 2013(7), CD doi: / cd pub3 Mercer, J. S., & Erickson-Owens, D. A. (2012). Rethinking placental transfusion and cord clamping issues. Journal of Perinatal & Neonatal Nursing, 26(3), doi: / JPN.0b013e31825d2d9a Mercer, J. S., & Erickson-Owens, D. A. (2014). Is it time to rethink cord management when resuscitation is needed? Journal of Midwifery & Women s Health, 59(6), doi: / jmwh Raju, T. N., & Singhal, N. (2012). Optimal timing for clamping the umbilical cord after birth. Clinics in Perinatology, 39(4), doi: /j.clp Sommerness, S. A., Gams, R., Rauk, P. N., Bangdiwala, A., Landers, D. V., Avery, M. D.,... Shields, A. (2017). The perinatal birth environment: Communication strategies and processes for adherence to a standardized guideline in women undergoing second-stage labor with epidural anesthesia. 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