Umbilical cord milking-benefits and risks

Standardizing cord clamping: bridging physiology and recommendations from leading societies

The timing of umbilical cord clamping has stirred much greater debate and evolution in the field of obstetrics and neonatology, spurred by advances in medical science as well shifting clinical paradigms. This review seeks to address the history, physiology and clinical applications of different umbilical cord clamping practices around a common theme. The history of these practices and their effects on the mothers as well as new-borns have been addressed in this article along with how modern evidence has been shaping our guidelines. By examining the physiological mechanisms underlying umbilical cord clamping (UCC) and the evolving clinical standards, this article seeks to inform healthcare providers and policymakers on the best approaches for optimizing maternal and neonatal health.

Extra-uterine placental transfusion and intact-cord stabilisation of moderately preterm to term infants in caesarean deliveries - A feasibility study with historical control (INTACT-2)

BACKGROUND

Although delayed umbilical cord clamping (DCC) is universally recommended, implementation has been difficult in caesarean deliveries. The study objective was to test if extra-uterine placental transfusion (delivering the placenta before cord clamping) to facilitate intact-cord stabilisation could be a feasible and safe alternative to DCC (≥ 1 min) for moderately preterm to term infants with caesarean delivery in regional anaesthesia and their mothers.

METHODS

This feasibility study included infants with GA 320 to 423 weeks with planned or emergency caesarean delivery. Primary outcome was intervention compliance. Safety outcomes were prevalence of blood loss ≥1000 ml or postoperative wound infection in mothers, and prevalence of early cord clamping (ECC), low 5-min Apgar scores and hypothermia in infants.

RESULTS

We included 123 mother-infant pairs in the intervention group and 158 in the historical control group. The intervention was successfully completed in 121 of 123 cases. There were no statistically significant differences in maternal outcomes. Significantly less infants in the intervention group had ECC before 60 s (OR 0.07, CI (0.01-0.51), P = 0.009) and 5-min Apgar scores <7 (P = 0.003) compared to historical controls. There was no significant difference in infant hypothermia.

CONCLUSION

Extra-uterine placental transfusion may be a reasonable alternative to DCC for term and near term preterm infants with caesarean delivery in regional anaesthesia. The intervention may be especially useful in low-income birth settings with high prevalence of iron deficiency/anaemia and no mobile resuscitation equipment.

A practical guide to reducing/eliminating red blood cell transfusions in the neonatal intensive care unit

Red blood cell transfusions can be lifesaving for neonates with severe anemia or acute massive hemorrhage. However, it is imperative to understand that red cell transfusions convey unique and significant risks for neonates. The extremely rare risks of transmitting a viral, bacterial, or other microbial infection, or causing circulatory overload are well known and are part of blood transfusion informed consent. Less well known, and not always part of the consent process, are more common risks of transfusing the smallest and most immature NICU patients; specifically, multiple transfusions may worsen inflammatory conditions (particularly pulmonary inflammation), and in certain subsets are associated with retinopathy of prematurity and neurodevelopmental delay. Instituting non-pharmacological transfusion-avoidance techniques reduces transfusion rates. Pharmacological transfusion-avoidance, specifically erythropoietic stimulating agents, further reduces the risk of needing a transfusion. The protocols described herein constitute an efficient and cost-effective transfusion-avoidance program. Using these protocols, many NICU patients can remain transfusion-free.

Milking of the Cut Cord During Stabilization of Infants Born Very Premature: A Randomized Controlled Trial

OBJECTIVE

To investigate the feasibility of cut-umbilical cord milking (C-UCM) during stabilization of preterm infants after birth.

STUDY DESIGN

This was a pilot randomized controlled trial of initial resuscitation. Infants born to eligible, consenting women presenting in preterm labor at <32 weeks' gestation were randomized to receive either the standard practice of deferred cord clamping (DCC) for 30-60 seconds at birth or C-UCM while supporting breathing and following 30 seconds of DCC. The primary outcome was feasibility in terms of percentage recruitment, intervention compliance, safety, and study completion. Short-term clinical outcomes were collected. Analysis was by intention to treat.

RESULTS

Of the 133 pregnant women approached, 93 consented to participate (70%). Fifty infants delivered <32 weeks' gestation were randomized to either C-UCM (25) or DCC (25). Baseline characteristics of infants were similar. All participants completed the study. One infant in the C-UCM group and 5 infants in the DCC group did not receive the allocated intervention. Median (IQR) time to cord milking was 62 (54, 99) seconds and median (IQR) length of the cut-cord milked was 20 (14, 29) cm. C-UCM was not associated with increased adverse effects compared with DCC.

CONCLUSION

Milking of the long-cut cord after 30 seconds of DCC while supporting breathing was feasible and not associated with significant adverse effects. A larger randomized controlled trial is required to assess the efficacy and safety of this approach on clinical outcomes. C-UCM may be especially useful in situations when DCC is not feasible.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03852134.

Resuscitation With Placental Circulation Intact Compared With Cord Milking: A Randomized Clinical Trial

Importance

Among preterm newborns undergoing resuscitation, delayed cord clamping for 60 seconds is associated with reduced mortality compared with early clamping. However, the effects of longer durations of cord clamping with respiratory support are unknown.

Objective

To determine whether resuscitating preterm newborns while keeping the placental circulation intact and clamping the cord after a long delay would improve outcomes compared with umbilical cord milking.

Design, Setting, and Participants

This randomized clinical trial (PCI Trial) was conducted at 8 Italian neonatal intensive care units from April 2016 through February 2023 and enrolled preterm newborns born between 23 weeks 0 days and 29 weeks 6 days of gestation from singleton pregnancies.

Interventions

Enrolled newborns were randomly allocated to receive at-birth resuscitation with intact placental circulation for 180 seconds or umbilical cord milking followed by an early cord clamping (within 20 seconds of life).

Main Outcomes and Measures

The primary outcome was the composite end point of death, grade 3 to 4 intraventricular hemorrhage, and bronchopulmonary dysplasia at 36 weeks of postconception age. Prespecified secondary end points were the single components of the composite primary outcome. An intention-to-treat analysis was conducted.

Results

Of 212 mother-newborn dyads who were randomized, 209 (median [IQR] gestational age, 27 [26-28] weeks; median [IQR] birth weight, 900 [700-1070] g) were enrolled in the intention-to-treat population; 105 were randomized to the placental circulation intact group, and 104 were randomized to the cord milking group. The composite outcome of death, grade 3 to 4 intraventricular hemorrhage, or bronchopulmonary dysplasia occurred in 35 of 105 newborns (33%) in the placental circulation intact group vs 39 of 104 newborns (38%) in the cord milking group (odds ratio, 0.83; 95% CI, 0.47-1.47; P = .53).

Conclusions and Relevance

In a randomized clinical trial of preterm newborns at 23 to 29 weeks' gestational age, intact placental resuscitation for 3 minutes did not lower the composite outcome of death, grade 3 to 4 intraventricular hemorrhage, or bronchopulmonary dysplasia compared with umbilical cord milking.

Trial Registration

Clinicaltrials.gov Identifier: NCT02671305.

Revolutionizing Neonatal Care: A Comprehensive Review of Intact Cord Resuscitation in Newborns

Neonatal resuscitation is a critical procedure aimed at ensuring the successful transition of newborns from intrauterine to extrauterine life. Traditionally, this involves immediate clamping and cutting of the umbilical cord, but recent advances have introduced intact cord resuscitation (ICR) as an alternative approach. This review aims to comprehensively analyze ICR, exploring its evolution, scientific basis, and clinical evidence. It seeks to evaluate the benefits and challenges associated with ICR and assess its impact on neonatal outcomes compared to traditional practices. A thorough review of the literature was conducted, including historical perspectives on neonatal resuscitation, the physiological rationale behind ICR, and critical clinical studies and trials. Current guidelines and recommendations were also examined, along with technological advancements and practical implementation issues. Evidence indicates that ICR offers significant benefits, including improved blood volume, better cardiovascular stability, and reduced risk of anemia in newborns. Comparative studies suggest that ICR can enhance neonatal outcomes and support a smoother transition to extrauterine life. Despite these benefits, challenges related to implementation and adherence to new practices persist. ICR represents a promising advancement in neonatal care, potentially improving newborns' health outcomes. Continued research and refinement of guidelines are necessary to fully integrate ICR into standard practice and address existing implementation challenges. This review highlights the need for ongoing evaluation and adaptation of resuscitation practices to optimize neonatal health and care.

Umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis

BACKGROUND

Placental management strategies such as umbilical cord milking and delayed cord clamping may provide a range of benefits for the newborn. The aim of this review was to assess the effectiveness of umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia.

METHODS

Three databases and five clinical trial registries were systematically reviewed to identify randomised controlled trials comparing umbilical cord milking or delayed cord clamping with control in term and preterm infants. The primary outcome was neonatal hypoglycaemia (study defined). Two independent reviewers conducted screening, data extraction and quality assessment. Quality of the included studies was assessed using the Cochrane Risk of Bias tool (RoB-2). Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis using a random effect model was done using Review Manager 5.4. The review was registered prospectively on PROSPERO (CRD42022356553).

RESULTS

Data from 71 studies and 14 268 infants were included in this review; 22 (2 537 infants) compared umbilical cord milking with control, and 50 studies (11 731 infants) compared delayed with early cord clamping. For umbilical cord milking there were no data on neonatal hypoglycaemia, and no differences between groups for any of the secondary outcomes. We found no evidence that delayed cord clamping reduced the incidence of hypoglycaemia (6 studies, 444 infants, RR = 0.87, CI: 0.58 to 1.30, p = 0.49, I2 = 0%). Delayed cord clamping was associated with a 27% reduction in neonatal mortality (15 studies, 3 041 infants, RR = 0.73, CI: 0.55 to 0.98, p = 0.03, I2 = 0%). We found no evidence for the effect of delayed cord clamping for any of the other outcomes. The certainty of evidence was low for all outcomes.

CONCLUSION

We found no data for the effectiveness of umbilical cord milking on neonatal hypoglycaemia, and no evidence that delayed cord clamping reduced the incidence of hypoglycaemia, but the certainty of the evidence was low.

Delayed cord clamping versus cord milking in vigorous neonates ≥35 weeks gestation born via cesarean: A Randomized clinical trial

BACKGROUND

Delayed cord clamping (DCC) is the recommended strategy in neonates not requiring resuscitation, but umbilical cord milking (UCM) can also be used in term babies. DCC has been found to offer advantages more than just placental transfusion.

OBJECTIVE

To compare the neonatal outcomes of DCC and UCM at birth in vigorous neonates ≥35 weeks born via cesarean section.

METHODS

We included all vigorous neonates born ≥35 weeks of gestation through the cesarean section in this open-label randomized controlled trial. They were randomized into Group-A (DCC-cord was clamped 60 s after birth) or Group B(UCM). For neonates in Group B, the intact cord was milked at 25 cm from the stump 3 times towards the neonate and then clamped. The primary outcome was hematocrit at 72 h of life. Secondary outcomes were serum ferritin between 6 and 10 weeks of life, serum bilirubin at 72 h of life, need and duration of phototherapy, respiratory distress, hypoglycemia, hypotension, and sepsis.

RESULTS

Baseline characteristics were similar in both the groups. The mean hematocrit at 72 h was more in the DCC group compared to the UCM group [(55.60±4.50) vs (53.89±4.44), MD (95% CI) = 1.71 (0.26, 3.16); p = 0.021]. There was no significant difference in median serum ferritin between the groups [102.88(84.67-173.24) vs 137.93(85.15-230.40); p = 0.173]. There was no significant difference in clinical outcomes.

CONCLUSION

In neonates born via cesarean section, DCC resulted in improved hematocrit levels by 72 hours compared to UCM. DCC results in better placental transfusion.