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Clinical Question Paper

Amber Dykstra
NURS 350

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Introduction

In the world of nursing there are many problems that occur daily. It is a nurses duty to
assess the situation, conduct research on what the best solution is, and present it to the patient or
fellow coworkers. This leads to Evidence Based Practice and promotes the safest and most
efficient care given to the patient.
Clinical Question
When a child is born there are many decisions that have to be made. The process of labor
and delivery is complicated and it is up to trained nurses to assist parents in making what they
feel is the best decision. A decision that is reviewed among parents and professionals is how long
an umbilical cord should stay attached to the placenta after birth. This decision is crucial in the
long term effects of a babys hemoglobin.
This question qualifies as a PICOT question because of the outcome trying to be
achieved. The patient is the newborn child, intervention is the delay of clamping the cord
compared to what is currently practiced in the hospital, the outcome is the babys hemoglobin
being higher and the time is what is an appropriate amount of time to clamp the umbilical cord.
By addressing the issue of cord clamping and discovering an appropriate amount of time
before clamping the cord, the babys hemoglobin will be an acceptable level as he or she grows
older. Currently, children have low hemoglobin levels as they age. By delaying cord clamping,
the babies will have the extra blood from the placenta to carry them through the first few months
of life.
Methodology
For a nurse to find the appropriate literature, CINAHL and PUBMED databases were
used. These data bases provide articles from medical journals. To find appropriate literature, the

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words delayed cord clamping were typed into the database search engine. This brought up
multiple results regarding delayed cord clamping. The results were then filtered by disregarding
the articles about preterm infants and delayed cord clamping. From there, the results were about
the benefits delayed cord clamping has on an infant immediately or long term.
The American Nurses Association defines nursing as the protection, promotion, and
optimization of health and abilities, prevention of illness and injury, alleviation of suffering
through the diagnosis and treatment of human response, and advocacy in the care of individuals,
families, communities, and populations, (ANA). This extends into what a nurses scope of
practice is. When a nurse discusses the benefits of delayed cord clamping with the patient, this is
promoting and optimizing the infants health. It is not an advanced nursing practice because it is
educating the patient. If the nurse were to actually do the clamping of the cord everytime, then it
would be more of an advance scope of practice.
Many of the studies for delayed cord clamping are at least a level 2 on a level of evidence
scale. One of the studies is a randomized control trial (Andersson 525). There are also many
studies that conduct meta-analysis. All studies are approved by an ethics board. Many studies
recruit patients through an OB/GYN office. One particular study recruited obstetricians, family
practice physicians and midwives. This study was a level three and observational (Hutton 39).
The research assistant recorded the times that the physicians and midwives clamped the cord.
Random control trials were also used in many studies regarding cord clamping. This is the most
reliable and highest level of evidence used. It is the most accurate and shows that the benefits of
cord clamping outweigh the negatives.
Discussion of Literature
Article One

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The first article that was used to assist in the research of delayed cord clamping was
Effects of delayed cord clamping on neurodevelopment and infection at four months of age: a
randomized trial by Andersson, Domellof, Andersson, and Hellstrom-Westas. The study was
conducted at the Hospital of Halland, Halmstad, Sweden and was approved by the Regional
Ethical Review Board. Andersson et al clearly stated that they were attempting to identify certain
effects from delayed cord after 4 months. The study was performed using a randomized sample
of 400 pregnant women who all met the same criteria. The women were divided into two groups
randomly. One group was selected to receive delayed cord clamping while the other group was
selected for early cord clamping. Blood was obtained from the infant on three separate occasions
(Andersson 526). This method of data collection was appropriate for this study.
The authors used a morbidity questionnaire to evaluate how many times the children
were sick. Andersson et al also used the types of sickness and how the patient was treated as
variables in the statistical analysis. The results of the studies showed that although delayed cord
clamping helps with childrens anemia levels when they are older, it does not help decrease the
risk for infection and sickness in children. This article is appropriate to use in nursing practice.
The practice of delayed cord clamping is becoming more common and nurses need to educate
patients on the benefits of delayed cord clamping.
Article 2
A second article useful for the research topic of delayed cord clamping is An
Observational Study of Umbilical Cord Clamping Practices of Maternity Care Providers in a
Tertiary Care Center, by Hutton, Stroll and Taha. This study is an observational study conducted
to review what the standard procedure for physicians and midwives is regarding delayed cord
clamping. It took place in British Columbia at the largest maternity hospital in Canada. The

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literature used to assist in writing this article was appropriately reviewed by the authors. The
sample used to conduct the observational study consisted of obstetricians, midwives, and family
physicians. Letters regarding the study were sent to the physicians and midwives and consent
forms to have a research assistant observe when they clamped the cord. The research assistants
also worked closely with the women giving birth who participated. A stopwatch was used to
collect data at certain times after delivery (Hutton 40). This was an appropriate tool to use for the
study because it was the same research assistant using the same stop watch and pressing the start
and stop button at precisely the same time.
The results of the study found that 56% of the physicians and midwives clamped and cut
the cord within 15 seconds of delivery. One physician asked what time she clamped the cord and
was surprised to learn it was sooner than expected. The research assistant wondered if it was
possible that other physicians were unaware of their time as well (Hutton 43). Another possible
reason for the short clamping time is that obstetricians will have a second party clamp and cut
the cord for them. This is usually a resident who is unaware of the time the umbilical cord is
clamped and cut. This article is appropriate for the research of delayed cord clamping because it
reviews the literature of why cord clamping is beneficial and it also makes physicians and
midwives more aware how long they are taking to clamp the umbilical cord. It is a great article
for nurses to review as well. The OB nurse can educate the patient on why umbilical cord
clamping is important and the patient will be able to discuss this option with their physician or
midwife.
Article 3
The third article that is informative about delayed cord clamping is, A Hospital Policy
Change Toward Delayed Cord Clamping is Effective in Improving Hemoglobin Levels and

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Anemia Status of 8-month-old Peruvian Infants, by Gyorkos, Giroux, Blouin, Creed-anashiro,

Casapia, Aguilar, Silva, Joseph, and Penny. The authors state that their main objective is to
observe how a hospital policy change in delayed cord clamping can improve the hemoglobin in
children up to 8 months of age. The work was approved by the Research Ethics Office of the
McGill University Health Centre and the hospitals ethics committee. The literature reviewed by
the authors is appropriate for use in this study. The subjects used in the study were pregnant
women admitted to the labor unit at the hospital prior to the policy change and pregnant women
admitted after policy change. Both sets of women had the same criteria to meet for eligibility.
The time recorded for both sets of women were the same, from when the infants first shoulder
was out to the time the cord was clamped. Follow up visits were administered to both sets of
infants at 4 and 8 months old (Gyorkos 436).
The results from the study did not show any significant change between the pre-policy
infants and post-policy infants until the 8th month. At the 4th month checkup both sets of infants
had approximately the same level of hemoglobin. However, at the 8th month checkup the prepolicy infants hemoglobin was significantly lower than the post-policy infants. The authors
acknowledge that although this study found an infants hemoglobin level to be higher in the 8th
month of life with delayed cord clamping, it is crucial to continue to study the long term effects
of delayed cord clamping. This article can be useful to nurses to review since more hospitals are
implementing this practice. Although it is not a standard protocol in the majority of hospitals, it
is becoming practiced more by individual physicians. This article is appropriate for the research
question, but it needs to be more specific on what time the hospital is using to clamp the cord.
Significance to Nursing

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The benefits of delaying the cutting of an umbilical cord have been proven
multiple times. The average time that a cord should be cut is after 2 minutes of being born. This
improves the quality of a newborns iron level. According to Andersson, if an infant has delayed
cord clamping is has a 45% higher chance of not have iron deficiency at 4 months of age. Iron
stores continue to be higher through 6 months of age (Andersson 525). In several studies, iron
deficiency anemia can have a negative impact on neurodevelopment later in life. By promoting
delayed cord clamping, we are promoting a healthier life later in an infants life.
In the article An observational study of umbilical cord clamping practices of maternity
care providers in a tertiary care center, this observation created a standard for nurses to learn
from. One lesson learned is although it may seem that time goes by quickly, but in reality time
goes by slower than we think. We can learn from this and accurately record time.
One hospital has put a delayed cord clamping policy in place. This has increased the
infants hemoglobin levels and there have not been any negative effects on the mothers
recovery. If more hospitals were to put this policy into place, the benefits would greatly outweigh
the negatives. The scope of practice for nurses means to promote health. By educating these
pregnant women on improving their infants health in the near future, nurses are performing their
duty.
Conclusion
In the recent past infant anemia has been a major concern. One way to prevent infant
anemia is to perform delayed cord clamping of the umbilical after birth for approximately 2
minutes. Delayed cord clamping has been studied more using randomized control trials, metaanalysis and observational studies. It has been proven to improve the infants hemoglobin
through 6 months of age. As nurses, it is our scope of practice to promote health to all patients.

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By educating pregnant women and physicians on this topic we are promoting a healthier future
for the infants being born today.

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References

American Nurses Association. (2014). Scope of practice. Retrieved from

http://www.nursingworld.org/scopeandstandardsofpractice
Andersson, O., Domellot, M., Andersson, D., and Hellstrom-Westas, Lena. (2013). Effects of
delayed cord clamping on neurodevelopment and infection at four months of age: a
randomized trial. Acta Paediatrica, p 525-531.
Fanaroff, A.A., Carlo, W.A., Donovan, E.F., McDonald, S.A., and Poole, W.K. (2011). Effects of
delayed cord clamping in very-low-birth-weight infants. Journal of Perinatology 31, pp
68-71.
Gyorkos, T.W., Maheu-Giroux, M., Blouin, B., Creed-Kanashiro, H., Casapia, M., Aguilar, E.,
Silva, H., Joseph, S.A., and Penny, M.E. (2012). A hospital policy change toward delayed
cord clamping is effective in improving hemoglobin levels and anemia status of 8-monthold Peruvian infants. Journal of Tropical Pediatrics 58,(6), pp 435-440.
Hutton, E.K., Stoll, K., and Taha, N. (2013). An observational study of umbilical cord clamping
practices of maternity care providers in a tertiary care center. Birth 40 (1), pp 39-45.
Niewswiadomy R.M. (2012). Foundations of nursing research (6th Ed.). Boston: Pearson.