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Umbilical Cord Management –

Until recent years, a common practice has been to clamp the umbilical cord soon after birth to quickly transfer the infant to the neonatal team for stabilization. This immediate clamping was deemed particularly important for infants at high risk for difficulty with transition and those most likely to require resuscitation, such as infants born preterm. During the 2010 CoSTR review, evidence began to emerge suggesting that delayed cord clamping (DCC) might be beneficial for infants who did not need immediate resuscitation at birth.1

The 2015 ILCOR systematic reviewNRP 787 confirms that DCC is associated with less intraventricular hemorrhage (IVH) of any grade, higher blood pressure and blood volume, less need for transfusion after birth, and less necrotizing enterocolitis. There was no evidence of decreased mortality or decreased incidence of severe IVH.2,3 The studies were judged to be very low quality (downgraded for imprecision and very high risk of bias). The only negative consequence appears to be a slightly increased level of bilirubin, associated with more need for phototherapy. These findings have led to national recommendations that DCC be practiced when possible.4,5 A major problem with essentially all of these studies has been that infants who were thought to require resuscitation were either withdrawn from the randomized controlled trials or electively were not enrolled. Therefore, there is no evidence regarding safety or utility of DCC for infants requiring resuscitation and some concern that the delay in establishing ventilation may be harmful. Some studies have suggested that cord “milking” might accomplish goals similar to DCC,6-8 but there is insufficient evidence of either its safety or utility to suggest its routine use in the newly born, particularly in extremely preterm infants.

In summary, from the evidence reviewed in the 2010 CoSTR1 and subsequent review of DCC and cord milking in preterm newborns in the 2015 ILCOR systematic review,2,3 DCC for longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth. (Class IIa, LOE C-LD)

There is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation at birth, and more randomized trials involving such infants are encouraged. In light of the limited information regarding the safety of rapid changes in blood volume for extremely preterm infants, we suggest against the routine use of cord milking for infants born at less than 29 weeks of gestation outside of a research setting. Further study is warranted because cord milking may improve initial mean blood pressure and hematologic indices and reduce intracranial hemorrhage, but thus far there is no evidence for improvement in long-term outcomes. (Class IIb, LOE C-LD)

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References

  1. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, Guinsburg R, Hazinski MF, Morley C, Richmond S, Simon WM, Singhal N, Szyld E, Tamura M, Velaphi S; Neonatal Resuscitation Chapter Collaborators. Part 11: neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122(suppl 2): S516–S538. doi: 10.1161/CIRCULATIONAHA.110.971127.
  2. Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, Szyld E, Tamura M, Velaphi S; on behalf of the Neonatal Resuscitation Chapter Collaborators. Part 7: neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(suppl 1):S204–S241. doi: 10.1161/CIR.0000000000000276.
  3. WyllieJ,PerlmanJM,KattwinkelJ,WyckoffMH,AzizK,GuinsburgR,Kim HS, Liley HG, Mildenhall L, Simon WM, Szyld E, Tamura M, Velaphi S; on behalf of the Neonatal Resuscitation Chapter Collaborators. Part 7: neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2015. In press.
  4. Committee Opinion No.543: Timing of umbilical cord clamping after birth. Obstet Gynecol. 2012;120:1522–1526.
  5. American Academy of Pediatrics. Statement of endorsement: timing of umbilical cord clamping after birth. Pediatrics. 2013;131:e1323.
  6. Hosono S, Mugishima H, Fujita H, Hosono A, Minato M, Okada T, Takahashi S, Harada K. Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks’ gestation: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2008;93:F14–F19. doi: 10.1136/adc.2006.108902.
  7. Katheria AC, Leone TA, Woelkers D, Garey DM, Rich W, Finer NN. The effects of umbilical cord milking on hemodynamics and neonatal out- comes in premature neonates. J Pediatr. 2014;164:1045–1050.e1. doi: 10.1016/j.jpeds.2014.01.024.
  8. MarchMI,HackerMR,ParsonAW,ModestAM,deVecianaM.Theeffects of umbilical cord milking in extremely preterm infants: a randomized con- trolled trial. J Perinatol. 2013;33:763–767. doi: 10.1038/jp.2013.70.
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Umbilical Cord Management –

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