The American university of Nurse-Midwives endorse this document. This Committee Opinion was occurred by the American college of Obstetricians and also Gynecologists’ Committee top top Obstetric practice in participation with committee members Maria A. Mascola, MD; T. Flint Porter, MD; and Tamara Tin-May Chao, MD.

INTERIM UPDATE: The contents in this Committee Opinion has been updated as highlighted (or eliminated as necessary) come reflect a limited, focused adjust in the data and also language regarding cord milking.

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ABSTRACT: delay umbilical cord clamping shows up to be advantageous for term and preterm infants. In ax infants, delayed umbilical cord clamping rises hemoglobin levels at birth and improves iron shop in the very first several month of life, i m sorry may have actually a favorable impact on developmental outcomes. Over there is a small increase in the incidence of jaundice that needs phototherapy in term babies undergoing delay umbilical cord clamping. Consequently, obstetrician-gynecologists and other obstetric treatment providers adopting delayed umbilical cord clamping in term infants should ensure that mechanisms space in ar to monitor and treat neonatal jaundice. In preterm infants, delay umbilical cord clamping is connected with far-ranging neonatal benefits, including improved transitional circulation, much better establishment of red blood cell volume, reduced need for blood transfusion, and lower incidence that necrotizing enterocolitis and also intraventricular hemorrhage. Delayed umbilical cord clamping was not linked with an enhanced risk of postpartum hemorrhage or increased blood loss in ~ delivery, nor to be it associated with a distinction in postpartum hemoglobin level or the require for blood transfusion. Given the services to most newborns and also concordant with other expert organizations, the American college of Obstetricians and also Gynecologists now recommends a hold-up in umbilical cord clamping in vigorous term and also preterm infants for at least 30–60 seconds after birth. The capacity to carry out delayed umbilical cord clamping might vary amongst institutions and also settings; decisions in those situations are finest made by the team caring for the mother–infant dyad.


Recommendations

The American university of Obstetricians and also Gynecologists’ Committee on Obstetric practice makes the adhering to recommendations about the timing of umbilical cord clamping ~ birth: In term infants, delay umbilical cord clamping increases hemoglobin levels at birth and also improves iron shop in the very first several month of life, i m sorry may have actually a favorable effect on developmental outcomes.

Delayed umbilical cord clamping is connected with significant neonatal services in preterm infants, including enhanced transitional circulation, better establishment that red blood cell volume, diminished need for blood transfusion, and also lower incidence that necrotizing enterocolitis and intraventricular hemorrhage.

Given the benefits to many newborns and also concordant through other expert organizations, the American college of Obstetricians and Gynecologists currently recommends a hold-up in umbilical cord clamping in vigorous term and preterm infants for at least 30–60 secs after birth.

There is a small increase in the incidence that jaundice that needs phototherapy in term infants undergoing delayed umbilical cord clamping. Consequently, obstetrician–gynecologists and also other obstetric care providers adopting delay umbilical cord clamping in term babies should ensure the mechanisms room in place to monitor and treat neonatal jaundice.

Delayed umbilical cord clamping walk not rise the threat of postpartum hemorrhage.


Introduction

Before the mid 1950s, the term early clamping was characterized as umbilical cord clamping in ~ 1 minute of birth, and late clamping was defined as umbilical cord clamping an ext than 5 minute after birth. In a series of tiny studies of blood volume alters after birth, it to be reported that 80–100 mL of blood move from the placenta come the child in the first 3 minute after birth 1 2 and also up to 90% of the blood volume move was achieved within the first few breaths in healthy term infants 3. Since of these early on observations and the absence of particular recommendations about optimal timing, the interval between birth and umbilical cord clamping started to be shortened, and it came to be common practice to clamp the umbilical cord soon after birth, normally within 15–20 seconds. However, much more recent randomized regulated trials of term and also preterm infants as well as physiologic research studies of blood volume, oxygenation, and arterial pressure have evaluated the effects of instant versus delay umbilical cord clamping (usually defined as cord clamping at least 30–60 seconds after birth) 4 5. Delayed umbilical cord clamping shows up to be helpful for term and also preterm infants. In ax infants, delayed umbilical cord clamping boosts hemoglobin level at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes. In preterm infants, prices of intraventricular hemorrhage and necrotizing enterocolitis are lower, and fewer newborns require transfusion when delayed umbilical cord clamping is employed. This cultivation body of evidence has led a variety of professional establishments to recommend delay umbilical cord clamping in term and also preterm infants. Because that example, the civilization Health company recommends that the umbilical cord not be clamped previously than 1 minute after birth in hatchet or preterm babies who execute not require hopeful pressure ventilation. Recent Neonatal Resuscitation regimen guidelines indigenous the American Academy that Pediatrics recommend delay umbilical cord clamping because that at least 30–60 secs for many vigorous term and preterm infants. The royal College of Obstetricians and also Gynaecologists also recommends deferring umbilical cord clamping for healthy and balanced term and preterm infants for at least 2 minute after birth. Additionally, the American college of Nurse–Midwives recommends delay umbilical cord clamping because that term and preterm infants for 2–5 minutes after bear http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/00000000290/Delayed-Umbilical-Cord-Clamping-May-2014.pdf . Re-cover September 1, 2016.">6. The universal implementation of delayed umbilical cord clamping has raised concern. Hold-up in umbilical cord clamping may delay timely resuscitation efforts, if needed, particularly in preterm infants. However, since the placenta continues to execute gas exchange ~ delivery, sick and also preterm babies are most likely to advantage most from extr blood volume obtained from ongoing placental transfusion. Another concern is that a delay in umbilical cord clamping might increase the potential for extreme placental transfusion. Come date, the literary works does not display evidence the an boosted risk of polycythemia or jaundice; however, in some research studies there is a slightly greater rate of jaundice that meets criteria because that phototherapy in ax infants. Offered the benefits to many newborns and concordant with other professional organizations, the American university of Obstetricians and Gynecologists currently recommends a delay in umbilical cord clamping for at least 30–60 seconds after birth in vigorous term and preterm infants.


Neonatal Outcomes

Physiologic researches in term infants have shown that a deliver from the placenta of approximately 80 mL of blood wake up by 1 minute after birth, reaching roughly 100 mL at 3 minutes after bear 7 8 9. Initial breaths take away by the newborn show up to facilitate this placental transfusion 10. A recent study of umbilical cord blood circulation patterns assessed by Doppler ultrasonography throughout delayed umbilical cord clamping 11 verified a significant increase in placental transfusion throughout the early breaths the the newborn, i beg your pardon is believed to be as result of the negative intrathoracic pressure created by lung inflation. This added blood offers physiologic amounts of iron, amounting come 40–50 mg/kg of body weight. This extra iron has been presented to reduce and also prevent steel deficiency throughout the very first year that life 12. Stole deficiency throughout infancy and also childhood has been attached to impaired cognitive, motor, and behavioral development that might be irreversible 13. Steel deficiency in childhood is specifically prevalent in low-income nations but also is common in high-income countries, where rates range from 5% come 25% 13.

A much longer duration of placental transfusion ~ birth additionally facilitates carry of immunoglobulins and stem cells, which are essential for tissue and also organ repair. The carry of immunoglobulins and also stem cells might be particularly beneficial after ~ cellular injury, inflammation, and also organ dysfunction, i beg your pardon are common in preterm bear 14 15. The magnitude of these services requires additional study, however this physiologic reservoir the hematopoietic and pluripotent stem cabinet lines may provide therapeutic effects and benefit for the infant later on in life 16.


Clinical Trials in Preterm Infants

A 2012 systematic review on time of umbilical cord clamping in preterm infants analyzed the outcomes from 15 eligible researches that affiliated 738 infants born in between 24 weeks and also 36 weeks of gestation 4. This review defined delayed umbilical cord clamping together a hold-up of an ext than 30 seconds, v a preferably of 180 seconds, and also included some research studies that likewise used umbilical cord milking in enhancement to delayed cord clamping. Delayed umbilical cord clamping was linked with fewer infants requiring transfusion for anemia (seven trials, 392 infants; relative risk , 0.61; 95% trust interval , 0.46–0.81). There to be a lower incidence that intraventricular hemorrhage (ultrasonographic diagnosis, all grades) (10 trials, 539 infants; RR, 0.59; 95% CI, 0.41–0.85) and necrotizing enterocolitis (five trials, 241 infants; RR, 0.62; 95% CI, 0.43–0.90) compared with immediate umbilical cord clamping. Optimal bilirubin levels were greater in babies in the delayed umbilical cord clamping group, however there to be no statistically significant difference in the require for phototherapy between the groups. Because that outcomes of infant death, significant (grade 3–4) intraventricular hemorrhage, and periventricular leukomalacia, no clear distinctions were identified between groups; however, countless trials were affected by incomplete report and large confidence intervals.

Outcome after ~ discharge native the hospital was reported in a small study in which no far-reaching differences were reported between the groups in typical Bayley II scores at period 7 month (corrected for gestational period at birth and involved 58 children) 4. In another study, delayed umbilical cord clamping among infants born prior to 32 main of gestation was connected with improved motor role at 18–22 month corrected period 17.


Clinical Trials in term Infants

A 2013 Cochrane testimonial assessed the impact of timing of umbilical cord clamping on term neonatal outcomes in 15 clinical trials that associated 3,911 women and their singleton infants 5. This evaluation defined at an early stage umbilical cord clamping together clamping at less than 1 minute after ~ birth and late umbilical cord clamping as clamping at much more than 1 minute or as soon as cord pulsation ceased. The reviewers found that newborns in the at an early stage umbilical cord clamping group had significantly lower hemoglobin concentration at bear (weighted median difference, –2.17 g/dL; 95% CI, –4.06 to –0.280) and at 24–48 hours after bear (mean distinction −1.49 g/dL; 95% CI, −1.78 to −1.21). In addition, in ~ 3–6 month of age, babies exposed to early umbilical cord clamping were much more likely to have iron deficiency compared with the so late cord clamping team (RR, 2.65; 95% CI, 1.04–6.73).

There to be no difference in the rate of polycythemia between the 2 groups, nor were as whole rates that jaundice different, but jaundice inquiry phototherapy was less common amongst those newborns who had early umbilical cord clamping (2.74% of infants in the early cord clamping group contrasted with 4.36% in the late cord clamping group; RR, 0.62; 95% CI, 0.41–0.96). However, the authors concluded that given the advantage of delay umbilical cord clamping in hatchet infants, delay cord clamping is valuable overall, detailed that the obstetrician–gynecologist or various other obstetric care provider has the capability to monitor and also treat jaundice.

Long-term results of delayed umbilical cord clamping have actually been evaluated in a limited number that studies. In a single cohort, assessed native 4 month to 4 year of period 13 18 19, scores of neurodevelopment did not differ by time of umbilical cord clamping amongst patients in ~ 4 months and 12 month of age. In ~ 4 years of age, kids in the beforehand umbilical cord clamping group had modestly lower scores in social and fine engine domains compared with the delayed umbilical cord clamping group 13.


Maternal Outcomes

Immediate umbilical cord clamping has actually traditionally been lugged out together with other methods of active management in the 3rd stage of labor in an effort to reduce postpartum hemorrhage. Consequently, concern has developed that delay umbilical cord clamping may increase the hazard of maternal hemorrhage. However, current data carry out not support these concerns. In a testimonial of five trials that included much more than 2,200 women, delay umbilical cord clamping was not linked with an raised risk of postpartum hemorrhage or boosted blood loss in ~ delivery, nor to be it linked with a distinction in postpartum hemoglobin level or require for blood transfusion 5. However, when there is raised risk the hemorrhage (eg, placenta previa or placental abruption), the services of delay umbilical cord clamping must be well balanced with the need for fashionable hemodynamic stabilization that the woman Table 1.


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Process and an approach of delayed Umbilical Cord Clamping

Delayed umbilical cord clamping is a straightforward process that enables placental transfusion of warm, oxygenated blood to flow passively into the newborn. The position of the newborn during delayed umbilical cord clamping typically has gone to or listed below the level that the placenta, based upon the presumption that heaviness facilitates the placental transfusion 20 21. However, a current trial of healthy term infants born vaginally found that those newborns put on the maternal abdomen or chest walk not have a reduced volume that transfusion compared with infants organized at the level the the introitus 22. This says that instant skin-to-skin care is appropriate while awaiting umbilical cord clamping. In the situation of cesarean delivery, the newborn can be inserted on the maternal abdomen or foot or hosted by the operated doctor or assistant in ~ close come the level of the placenta till the umbilical cord is clamped.

During delay umbilical cord clamping, early treatment of the newborn need to be initiated, consisting of drying and also stimulating for very first breath or cry, and maintaining typical temperature with skin-to-skin contact and also covering the infant with dry linen. Secretions need to be cleared just if they space copious or show up to it is in obstructing the airway. If meconium is present and the infant is vigorous at birth, plans because that delayed umbilical cord clamping can continue. The Apgar timer might be advantageous to monitor elapsed time and also facilitate an interval the at the very least 30–60 seconds in between birth and also cord clamp.

Delayed umbilical cord clamping have to not interfere with energetic management the the 3rd stage that labor, consisting of the use of uterotonic agents after distribution of the child to minimize maternal bleeding. If the placental circulation is no intact, such together in the case of abnormal placentation, placental abruption, or umbilical cord avulsion, prompt cord clamping is appropriate. Similarly, maternal hemodynamic instability or the need for immediate resuscitation that the child on the warmer would certainly be an indication for instant umbilical cord clamping Table 1. Communication with the neonatal treatment provider is essential.

The capacity to provide delayed umbilical cord clamping might vary among institutions and also settings; decisions in those situations are ideal made by the team caring because that the mother–infant dyad. There are several situations in which data are limited and decisions about timing the umbilical cord clamping must be individualized Table 1. For example, in instances of fetal growth restriction through abnormal umbilical artery Doppler researches or other cases in i m sorry uteroplacental perfusion or umbilical cord flow may it is in compromised, a discussion between neonatal and obstetric groups can assist weigh the loved one risks and benefits of instant or delay umbilical cord clamping.

Data are rather conflicting about the impact of delayed umbilical cord clamping on umbilical cord pH measurements. 2 studies indicate a small but statistically far-ranging decrease in umbilical artery pH (decrease of around 0.03 through delayed umbilical cord clamping) 23 24. However, a bigger study of 116 infants found no distinction in umbilical cord pH levels and found rise in umbilical artery pO2 level in infants with delay umbilical cord clamping 25. This studies contained infants that did not require resuscitation in ~ birth. Even if it is the impact of delay umbilical cord clamping ~ above cord pH in nonvigorous infants would be similar is an essential question requiring additional study.


Umbilical Cord Milking

Umbilical cord milking or stripping has actually been considered as a technique of achieving raised placental transfusion come the newborn in a fast time frame, usually less than 10–15 seconds. That has particular appeal for scenarios in i m sorry the 30–60-second delay in umbilical cord clamping may be also long, such as when immediate infant resuscitation is required or maternal hemodynamic instability occurs. However, umbilical cord milking has not to be studied as rigorously together delayed umbilical cord clamping. A recent meta-analysis 26 of seven studies that associated 501 preterm infants contrasted umbilical cord milking with prompt cord clamping (six studies) or through delayed umbilical cord clamping (one study). The technique of umbilical cord milking varied significantly in the trials in terms of the variety of times the cord was milked, the length of milked cord, and whether the cord was clamped before or after milking. The analysis found that infants in the umbilical cord-milking teams had higher hemoglobin levels and decreased incidence that intraventricular hemorrhage through no increase in disadvantage effects. Subgroup evaluation comparing umbilical cord milking straight with delay umbilical cord clamping was not able to be lugged out since of little numbers in those groups. Number of subsequent studies have been published. A 2015 trial in term infants comparing delayed umbilical cord clamping with umbilical cord milking found that the two tactics had similar effects on hemoglobin and ferritin levels 27. An additional 2015 trial examining infants born prior to 32 main of gestation uncovered that amongst those babies born through cesarean delivery, umbilical cord milking was associated with higher hemoglobin levels and also improved blood pressure compared with those in the delay umbilical cord clamping group, but the distinctions were not seen amongst those born vaginally 28. Long-term (at period 2 years and 3.5 years) neurodevelopmental outcomes evaluate in one tiny study proved no difference between preterm babies exposed to delay umbilical cord clamping contrasted with umbilical cord milking 29. A 2019 examine of umbilical cord milking was stopped early, through 474 babies enrolled, due to the fact that extremely preterm infants (23–27 weeks of gestation) in the cord milking arm more often emerged intraventricular hemorrhage compared with similar infants in the delay cord clamping team 30. Given this many recent data, cord milking need to not be provided for very preterm infants (less than 28 mainly of gestation), and there is insufficient evidence to either assistance or refute umbilical cord milking in infants born at 32 mainly of gestation or more, including term infants.


Multiple Gestations

Many that the clinical trials that evaluated delayed umbilical cord clamping walk not incorporate multiple gestations; consequently, over there is little information with regard come its security or efficacy in this group. Because multiple gestations increase the risk of preterm birth with inherent risks to the newborn, this neonates could derive particular benefit from delay umbilical cord clamping. Theoretical threats exist because that unfavorable hemodynamic alters during delayed umbilical cord clamping, particularly in monochorionic many gestations. At this time, over there is not sufficient evidence to recommend because that or versus delayed umbilical cord clamping in lot of gestations.


Effect on Umbilical Cord Blood Banking

The impact of delayed umbilical cord clamping ~ above umbilical cord blood repertoire for bank recently has been evaluate in a windy umbilical cord blood bank setup ( 31 ). The authors discovered that delayed umbilical cord clamping considerably decreased the volume and total nucleated cell counts of cord blood donations. The relationship of devices that met early stage screening criteria decreased considerably from 39% with immediate umbilical cord clamping to 17% in situations in which there was a 60-second hold-up in umbilical cord clamping. In instances in i m sorry a patient and also family are planning donation that umbilical cord blood, prompt cord clamping may rise the yield of cord blood obtained. However, in the absence of directed donation, the services to the infant of transfusion of extr blood volume in ~ birth likely exceed the services of banking the volume for possible future use. Family members who are considering banking of umbilical cord blood have to be counseled accordingly.


Future Research

Although numerous randomized controlled trials that connected term and preterm infants have compared the benefits of delay umbilical clamping with those of prompt cord clamping, the best timing for umbilical cord clamping in details circumstances warrants more investigation. For example, babies requiring resuscitation may advantage considerably from placental transfusion, yet their need for instant attention raises questions about whether they should undergo immediate or delayed umbilical cord clamping and whether umbilical cord milking may offer a distinct benefit. The feasibility that resuscitation at the bedside with intact placental circulation additionally is critical question. The optimal timing of uterotonic agents after birth in relationship to umbilical cord clamping needs additional study, as does the optimal practice in lot of gestations and also pregnancies through risk components for neonatal polycythemia. Finally, the value of amplified stem cell and plasma transfusion linked with delay umbilical cord clamping through respect to immediate and also long-term immunity, host defense, and also repair is one more important area for future research.


Conclusion

Term and also preterm infants show up to derive advantage from delay umbilical cord clamping; therefore, delayed umbilical cord clamping for at the very least 30–60 seconds is recommended in term and preterm infants other than when prompt umbilical cord clamping is necessary because of neonatal or maternal indications. In hatchet infants, delayed umbilical cord clamping boosts hemoglobin level at birth and also improves iron shop in the first several month of life, which may have a favorable result on developmental outcomes. Over there is a tiny increase in jaundice inquiry phototherapy in term babies undergoing delayed umbilical cord clamping. Consequently, obstetrician–gynecologists and also other obstetric care providers adopting delay cord clamping in term babies should ensure that mechanisms are in location to monitor and also treat neonatal jaundice.

Similarly, evidence likewise supports delay umbilical cord clamping because that at least 30–60 secs in preterm infants. Delay umbilical cord clamping is associated with far-ranging neonatal benefits in preterm infants, including enhanced transitional circulation, much better establishment the red blood cabinet volume, decreased need because that blood transfusion, and lower incidence the necrotizing enterocolitis and also intraventricular hemorrhage.

In terms of maternal outcomes, delay umbilical cord clamping does not increase the threat of postpartum hemorrhage or the need for blood transfusion. Additionally, postpartum maternal hemoglobin levels room not influenced by delayed contrasted with immediate umbilical cord clamping.


Published virtual on November 19, 2020.

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Delayed umbilical cord clamping after birth. vxcialistoufjg.com Committee Opinion No. 814. American college of Obstetricians and Gynecologists. Obstet Gynecol 2020;136:e100–6.

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