Delayed Cord Clamping and Cord Milking
Anup C. Katheria
Debra A. Erickson-Owens
Judith S. Mercer
A. Definitions
1. Placental transfusion: Placental transfusion is the transfer of residual placental blood to the baby during the first few minutes of life. A placental transfusion will supply the infant with whole blood, red blood cells, and stem cells. This occurs in both term and preterm infants.
2. Delayed umbilical cord clamping (DCC): The practice of DCC is waiting to clamp the umbilical cord for a specific time period.
3. Umbilical cord milking (UCM)
a. Intact umbilical cord milking (I-UCM): The practice of I-UCM is when the umbilical cord is grasped between the thumb and forefinger and firmly milked (or stripped) pushing blood from the placental end toward the infant several times before clamping the umbilical cord.
b. Cut umbilical cord milking (C-UCM): The practice of C-UCM is when a long segment (typically 30 to 40 cm) of umbilical cord is immediately clamped and cut (near the introitus or at the cord insertion site on the placenta), untwisted and slowly milked toward the infant before clamping at the base of the cord.
4. Immediate cord clamping (ICC): The practice of immediately clamping the umbilical cord after birth. ICC does not support placental transfusion and leaves a large amount of the infant’s blood volume behind in the placenta.
B. Background
1. The decision of when to clamp and cut the umbilical cord may have both short- and long-term effects on the newborn. In the first few minutes after birth, a delay in clamping the umbilical cord or milking the cord can result in a significant return of blood volume from the placenta to the infant. This blood, the infant’s own blood, can serve as a major source of warm, oxygenated blood volume, iron-rich red blood cells, and millions of stem cells (1).
2. Placental transfusion via DCC or UCM provides a number of short- and long-term benefits.
b. Additional iron which can boost infant iron stores out to 4 to 6 months of age (6, 7). This may prevent iron deficiency anemia and has been shown to increase white matter growth in the infant’s developing brain (8).
c. Both UCM and DCC also have hemodynamic benefits in term and preterm infants including improved blood pressure and less inotropic use (5).
d. Improved systemic and cerebral blood flow as measured by heart ultrasound and cerebral oximetry (9, 10).
e. Improved neurodevelopmental outcomes in term infants at 4 years of age and in preterm infants at 18, 24, and 42 months of age (11, 12, 13).
f. A recent meta-analysis suggests that DCC results in a 30% reduction in all-cause mortality for preterm infants (14).
C. Factors That Can Either Support or Hinder Placental Transfusion
1. Timing of cord clamping: Infants who receive ICC can leave up to 30% (term infants) or 50% (preterm infants <30 weeks) of their blood volume behind in the placenta (1).
2. Gravity: While recent studies suggest that placing the infant on the abdomen does not affect the amount of a placental transfusion, holding the infant above the level of the placenta slows placental transfusion while holding an infant below accelerates it (15).
3. Maternal uterine contractions and use of uterotonic medications (1). Frequent uterine contractions (spontaneous or stimulated by uterotonic medications) can accelerate a transfusion to the infant (16).
4. International and national health care organizations have published opinion papers supporting DCC.
a. Various institutions across the world (American College of Obstetricians and Gynecologists [ACOG], Royal College of Obstetricians and Gynaecologists [RCOG], International Liaison Committee on Resuscitation [ILCOR], American Academy of Pediatrics [AAP], European Association of Perinatal Medicine [EAPM], World Health Organization [WHO], American College of Nurse-Midwives [ACNM]) have developed and implemented DCC guidelines (6, 17, 18, 19, 20, 21, 22, 23).
b. UCM has only been recommended by the European Task Force on Resuscitation (21).
D. Indications
1. Delayed cord clamping (DCC)
a. To facilitate placental transfusion for infants of all gestational ages.
b. Supports transfer of whole blood, red cells, and stem cells from placenta to the newborn in the first few minutes of life.
(1) Can be used at all modes of delivery. DCC may be less effective with a cesarean section. A cut uterus may not effectively contract around the placenta to keep the placental pressure high. Some obstetrical providers may be uncomfortable waiting several minutes because of concerns with uterine bleeding.
(2) There also may be clinical situations where waiting 30 to 60 seconds may be unacceptable. In all of these situations, UCM may be a preferred option.
2. UCM
a. To accelerate placental transfusion when the clinical situation does not allow a delay in cord clamping.
b. Preferred in “cut and run” clinical situations such as cesarean section.
E. Concerns and Widely Held Beliefs
1. Overtransfusion
a. Yao et al. demonstrated that overtransfusion does not occur (16).
b. The residual blood is the infant’s own blood volume that has been circulating continuously throughout pregnancy.
c. There is a finite blood volume available.
2. Symptomatic polycythemia
a. DCC is associated with asymptomatic (benign) polycythemia requiring no treatment (24).
b. In examining the evidence over the past 30 years, there has been no association between DCC (and milking) and symptomatic polycythemia (2, 14).
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