Guideline No. 424: Umbilical Cord Management in Preterm and Term Infants

ObjectiveTo assess the impact of deferred (delayed) cord clamping (DCC) and umbilical cord milking in singleton and twin gestations on maternal and infant mortality and morbidity.Target PopulationPeople who are pregnant with preterm or term singletons or twins.Benefits, Harms, and CostsIn preterm singletons, DCC for (ideally) 60 to 120 seconds, but at least for 30 seconds, reduces infant risk of mortality and morbidity. DCC in preterm twins is associated with some benefits. In term singletons, DCC for 60 seconds improves hematological parameters. In very preterm infants, umbilical cord milking increases risk for intraventricular hemorrhage.EvidenceSearches of Medline, PubMed, Embase, and the Cochrane Library from inception to March 2020 were undertaken using Medical Subject Heading (MeSH) terms and key words related to deferred cord clamping and umbilical cord milking. This document represents an abstraction of the evidence rather than a methodological review.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).Intended UsersMaternity and newborn care providers.RECOMMENDATIONSFor ease of implementation, recommendations for preterm versus term infants have been kept distinct. Note that as the preterm period progresses, the risks of prematurity decrease substantially, such that the absolute benefits of deferred (delayed) cord clamping also decrease.1.Singletons:a.In both preterm (<37 weeks) and extremely preterm (<28 weeks) singletons, deferred (delayed) cord clamping is recommended for 60 to 120 seconds because it decreases newborn mortality and morbidity and improves hematological outcomes after the newborn period. When cord clamping cannot be deferred for a full 60 to 120 seconds, then deferred (delayed) cord clamping for at least 30 seconds is superior to immediate clamping. Deferred (delayed) cord clamping should be performed with the infant at or below the level of the introitus or at the level of the cesarean incision (strong, high).b.In term singletons, deferred (delayed) cord clamping is recommended for 60 seconds because it improves hematological outcomes at birth and past the newborn period. Deferred (delayed) cord clamping beyond 60 seconds increases the risk of hyperbilirubinemia requiring phototherapy. Deferred (delayed) cord clamping can be performed with the infant at or below the level of the introitus, or at the level of the cesarean incision (strong, high), or on the mother’s abdomen (conditional, low).2.Stabilization or resuscitation with an intact cord for longer durations in preterm and term infants is feasible for centres with appropriate experience and equipment, although larger trials are needed to understand benefits and risks (strong, moderate).3.For maintenance of temperature during deferred (delayed) cord clamping:a.Preterm infants should be placed in warm towels, medical grade plastic bags, or medical grade plastic wrap to maintain temperature (strong, high).b.Term infants can be placed in warm towels or on the mother’s abdomen (conditional, low).4.Twins:a.In preterm twins, deferred (delayed) cord clamping is associated with some benefits and should be considered, except when contraindicated (conditional, low).b.In term twins, deferred (delayed) cord clamping may be considered based on presumed extrapolation of benefits in term singletons, except when contraindicated (conditional, low).c.The evidence regarding optimal duration of deferred (delayed) cord clamping in twins is insufficient. Deferred (delayed) cord clamping for 30 to 60 seconds can be considered (conditional, low).d.When deferred (delayed) cord clamping is performed, not delaying delivery of the second twin is recommended (conditional, low).5.Uterotonic medications increase uterine tone to prevent postpartum hemorrhage:a.In preterm pregnancies, due to concerns about a potential bolus of blood to preterm infants, it is recommended that intravenous uterotonic medications be administered after clamping the cord (conditional, low).b.In term pregnancies, with lower risk for bolus effects of blood, lower benefits of deferred cord clamping, and higher risk for maternal postpartum hemorrhage, it is recommended that intravenous uterotonic medications be administered with delivery of the anterior shoulder of the final infant (conditional, low).6.Absolute contraindications to deferred (delayed) cord clamping are few, and include (but are not limited to) fetal hydrops, the need for immediate resuscitation of mother or infant (except in centres with appropriate experience and equipment), disrupted utero-placental circulation (e.g., bleeding vasa previas), and known twin-to-twin transfusion syndrome or twin anemia polycythemia sequence (strong, high).7.Relative contraindications to deferred (delayed) cord clamping are few but include (in term infants) risk factors for significant hyperbilirubinemia (e.g., significant polycythemia, severe intrauterine growth restriction, pregestational diabetes), and cases where maternal antibody titres are high or when the first infant in a pair of monochorionic twins is delivered. In all these circumstances, immediate cord clamping should be considered. (conditional, low).8.Cautions regarding deferred (delayed) cord clamping are few but include (in preterm infants) risk factors for significant hyperbilirubinemia (e.g., significant polycythemia, severe intrauterine growth restriction, and cases where maternal antibody titres are high or when the first infant in a pair of monochorionic twins is delivered. In all these circumstances, discussion with the newborn’s care providers regarding benefits and risks and the duration of deferred (delayed) cord clamping is encouraged. The infant’s gestational age should be taken into account, with consideration of deferral for 30 seconds (conditional, low).9.Umbilical cord milking:a.Umbilical cord milking is not recommended in very preterm infants <32 weeks, due to increased risk for severe intraventricular hemorrhage (strong, moderate).b.In preterm and term infants, deferred (delayed) cord clamping should be performed instead of umbilical cord milking (strong, high).