Neonatal healthcare professionals’ experiences of intact cord resuscitation in the mother´s bed- an interview study

Approximately 5–10% of neonates worldwide need assistance with breathing after childbirth [1]. Although adverse perinatal outcomes are uncommon, approximately every 10th neonate in Sweden requires assistance to establish independent breathing after childbirth and 1% need extensive medical interventions (The Swedish National Board of Health and Welfare [NBHW], [2] defined as neonatal cardiopulmonary resuscitation [3]. Childbirth can become life-threatening when it involves risks and complications for the neonate, such as birth asphyxia, which is caused by impaired gas exchange and can occur before, during, or after birth [4]. Complications leading to birth asphyxia include placenta abruption, uterine rupture, tight nuchal cord, cord prolapse, or infection [5]. Other factors that can cause suspected birth asphyxia are incautious use of synthetic oxytocin, shoulder dystocia, or a difficult breech birth, which commonly leads to immediate cutting of the umbilical cord and starting resuscitation [6].

Until 2008, the routine for non-vigorous neonates in most Swedish labour wards was to clamp the umbilical cord within 30 s (early cord clamping) after childbirth [7]. Evidence demonstrates that early cord clamping is associated with lower Apgar scores and increased risk of intraventricular haemorrhage after preterm birth, leading to a higher risk of prolonged asphyxia and permanent impairment for the neonate [8]. Andersson et al. [9] reported that intact cord resuscitation (ICR) in the first three minutes of life improved oxygenation and Apgar scores during the first ten minutes of life in late preterm and term neonates. Regardless of birth mode, it is feasible to perform resuscitation on neonates during sustained cord circulation, clamping the umbilical cord only when the neonate is physiologically ready [10]. The practise of ICR implies the umbilical cord still being connected to the placenta for at least one minute while providing temperature control and equipment for resuscitation [11]. More advanced resuscitation including early and continuous positive pressure ventilation and/or intubation, minimizing hypoxia followed by acidosis and maintaining normal temperature are strategies to potentially reduce neonate mortality [4].

It has been described that changing practises can face obstacles within healthcare [12]. International studies have described that healthcare professionals described practical challenges in providing ICR, as well as concerns about having the resuscitation equipment available in a timely manner. Other challenges mentioned were the integration of ICR into a clinical routine and team training, as well as providing ICR beside the mother with a non-vigorous neonate while witnessed by parents [13]. Thus, neonatal interventions can be challenging in various ways. To the best of our knowledge, there are few previous studies on neonatal healthcare professionals’ experiences of providing ICR in the mother’s bed. To narrow this knowledge gap and obtain a more comprehensive view of this issue, it is essential to illuminate neonatal healthcare professionals’ experiences of practicing ICR.

This is important as neonatal healthcare professionals caring for a non-vigorous neonate are obliged to work according to best evidence. This interview study aims to explore neonatal healthcare professionals’ experiences of providing intact cord resuscitation in the mother’s bed.

A qualitative reflexive thematic analysis by Braun & Clarke [16] was chosen as it provides a meaningful amount of data through a systematic repetitive process including a back-and-forth movement throughout the six phases [16]. The first phase involved verbatim transcription of the interviews by K.P. The interview text was then analysed by K.P. and M.R and further validated by LTL. The text was read in its entirety to gain familiarity with the content and initial reflections were noted. In the second phase, statements relevant to the aim were coded. The third phase consisted of searching for sub-themes. All data relevant to the aim including similarities and differences were grouped into sub-themes based on the code’s consensus. The fourth phase involved reviewing the sub-themes through further analysis to verify how the data related to each other. The characteristics of each sub-theme were defined and named. The sixth and final phase concerned describing and labelling the overarching theme. A thematic structure of sub-themes and themes emerged through the analysis process, which constitutes an interpretation of the participants’ experiences of ICR in the mother’s bed.

Ethical approval and permission to conduct the study were obtained from the Swedish Ethical Review Authority (Dnr 2021–03688). The study complied with internationally accepted ethical principles for medical research involving human subjects, designed to protect individuals and ensure respect for human dignity [18]. All participants gave their informed consent. According to the European General Data Protection Regulation (GDPR), the informed consent must be documented, specify a clear purpose, be voluntary, time-limited, easy to understand and possible to withdraw without any explanation [19].

The results highlighted both positive and negative experiences of providing ICR among healthcare professionals within neonatal care. It emerged that the healthcare professionals experienced psychological och practical challenges. With a total of three themes and eight sub-themes emerged from the qualitative data analysis, as presented in Table 2. Each sub-theme is strengthened by quotations from the participants.

The aim of the present study was to explore neonatal healthcare professionals’ experiences of providing intact cord resuscitation in the mother’s bed. The results presented provide some insight into the participants’ experiences of the prerequisites for providing neonatal care in intact cord resuscitation and complement to the scarce research regarding healthcare professionals’ experiences of ICR. The most prominent result was how the healthcare professionals identified themselves with the mother who in their view was in a vulnerable position and situation.

The sense of the mother's vulnerability was noticeable, as the participants reported that they needed to protect and preserve the mother´s integrity by preventing exposure and maintaining dignity. Participants expressed that midwives were aware of the need to protect the mother from exposure and placed a towel over her abdomen. Nevertheless, the participants experienced the mother’s vulnerability, which may originate in identification with the mother’s situation. This could be an expression of the fact that they were not used to working close to a mother in a lithotomy position. Participants needed handling their emotions in an unfamiliar situation. On the other hand, they highlighted the benefits of providing ICR as neonates and parents were not separated. Bergman [20] highlights separation from the mother immediately after birth as a toxic stress for the neonate [20]. As birth involves two patients, namely mother and neonate, the starting point for the interprofessional team must be to avoid separating neonates and parents, thus promoting attachment between the mother and the neonate. Mothers expressed anxiety about being physically separated from their neonate who required care outside the delivery room, especially when there was unclear communication about where the neonate was taken [21].

The practical challenges in the environment included managing ICR in limited space and gaining access to the equipment needed for ICR. Due to an increased number of healthcare professionals and the equipment required for resuscitation, the labour rooms were often perceived as too small. Being unable to reach the equipment needed for resuscitation and observation of the neonate stressed the participants. Being the only representant in the profession can be experienced as lonely and vulnerable and it can be difficult to determine when to ask for help from one’s professional colleagues. A Swedish interview study with midwives indicates that feelings of being part of a team were important, as the team gave support in emotionally difficult and stressful situations [7]. The participants’ work experience increased their sense of security, hence where the resuscitation took place was not an issue. Physicians in obstetrics expressed that they felt lonely most of the time during obstetric emergencies, but those who had gained work experience invariably had both routines and know-how [22]. Therefore, it is important that all professionals involved in the ICR of the neonate have simulation training together to become a team.

The desire for interprofessional team training involved proper education and training as well as debriefing to manage ICR in the mother’s bed. Research indicates that team training is becoming increasingly important in healthcare contexts [13]. The healthcare organizations rely on teams to manage complex situations such as ICR. It is therefore essential that team members work together cohesively and effectively. Team training can help to address a range of issues that might arise, such as poor communication, lack of trust and conflicts between team members [23]. In addition, other challenges described in the literature were the integration of ICR into a clinical routine as well as team training and providing ICR to a non-vigorous neonate when witnessed by parents [13]. Team training can contribute to improved performance, increase job satisfaction, reduce stress and strengthen effectiveness and safe management by providing team members with the tools and techniques they need to work together effectively [24]. The interprofessional team members’ interpretation of a shared mindset indicated that the purpose of ICR was interpreted and valued differently based on their professions and specialties. This influenced interprofessional team collaboration. Thus, team training can foster a sense of companionship and a shared mindset including a common goal among team members [25]. Different types of team training can be effective depending on the needs of the team. Conflict resolution training including communication training can help team members to communicate more effectively, leading to fewer misunderstandings and efficient team collaboration. In addition, leadership training can assist team members to develop the skills they need to lead effectively, which is especially important in teams where there is no clear leader. Participants expressed that in ICR situations where the team is already at capacity, the team leader must decide which current member will be released to ensure an optimal team composition. A particular challenge expressed was that the team leader often changes in accordance with the composition of the team. Isacson et al. [7] highlighted midwives’ experiences of being a team member and participating in critical situations, i.e. an ICR situation. Negative feelings of insufficiency were expressed, which were caused by the midwives trying to balance different tasks at the same time. They wanted to calm the parents and explain what was happening, while simultaneously performing medical tasks required by the mother or neonate. Midwives balanced this by being a good team member and trying to consider the views of colleagues such as neonatal nurses, paediatricians, or obstetricians [7]. As ICR situations can be challenging in several ways, it is important to be vigilant about only adding team members when necessary. Too many team members can lead to miscommunication, confusion and unclear roles as well as a lack of effectiveness. It is therefore important to have a clear and concise plan of action as well as familiarity with guidelines. Participants expressed the need to be prepared for intact umbilical cord resuscitation together in the interprofessional team to have a shared mindset, thus preventing issues such as reduced control of the equipment, poor communication and conflict. In the literature, simulation training is a well-known method for increasing team members' competence and capacity in critical situations within healthcare organizations [26]. Debriefing is an essential part of simulation training, as it allows participants to reflect on their performance and identify areas for improvement. By discussing what went well and what could have been done differently, participants can develop a deeper understanding of the task at hand, improve interaction and be better prepared for future scenarios [23]. The analysis of data from the individual interviews had a qualitative inductive approach and some methodological considerations should be mentioned. One weakness in qualitative research is the lack of generalisability of the results. As qualitative research often involves a small sample size, the results may not be applicable to a larger population. However, the method used in the present study allowed in-depth exploration of a complex phenomenon, which involved collecting rich, detailed data from individual interviews. This provided a deeper understanding of the experiences and perspectives of participants, as well as the context of the study. A purposive sampling was used and the results represent 20 neonatal healthcare professionals’ experiences of providing ICR in the mother’s bed. The results are logical and congruent with the study aim. The formulated overarching theme The prerequisites for providing neonatal care in intact cord resuscitation run through the themes and sub-themes. In addition, the results were confirmed by using representative quotations in each sub-theme. Finally, there is a potential for subjectivity in the interpretation of the data. This is because qualitative research often relies on the researcher’s own interpretation of the data, which can be influenced by biases. It was therefore necessary to adopt an open approach to the interview text during the analysis process. In order to confirm the results, an outside expert (LTL) was asked to ensure the validity of the results and associated themes, i.e. achieve consensus.

In conclusion, the result of the present study highlights that neonatal healthcare professionals’ experiences of providing ICR in the mother’s bed were positive and had significant benefits for the neonate, namely zero separation between the neonate and parents and better physical recovery for the neonate. However, the fact that ICR in the mother’s bed can be challenging in several ways, such as emotionally, managing environmental circumstances and ensuring effective team collaboration. Therefore, it is of the utmost importance that healthcare professionals are given the opportunity to reflect and train together as a team. Future recommendations are to summarize evidence-based knowledge to design guidelines for ICR situation.