Delayed Umbilical Cord Clamping

Reading: CO 814 https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/12/delayed-umbilical-cord-clamping-after-birth 

Delayed Cord Clamping - An Overview

• Small studies initially demonstrated 80-100cc of blood transferring from the placenta to the newborn within 3 minutes after birth, and

• 90% of that blood volume transfer is achieved within just a few breaths in healthy term infants.

  • A 3kg infant (6lb 10oz) has a typical blood volume of around 250 cc… so the difference is potentially huge!

• Modern studies of “delayed” cord clamping is usually defined as 30-60 seconds of delay after birth to clamp the cord, and shows benefits for both term and preterm infants.

• For term babies:

  • Improved hemoglobin levels

  • Improved iron stores (lasting even to a few months of life) → potentially favorable neurodevelopmental outcomes

• For preterm babies:

  • Reduced rates of IVH and NEC

  • Lower risk of transfusion

• Basically for these reasons, most organizations across the world recommend 30-60 seconds of DCC for most term and preterm infants, though the range ca be up to 5 minutes (ACNM). 

  • ACOG specifically recommends 30-60 seconds of DCC for vigorous term and preterm infants. 

• Are there concerns? Theoretically, yes:

  • Perhaps delayed cord clamping delays resuscitation for babies who need it?

    • Sick/preterm babies may actually benefit from placental transfusion as the placenta continues gas exchange after delivery while still attached!

  • Maybe delayed cord clamping causes polycythemia or jaundice?

    • No solid evidence of this in preterm infants

    • Perhaps some evidence in term infants, but slight.

What’s the evidence?

• Studies of Doppler sonography during DCC have demonstrated marked increase of placental transfusion during those breaths.

  • The extra iron load provided by DCC here has been shown to reduce/prevent iron deficiency through 1 year of life.

  • Iron deficiency has been linked to cognitive, motor, and behavioral developmental delays that may be irreversible.

    • Iron deficiency is definitely prevalent in low-income countries, but also common in higher income countries too! (5-25%)

  • Additionally, that blood and plasma volume will transfuse over immunoglobulins and stem cells, which may be of particular benefit to preterm babies.

• In preterm infants:

  • Systematic review of 15 trials of 738 infants demonstrates DCC over immediate clamping leads to:

    • Fewer transfusions for anemia (RR 0.61)

    • Lower risk of IVH (all grades, sonographic dx) (RR 0.59)

    • Lower risk of NEC (RR 0.62)

• In term infants:

  • Systematic review of 15 trials involving 3911 women and their singleton infants:

    • DCC had higher immediate hemoglobin levels (2.17 g/dL difference) and to 24-48h after birth (1.49 g/dL)

    • At age 3-6 months, immediate clamping had a RR of 2.65 for iron deficiency!

    • NO difference in rates of polycythemia or jaundice, but jaundice requiring phototherapy was slightly higher risk for DCC (2.74% vs 4.36%, RR 0.62).

    • Neurodevelopmental outcomes limited, but no difference versus slight benefit to DCC over ICC. 

      • Overall, seems to be beneficial for babies, at least in the immediate term, with more definite benefit for preterm infants.

• What about maternal risks?

  • Five trials of over 2200 women did not demonstrate any increased risk of PPH, estimated blood loss, difference in hemoglobin level, or risk of transfusion -- even at cesarean!

    • ACOG does caution though that with previa/abruption or other situations for high increased risk of hemorrhage, benefit versus risks of DCC should be weighed.

Can I screw it up?

In a word, yes. Here are some tips:

• Newborn care should proceed as usual.

  • Dry and stimulate for the first breath/cry, maintain normothermia with skin-to-skin contact.

    • Positioning on the chest/abdomen (versus holding infant at level of introitus or lower) doesn’t seem to have an effect on the amount of blood transfused.

  • Clear secretions only if copious or obstructing the airway.

  • Even with meconium, DCC can continue as long as infant is vigorous.

• Continue with active management of 3rd stage.

  • Use uterotonics (oxytocin at this point, typically) to minimize bleeding

• Use common sense on when to not use DCC.

  • If maternal hemodynamic or neonatal stability is of concern, then DCC should not be continued.

• If you need/plan to get umbilical cord gases:

  • Studies are mixed here. A definitive study would be nice, if you’ve got some funding opportunities around you!

• Milking the cord -- don’t do it!

  • It seems to make some sense -- if we push blood faster through the cord, we get the transfusion benefit of DCC in less time -- perhaps some use for the infant in need of resuscitation or extreme prematurity?

    • A recent study of infants undergoing milking at extreme prematurity (23-27 weeks) was halted early due to higher risk of IVH in the milking group compared to DCC.

      • ACOG recommends not milking at under 28 weeks gestation.

    • Prior studies to this including infants of later gestational ages, that showed some potential benefit to hemoglobin levels, but were overall mixed. ACOG interprets this as no definitive evidence for milking at greater that 32 weeks -- but we’d recommend against it at this point, given the pretty definitive risk of harm for premature infants at least.

• If patient desires cord blood banking… reconsider.

  • Cord blood banking success is significantly decreased when there is a 60 second delay in DCC.

  • Families considering banking should be aware of this risk… 

    • It’s arguable that DCC may have more benefits than cord blood banking.