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Hi, everyone. And welcome to this this webinar with arms from medical on optimal court manager is already wanted to focus on the perinatal teamwork elements off this. And we'll go through that in the next 20 minutes will say so. I'm Sarah Bait Simon, neonatal consultant from SWIMMED. And I'm also the operational clinical lead for Peri Creme, which is a perinatal optimization project for preterm babies running across the southwest of England on I also hold some roles for welcome. So I've been very involved with the quality tool kits for bathroom. The Paronychia optimization tool kits on do a lot of the content of this. I'll be sharing from the optimal called management tool kit. So I'd like to kind of split the talking to three sections. Look, a why wide is optimal cord management matter. What's the evidence behind it, and why not? Why haven't we been doing this one of the barriers and and how might we even come that and perhaps share some of our experience from the Southwest? Um, wrapping that up with what we Sometimes it's not that easy to just know what the barriers are and overcome them. How can we really focus on what matters in perinatal teen quality improvement. So let's look first at the evidence. Then let's look at where they're six in terms of the bigger national picture for the and it's just long term implants that this really ambitious target to reduce death and brain injury in babies. And of course, the large volume of that is within our pre term population on. But that really hasn't been changing over over many years. We haven't really moved the mortality statistics nor the brain injury statistics, but fortunately we're blessed with quite a lot of evidence about the things that might enable us to do that. But it's implementation that have seen the problem on this, I think is them. What really underpins that That journey where where does that evidence lie on? The evidence lives along this pathway from taking a baby from an in utero environment through a period of delivery and stabilization. Onda, with the theories of interventions on optimal journey through that perinatal period, to try and achieve the best motor outcome so that these big babies might be able to grow up and run around in a field to achieve the very best cognitive speech and language development outcomes so that they could make friends different on land in a field with It's about really delivering the best journey we can during the perinatal period to try and optimize these babies outcomes. But although we've known the evidence in some cases, we know the evidence for stunt time. It's dissemination and implementation that have bean the the root cause of the delay in this area. And let's look at some of the statistics in that area. We know about steroids on into part of magnesium, the national preset projects being a huge success there. We know that place of birth matters, and we know and have known for at least 5 to 6 years. That delayed cord clamping seems to reduce the risk of death. But yet we don't know the statistics on that nationally and Napa just starting to collect that now on. Do those people who do publish that statistic seem to suggest that a lot of babies are missing out why I might not be. I think one of the issues have bean the terminology we use. It's delayed or deferred implies that we are deferring care or delaying care. They're both quite negative words on, but I think that's why Bapineuzumab octin for optimal cord management. Let's take steroids, for example. It took, uh, 40 years to get the rates of antenatal steroids up so that the majority of babies born early were exposed to adequate into natal steroids. And even now, although with giving some antenatal steroids, how many of us are giving them and optimally time and course cause I know certainly when we looked back in my own unit and across the Southwest with Perry Prem that that is not easy. So I've talked about Perry. I'm a little bit the This is Perry Gram on. It's essentially putting the the interventions together in a journey on Die cannot overemphasize enough importance of Paranasal team collaboration. This cannot be implemented by neonatologist. It cannot be implemented by obstetricians. It has to be is a working together. We need to stop being separate teams on, come together to deliver these goals, to deliver the improvement, and we need to work in collaboration with our midwifery and nursing and colleagues. To do this. This is their peri print journey on. Of course, we're focusing very much in on optimal cord management here on this, um, the work that we've done in Pericranium very much being in collaboration with be a P M. Who have worked together with and naps create the series of paranasal optimization tool kits. They start with a normal for me, a toolkit, but I'm sure that many, if you will have seen the a tool kit, the MBM on my the optimal cord management on. Of course, this is all paving the way for an a chest. England's work on an HS Improvements work with the maternity in the NHL safety improvement program to deliver their key driver of optimization of the preterm infant. This is what the optimization pathway looks like. I was privileged to China. Maternal breast milk toolkit on. You can see where optimal cord management sits. They want to the court management tool kit from bathroom on diet. Think that parental involvement in paranasal optimization is just vital on this is a parent. I was privileged and after the cast on, and she shared her story with the baton to get green, and I think it's really important we understand how parents might feel about this delayed called plumping Many of them can be quite afraid if they think that we're gonna wait to provide the initial care and stabilization. So it's really important about how we describe that parents. I often say, Well, we're gonna wait this minute before we clump a cord because that is vital for your baby. It gives me all sorts of benefits, but during that time we're going to be keeping warm. I'm providing care. So where are we being with the evidence? Danny, We have the first Cochran of you. 90,012. I was privileged to work with high carob on on the court camping toolkit on. Of course they just updated that the Cockrum of you and 2020 but that already identified quite significant benefit in 2015 and a less change their guidance to recommend the lady called clumping on that has been maintained in the later 2020 called guidance and then run about 2017 and onwards to the most recent Cochran Review. We've got clear evidence for benefit in terms of reduction and death on it reduces death in our pre term population by nearly a third, and I think that's such a striking statistic on that a lonely should empower us to deliver the intervention to all of homework return population. I think when you talk to people who have clumped the cord early on, they often see what I really needed to get the baby to unite. Ologist saw the neonatologist really felt I needed to get the baby from the obstetricians. I think a lot of that could be either come biased stopping being fat for teens. But we really need to remember that when we clumps accord early, we impose on increased risk of death that is, in live you not acceptable. And if we look at the number of member of needed to treat if we think about the least mature babies, if we can wait to clump the cord for at least a minute in 20 babies, we will save one of thumb. And I think that that is something we all need to look at in our own population. How many babies do we deliver in our unit? And how many could we say if if we implemented the for call pumping or optimal called management for? So why don't we? Then the evidence is really really compelling. And what are the barriers and ham, right? Were you to come them? So this stems from some work that we did in my own unit just over 405 years ago, and we were able to really kind of split this. This was a dramatic analysis of interviews with the whole pony. 20 t were able to really split into these key areas, and if we look at these areas, let's take attitude's. For example, one of the most common reasons for early cord clumping that's quoted is not necessarily a lack of awareness of the benefits, but it's It's the feeling that the baby's compromise don't must get to resuscitate on by think that although people are aware of the benefits when you talk to people it much more around, there's reduce risk of transfusion. Maybe less need for minor troops on all of these things are very true, but for an obstetrician they can feel quite distant or unconnected. Where is a third? Reduction in death is very powerful, and I think we need to raise awareness of those benefits. Um, let's look a some of the neonatal and environmental concerns cause there's a really quite valid, specifically environmental concerns that we all know that normal exam me A for preterm babies is really vital. Its benefits off the same order. I asked if they call cramping so it would be in my mind or fill if we implemented to for call camping. But all the babies got cold, so providing family care during your one minute is really important and how you do that. There isn't one right way, and there's lots of different Mac N F in that people have have come up with them involving the spoke Cialis or not respectful. He's That's sterile plastic bags, Um, and there's lots of different ways in which you can do that. And I think also people are really worried about that kind of the concept of this compromised infant and and less describes it, doesn't it? In an uncompromising infant, definitely delayed call plumping. But how subjective assessment. Because a lot of pre turn babies can look especially to the untrained eye. If they were being born in units that see these less toxins, they look really quite rampy on Go being Able Teo offer initial state equalization by provisional thermal care. If we think about the ANA less algorithm provision of thermal care comes first on, then opening the airway and lung inflation if needed. Now in the cord. Clumping toolkit Great for bathroom. We spoke about this at length, and there are lots of units who are well aware of the evidence that around 90% of preterm babies will start breathing by themselves in the first minute as long as their airways open on they have some gentle stimulation. There are lots of units who feel that's fine, and they don't need to provide airway support. But equally there are a lot of units you feel actually often that's what causes people to panic. And if we can offer support for airway and long inflation prior to delivery, then that's what really matters on. Of course, the European RDS guidelines do talk about the CPAP or people delivery on a physiological evidence seems to suggest the opening the lungs really doesn't matter before you come accord, and that's quite easy to do it. A vaginal delivery, but a songs you mean you're get around, but it's not easy to do in a very in section, but lots of people who come and have overcome this. But I think one of the remaining barriers is the Is the availability off steroidal respectfully circuit equipment. And that's when the manufacturers really need to address this problem. So overcoming these barriers, the thing which I cannot overstate is the need for paranasal team working. It's the need to work together with your team. Get to know your team, the mid wives, the nurses, the obstetricians, the neonatal team get together, work out how it works in your unit. In your obstetrics eaters, be a fire stimulation, which is what we're doing on the left side there. And let's not forget that actually, the 60 seconds exists on the Alesse guide and said the arrow on the right for a reason because actually, it takes some time to provide the thermal care. It takes some time to have a look at them on Ben. It takes some time to open the airway on in a really compromised baby. Actually, sometimes these babies are the ones who desperately need the deferred called something with the extra time. So why know? Initiate that just the start of that process. Obviously, there's manager that they're looking at much morp along called intact stabilization. But just for the purposes of achieving this 60 seconds, this is what we need to be doing, and it is doable. This is what we do in Swindle in the Anatomic just scrubs up on we put the baby in a bag on. We have respiratory circuit, Yeah, but it really needs to be done with a really nice structured operating procedure. Standard operating procedure on Do you confined the use of picks, drop diagrams that one, So I'll be quite useful for help. People understand where where they should go. So I just wanted to touch an apology for the busy slide on the issue of court milking, which is often floated as an alternative to difficult camping or optimum called management. When you're worried about a compromise, baby on the evidence is really conflict in this area. I certainly a quite concerned about the study showing the increased risk of IVF, each with umbilical cord milking and makes physiological sense getting the huge changes in blood pressure that would result from court milking on. But I think for men, many people, if you can successfully implement optimal court management, which is possible that actually, the issue of called milking becomes a moot point largely on the bath. Um group of concluded that, you know, it should really only reserve called milking for the rare situations such a maternal collapse where we need to expedite it. But largely we should be focusing on optimal called management for a least 60 seconds. And this is what happened in our unit. We implemented this technique on I can tell you there are numbers throughout 2020 and 2021 have stayed up between 85 100% of babies born below 32 in there, 34 weeks receiving at least 66 on this. This well where we are is a region across the Southwest. So in back before we started peripartum, the baseline figures that we had available were around a third of babies were receiving difficult clumping. And this is below 34 weeks in Alltel perinatal units across the Southwest, and you can see by December and November. In December, we achieved 85% on we're well over two thirds. There's bean, a huge progress, and that's perinatal collaborations, sharing ideas, overcoming barriers, so I would recommend you have a look at the toolkit, it's It's a great source of information. Best practice and this is the focus of the toolkit is really around Human factors Multi disciplinary paranasal team Working, Planning ahead doing things like including the plan for court management within your huge checklist. This is Amy in sections, working out exactly how you provide normal for me A care on, I can tell you during the last four years where we've implemented divert called clumping for all babies, our normal. For me, a rates have improved. A rule is well, how you gonna manage this issue of spontaneous breathing and lung inflation on how are you crucially going to involve and informed parents? So just finally, in the last couple of minutes, just a few take home top tips for Q I d. Um, I'm back to this. I make no apologies for emphasizing this again and again. It is about the paranasal team. You have to work to get the with your obstetrician's. I'm so blessed to where it was Charlotte, Fantastic obstetrician. On a really good friend, it is working together that we've been able to deliver a lot of this work So just two analogy for my last few slides on this is my son Andi. He set himself a very ambitious goal off climbing the well three thousands, which is the 18 highest peaks in Wales before he finished primary school. And I think that sometimes that kind of ambitious goal kind of line really nicely to trying to achieve something big in quality improvement, on sometimes implementing to focal company come feel like that. It can feel like an uphill battle. You feel like you've educated everyone on. Then there's somebody who, still, though they're about it, and it can feel in achievable when you're battling with kind of the need for sterile equipment but taking small steps on words in upwards, increasing the education, increasing the awareness and posters and teach really training on disses. My son climbing Trevan a very challenging now thing for him on He said to me, Mom, I don't know if I can do this and I said, Well, just keep going. Tiny steps. I cannot recommend enough bringing together a great team, so not people who get nominated because they need a Q I project. But people who are so passionate and enthusiastic for the journey. People who smile and bring positivity to the project. But sometimes, even with those great people around, you can feel like a huge, scary leap of faith. In 2017, we really want to provide for aspiratory support. During difficult camping, we couldn't get hold of sterile respiratory equipment still awesome, able to the best of my knowledge. And so we opted to use clean equipment. We spoke to manufacturers of length on. We started closely monitoring our rate of infections, posters there in section that felt scary, that felt it like a leap of faith. But four years on, it's working brilliantly with no complications from it. That said, I'd love some sterile equipment when it's available. But yeah, it can sometimes feel very scary. But you must always remember that the view from the top is always with the climb on. My son achieved his goal, and this is him on the final crib got rejected, Snowed and um, and it It's really important when we look back and I see babies come in at two years of age into my follow up clinic, and I know that they got deferred call camping that got optimal course management and they're doing brilliantly, and I can't help but wonder how much of that was because of the optimization we gave him in the in the perinatal period. We're monitoring our outcomes and Swindon, and we can see that the survival to this chart, the rate of brain injury, the rate and appetizing enter client. This is all pretty thing, and I don't know if that's because of the work that we've been doing. But I have to say that every time I look back and think, Well, actually, all that if it was worth it and the view from the top when we improve the outcomes for pre 10 babies is always with the effort. So just finally, there's lots of national work going on in this across the UK, and so there's lots of resources out there on, but we're all gonna be asked to be focusing on this, so it's really worth looking at this within your immunity on bank you. So much for your time. I look forward to seeing you alone for questions, but by