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Delayed Cord Clamping for Newborns

Preterm Deliveries

Delayed cord clamping for preterm newborns has been endorsed by several national and international organizations including ACOG, WHO, AAP and AWHONN.  Evidence for benefit includes studies showing reduced need for transfusion and higher neonatal hemoglobin values, as well as reductions in intraventricular hemorrhage and NEC.

The greatest benefit seems to occur with 60 seconds or longer delay in cord clamping.  Cord milking should not be performed in neonates at 28 weeks or less due to an association with an increased risk of IVH.

ACOG and WHO recommend waiting on the active management of the third stage in labor in order to facilitate delayed cord clamping in areas where uterotonic medications are readily available and immediate resuscitation of the neonate is not required.

Term Deliveries

ACOG now recommends delayed umbilical cord clamping in vigorous term infants for at least 30-60 seconds after birth. The delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first several months of life, which may improve developmental outcomes. There is a small increase in jaundice requiring phototherapy in this group of neonates; therefore, mechanisms should be in place to monitor for entry neonatal jaundice.

Recommendation

Delayed cord clamping is preferred for all deliveries in the absence of contraindications.

Contraindications would include placental abruption or significant undiagnosed bleeding occurring in the immediate antenatal period, true knot in the umbilical cord, suspected or confirmed twin to twin transfusion, need for maternal resuscitation at delivery, a neonate deemed to be not a candidate for resuscitation, or any neonatal or obstetric complication which requires immediate intervention.  Other evidence of acute utero-placental insufficiency such as a category III fetal heart rate tracing should also be considered a contraindication.

Procedure

Prior to delivery, the obstetrician assesses for exclusion criteria, counsels the family, and discusses plan for cord clamping with the NICU (immediate clamp, 30 second delay, 60 seconds, or cord milking).

Delivery room temperature should be set to 78 degrees F or higher.

The circulating OB nurse will announce the time of delivery and then call out elapsed time in ten second intervals until 30 or 60 seconds have passed.

NICU team will start the Apgar timer at the time of birth.

The delivering clinician will wrap the infant in warm blankets, and dry, suction and stimulate the infant.

During this time the neonataologist will be gowned and gloved in sterile fashion (it is not necessary to scrub) and  be available to assist the delivering clinician as needed with resuscitation or decision to move the infant to the warmer for further resuscitation.  The NICU team may be asked to help during this time at the discretion of the delivering clinician or neonatologist.

After the designated interval has passed the delivering clinician clamps and cuts the cord and passes the infant to the NICU team.  Those infants <28 weeks will be placed in the plastic vapor barrier bag and resuscitation continues.

Current research indicates that transfusion from the placenta to the newborn is unaffected by the position of the newborn relative to the placenta.  It may be possible to place the infant on the mother’s torso during the early resuscitation.

At cesarean delivery, the infant may be placed on the surgical drape over the mother’s thighs.

Drawing cord blood for analysis and blood gas must be delayed until cord clamp.  This may invalidate the results of cord blood gas analysis.

Cord milking (or stripping) is performed by stripping the full length of the visible cord between two fingers in the direction of the infant.  This should be done 4 times, with 4-5 seconds delay between strippings to allow the cord to refill.

Documentation

In the delivery note delayed cord clamping should be documented or the contraindication to such. If cord milking is done, the time of milking and number of times cord milked should be documented.

References

  1. Backes, C. “Placental transfusion strategies in Very Preterm Neonates; A Systematic Review and Meta-analysis.” Obstet Gynecol. 2014. Jul;124(1);47-56.
  2. Elimian, A. et al “Immediate compared with delayed cord clamping in the preterm neonate: a randomized controlled trial.” Obstet Gynecol. 2014 Dec;124(6); 1075-9.
  3. Jaiswal, P. et al. “comparison of two types of intervention to enhance placental redistribution in term infants: randomized control trial.” Eur J Pediatr. 2015 Mar 24.
  4. McDonald, SJ. “Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.” Evid Based Child Health. 2014; Jun;9(2);303-97.
  5. Patel, S. et al. “Effect of umbilical cord milking on morbidity and survival in extremely low gestational age neonates.” Am J Obstet Gynecol. 2014. Nov;211(5) 519e1-7.
  6. Rabe, H et al.  “Milking compared with delayed cord clamping to increase placental transfusion in preterm neonates: a randomized controlled trial.” Obstet Gynecol 2011. Feb; 117(2pt 1); 205-211.
  7. Vain, NE. et al.  “Effect of gravity on volume of placental transfusion: a multicenter, randomized, non-inferiority trial.” Lancet 2014. Jul 19; 384 (9939); 235-40.
  8. Valero, J. et al.  “Effect of delayed umbilical cord clamping on blood gas analysis.” Eur J Obstet Gynecol Reprod Biol.  2012 May; 162(1); 21-3.
  9. “Timing of Umbilical Cord Clamping after Birth”  ACOG Committee Opinion Number 543. Dec 2012.
  10. Delayed umbilical cord clamping after birth. Committee Opinion No. 684. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129 e5-10.

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