Updated Guidance on Delayed Umbilical Cord Clamping Released

Marcia Frellick

December 22, 2016

Updated guidance from the American College of Obstetricians and Gynecologists (ACOG) recommends delaying clamping of the umbilical cord by 30 to 60 seconds.

The ACOG committee opinion report is published online and appears in the January 2017 issue of Obstetrics & Gynecology. It updates the 2012 committee opinion, which focused on the benefits for preterm infants.

The document was developed by ACOG's Committee on Obstetric Practice in collaboration with committee members Maria A. Mascola, MD; T. Flint Porter, MD; and Tamara Tin-May Chao, MD.

For term infants, delayed clamping improves iron stores in the first few months, which may help development, the authors write. Low iron, linked to decreased cognitive, motor, and behavioral skills, is more prevalent in low-income countries, but it is common in high-income countries, with rates ranging from 5% to 25%. Delayed clamping also increases hemoglobin levels at birth.

However, in term infants who have had delayed clamping, there is a slight increase in incidence of jaundice that will require phototherapy, so providers using this technique should have tools at the ready to detect and treat it.

For preterm infants, the delay improves circulation, boosts red blood cell volume, and reduces the need for blood transfusions. The delay also results in lower incidence of necrotizing enterocolitis and intraventricular hemorrhage, according to the guidelines.

No Increase in Maternal Hemorrhage

Regarding the mother, researchers found no increase in postpartum hemorrhage or increased blood loss at delivery when clamping is delayed.

The authors note that delaying clamping does not mean delaying care.

"During delayed umbilical cord clamping, early care of the newborn should be initiated, including drying and stimulating for first breath or cry, and maintaining normal temperature with skin-to-skin contact and covering the infant with dry linen," they write.

In some cases or at some institutions, the delay may not be the best choice, or there may not be enough data to make that choice. "For example, in cases of fetal growth restriction with abnormal umbilical artery Doppler studies or other situations in which uteroplacental perfusion or umbilical cord flow may be compromised," the authors write. The neonatal and obstetrics teams should make the decision together in those cases.

No Ruling on Umbilical Cord Milking

ACOG did not weigh in on umbilical cord milking, or the practice of pushing blood in the cord toward the infant several times before clamping, stating that there was insufficient evidence for a ruling for or against it.

The technique is used to increase placental transfusion to the newborn quickly and can be an attractive option when the 30- to 60-second delay is too long, such as cases when the infant needs immediate resuscitation or when the mother's blood pressure becomes unstable.

"This is an area of active research, and several ongoing studies are evaluating the possible benefits and risks of umbilical cord milking compared with delayed umbilical cord clamping, especially in extremely preterm infants," the authors write.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2017;129:e5-e10. Full text

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