Introduction

Cord clamping (CC) practices, particularly in resuscitation scenarios, remain inconsistent worldwide, despite robust evidence supporting delayed CC [1,2]. There is a lack of consensus regarding the definition of delayed CC and recommendations vary between sources [3].

Leaving the umbilical cord intact after birth allows for a placental transfusion and enhances physiological transition from fetal to neonatal life [4,5]. In preterm neonates, delayed CC reduces blood transfusions and decreases mortality [6,7]. In term neonates, delayed CC for 2–5 min increase iron stores, improve brain myelination and neurodevelopmental skills [8–11]. Neonates requiring resuscitation at birth are often excluded from delayed CC studies due to practical challenges, yet emerging evidence suggests that intact cord resuscitation (ICR) may offer benefits, such as improved oxygenation and higher Apgar scores [12,13]. Large randomized controlled trials (RCTs) – including the ongoing SAVE study (NCT04070560), and a recent trial by Knol et al. [14,15] – are investigating ICR. Deferring CC is strongly recommended by multiple professional organizations and is the top message in the 2021 European Resuscitation Council guidelines [16]. Current Swedish national guidelines, published in 2022, recommend waiting with CC until the umbilical cord is white and limp in healthy, vaginally born neonates. For cesarean section, the recommendation is to wait at least one minute and in resuscitation situations to clamp in time to ensure initiation of resuscitation measures within 60 seconds [17].

Available data suggest that CC practices differ widely between settings and countries, and more data is needed to understand the attitudes of cord management [2,18,19]. The variability in implementation may arise from factors such as professional attitudes and clinical environments, which create discrepancies in neonatal care, as noted by Blank et al [20]. In Sweden, maternity care is organized around midwives, who independently manage low-risk births and perform delayed CC, often guided by event-based clinical signs such as cessation of pulsations, or placenta delivery [21]. Obstetricians oversee high-risk labors, manage cesarean sections and, together with neonatologists, lead emergency care of mother and newborn. This division of responsibilities influences CC practices: while midwives’ autonomy facilitates adherence to delayed clamping in uncomplicated deliveries, obstetricians and neonatologists may prioritize earlier clamping to facilitate prompt neonatal care when clinical urgency arises.

As new evidence emerges regarding the benefits of delayed CC and ICR, implementation of this evidence into clinical practice is essential [22]. However, implementing new methods, especially complex ones such as ICR, requires involvement of the entire multidisciplinary team [20]. Acceptability is a key outcome in implementation, as it determines whether new interventions – such as ICR – are adopted and sustained in clinical practice [23]. Healthcare professionals’ attitudes and beliefs strongly influence readiness for change and successful adoption of evidence-based practices. Despite Sweden’s uniquely long clamping times, there is a knowledge gap regarding professional perspectives on CC management. Addressing this gap is critical for developing effective implementation strategies. This study is part of the SAVE-study, a hybrid multicenter trial described by Ekelöf et al, which evaluates both clinical outcomes and implementation factors of the SAVE-method for ICR in Sweden [14]. By surveying multidisciplinary team attitudes toward CC timing, this study aims to support the implementation process of the SAVE-study.

Method

Results

A total of 1040 individuals responded to the survey, of whom 202 were excluded for completing only the background questions. The final sample comprised 838 participants, included in the analysis. The exact number of respondents is reported for each question. Information on the number of employees was available for 25 units. For these units, the median response rates (%; range) was 44 (8–92) for midwives, 20 (5–41) for pediatric physicians, and 13 (2–40) for obstetric physicians. Respondents included all major perinatal professional groups, with midwives as the largest. There was an even age distribution and clinical experience varied widely. Participation covered all major Swedish healthcare regions, with somewhat lower representation from the northern and southeastern areas. All NICU levels were represented, and overall, 40 of 44 labor units participated. Detailed characteristics are presented in Table 1.

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Table 1. Background characteristic.

https://doi.org/10.1371/journal.pone.0332745.t001

Perceived importance of cord clamping timing

Among included respondents, 94% (775/824), reported timing of CC being either “very important” or “moderately important” for neonatal outcomes. A statistically significant difference in responses was observed between the professional groups (Kruskal-Wallis test, p < 0.001). Post hoc pairwise comparisons showed that all nursing professions differed significantly from both physician groups (Mann-Whitney, p < 0.001). The overall response distributions for each group are presented in Fig 1.

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Fig 1. Responses on importance of cord clamping timing.

Bar chart displaying responses from each professional group (pediatric- and obstetric physicians, midwives, nurses, and assistant nurses; y-axis). Bars are divided into colored segments representing response categories, with color explanations provided within the figure. N (%) are shown within bars where space permits. Complete data for all categories are provided in S1 Table. The total number of respondents for each profession is indicated on the y-axis.

https://doi.org/10.1371/journal.pone.0332745.g001

When responses were analyzed by gestational age category, significant differences between nursing staff and physicians remained across all categories (Kruskal-Wallis, p < 0.005). The largest differences (post hoc Mann-Whitney, p < 0.001) were seen at higher gestational ages (> 36 weeks), while at lower gestational ages, significant differences remained primarily between midwives and physicians (p ≤ 0.005). Among physicians, there was a trend towards fewer respondents rating “very important” for higher gestational age categories, a pattern that was not observed among the nursing staff. The response alternative “I don’t know” was more frequently reported at lower gestational ages across all professions. Response distributions by gestational age category for each profession are presented in Fig 2.

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Fig 2. Responses on importance of cord clamping timing, stratified by gestational age.

Bar charts display responses for each professional group (pediatric- and obstetric physicians, midwives, nurses, and assistant nurses; y-axis) across four gestational age groups: < 28 weeks, 28-31 weeks, 32-36 weeks, and > 36 weeks. Bars are divided into colored segments representing response categories, with color explanations shown in the figure. N (%) are shown within bars where space permits. Complete data for all categories are provided in S1 Table. The total number of respondents for each professional group is indicated on the y-axis of each chart.

https://doi.org/10.1371/journal.pone.0332745.g002

Timing of cord clamping

All responses stratified by profession and clinical situation are presented in Table 2. Most respondents preferred to clamp the cord ≥ 60 seconds or at cessation of umbilical pulsation. For normal vaginal births, 89% of midwives (312/351), preferred an event-based approach to CC rather than a time-based approach. Midwives and pediatric physicians differed in their answers on timing of CC in instrumental deliveries. Midwives were more inclined to use an event-based approach compared to pediatric physicians, 86% (298/346) vs 28% (17/60), respectively (Fisher’s exact test, p < 0.001). In elective cesarean sections, 71% of obstetric physicians, (74/104), considered a time-based approach to be most suitable, with the predominant response being “60 seconds to 3 minutes”.

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Table 2. Approach to timing of cord clamping.

https://doi.org/10.1371/journal.pone.0332745.t002

Resuscitation.

Attitudes toward CC in resuscitation situations varied by profession (Table 2). Most obstetric physicians (71%, 79/112) preferred CC < 30 seconds, compared to 30% (18/61) of pediatric physicians, who more often chose 30–60 seconds (Fisher’s exact test, p < 0.001). For vaginal births requiring resuscitation, midwives were more prone to choose a time-based approach, though 27% (87/326) still preferred event-based CC, versus 10% (6/59) of pediatric physicians. The proportion of midwives preferring event-based CC during resuscitation did not differ significantly between SAVE and non-SAVE units, 31% (34/109) vs 24% (53/217), respectively (Fisher’s exact test, p = 0.23).

Regarding delayed CC (>1 min) during resuscitation, 47% (53/113) of obstetric and 46% (30/65) of pediatric physicians agreed it should be avoided, while 51% (184/360) of midwives disagreed.

Discussion

This cross-sectional survey revealed that health care professionals involved in neonatal resuscitation considers timing of umbilical CC being an important issue. This result was somewhat expected since Sweden has a long tradition of delayed CC in vigorous neonates born vaginally, with recommended time to CC > 2 minutes since 2008 [25]. Recent observational studies have identified a median CC time of 6 minutes for vigorous neonates born vaginally [26,27]. The general agreement on the importance of CC timing suggests high acceptability – a key implementation outcome according to Proctor et al. - which is important for successful adoption of new clinical practices [23]. However, variations were observed in health care professionals’ attitudes regarding the significance of CC timing, as well as in their preferences for time-based versus event-based approach.

Our analysis revealed variations between professions, with midwives categorizing timing of CC as “very important” to a greater extent than obstetricians and pediatricians. Midwives were also more likely to employ an event-based approach for determining CC timing. This is in line with international and national research. An integrative review by Peberdy et al. identified that attitudes and opinions about CC timing differed among midwives and obstetricians, where midwives preferred delayed CC to a higher degree [28]. However, while most obstetric and pediatric physicians preferred a time-based approach for CC, unexpectedly many physicians considered “cessation of pulsations” as the most appropriate criterion for timing in elective cesarean sections and instrumental deliveries. The attitude towards extended CC times observed among Swedish physicians appears to differ from that reported in studies from other countries. In a Dutch survey from 2015 by Boere et al. early CC < 1 minute was applied in 81% of the obstetric practices in cesarean sections [29]. In a study by Leslie et al from 2018, only 3.0% of U.S. obstetricians indicated a preference for delaying CC until pulsation cessation in healthy, term neonates delivered by cesarean section [18]. In a more recent study from 2021 by Aydogan Kirmizi et al. 75.8% of Turkish obstetricians stated that they clamp the cord within the first minute and only 2.3% waited until pulsations ceased [30]. While our study does not provide data on reasons for this preference, the high proportion of obstetricians selecting delayed CC until cessation of pulsations during cesarean section may possibly reflect the influence of the Swedish midwife-led care model and a professional culture that emphasizes physiological birth and interdisciplinary collaboration [31]. However, this interpretation remains speculative.

Although there seemed to be some consensus among midwives and pediatric physicians regarding timing of CC in resuscitation situations, a surprisingly high share of midwives preferred waiting until cessation of pulsations or until placenta was delivered. It is possible that midwives selecting this option might have presumed an ICR-setting with mobile equipment; however, we did not collect data on this aspect, and this interpretation remains speculative. It may also reflect that midwives historically have been more prone to clamp the cord only after the onset of respiration or delivery of the placenta [32]. The lack of difference between midwives working in SAVE and non-SAVE units may suggest a broader acceptance of ICR and longer clamping times in Sweden, but this interpretation should be made cautiously given the study’s limitations. For neonates requiring resuscitation after cesarean delivery, obstetric physicians preferred CC within 30 seconds of birth, earlier than what the pediatric physicians stated. This variability in timing between physicians could perhaps be due to time pressure to transfer the neonate to the neonatal team, a barrier to delayed CC identified among midwives [33]. Both midwives and physicians cared to avoid delay of resuscitation, but a stronger reluctance for early CC was identified among midwives. Although the research on ICR remains limited, the results align with other studies indicating a strong preference among midwives for delayed CC, even in situations requiring interventions [34–36]. This inclination parallels recent research advocating for a shift from time-based CC toward a physiological-based approach [37]. Another notable finding was the frequent “I don’t know” responses about local guidelines, particularly in resuscitation scenarios and among staff less involved in CC decisions, likely reflecting professional roles. In Sweden, national guidelines on CC timing are clear for most deliveries, possibly contributing to generally liberal attitudes. However, for resuscitation, national guidelines are less explicit, and as local protocols often follow these, clarity may also be lacking locally. This may explain the higher “I don’t know” responses rate and emphasize the need for clear cord management protocols during resuscitation.

In summary, our findings show a general consensus regarding the importance of CC timing and a relatively high proportion of physicians favoring event-based clamping, but at the same time reveal differences between professional groups and gaps in institutional guidance, highlighting challenges to achieving consistent practice. According to Proctor et al., acceptability is influenced not only by individual attitudes but also by organizational context and support [23]. Addressing both these dimensions is essential to enhance acceptability and thereby facilitate successful implementation of evidence-based guidelines.

Conclusion

The study reveals a generally positive attitude towards delayed CC among health care professionals in Sweden, but notable differences exist between professional groups, particularly in resuscitation situations. These findings highlight gaps in institutional guidance and underscore the need for harmonized, interdisciplinary protocols to ensure consistent practice. The overall positive attitudes suggest a favorable environment for implementing ICR in Sweden. Our results may inform the development of clinical guidelines and targeted training initiatives to support this process. Further research is needed to evaluate the practical challenges and outcomes of ICR implementation.

Supporting information

Acknowledgments

We would like to express our sincere gratitude to Dr Anna Santesson, Dr Susanne Hesselman, Camilla Rosenquist and Dr Ángel Ruiz Christina from the iSAVE research group for their valuable contributions in developing the survey instrument.