Delayed Cord Clamping: Recommended Practice and Management
For healthy term and late preterm infants not requiring resuscitation, delay umbilical cord clamping for at least 60 seconds after birth to improve iron stores, hemoglobin levels, and reduce mortality risk. 1
Evidence-Based Timing Recommendations
Term Infants (≥37 weeks)
- Delay cord clamping for at least 60 seconds in all vigorous term infants not requiring immediate resuscitation 1
- This practice improves iron status through early infancy and increases hemoglobin/hematocrit levels at 24-48 hours after birth 1
- The intervention provides an additional 25-30 mL/kg of blood volume, stabilizing left ventricular output during cardiopulmonary transition 2
Preterm Infants (34-36+6 weeks)
- Delay cord clamping for at least 60 seconds as the primary approach 3
- If delayed clamping is not feasible, cord milking can be considered as an alternative 3
- Benefits include higher blood pressures during stabilization, lower incidence of intraventricular hemorrhage, and fewer blood transfusions 1
Very Preterm Infants (28-33+6 weeks)
- Delay cord clamping for at least 60 seconds when possible 3
- Intact cord milking (approximately 20 cm toward umbilicus, repeated 3 times) is a reasonable alternative when delayed clamping is not feasible 3
- This improves hematologic outcomes and reduces need for inotropic support 3
Extremely Preterm Infants (<28 weeks)
- Avoid umbilical cord milking entirely due to increased risk of severe intraventricular hemorrhage 3
- Defer cord clamping for at least 60 seconds instead, which is associated with reduced mortality 3
Clinical Implementation
When Delayed Clamping is Appropriate
- All vigorous newborns not requiring immediate resuscitation 1
- Elective cesarean deliveries at term (does not increase maternal blood loss or postoperative infections) 2, 4
- Both vaginal and cesarean deliveries can safely implement this practice 2, 4
When to Proceed with Early Clamping
- Insufficient evidence exists to recommend delayed clamping in babies requiring immediate resuscitation 1
- Current practice allows early clamping when infants are perceived to need resuscitation, though optimal management remains unresolved 1
Benefits and Risks
Documented Benefits
- Improved iron status and reduced childhood anemia (critical for neurodevelopment) 1, 5
- Higher hemoglobin and hematocrit levels at 24-48 hours (mean difference of 6% hematocrit increase) 4
- Reduced intraventricular hemorrhage in preterm infants 1, 6
- Decreased need for blood transfusions in preterm infants 1, 6
- Improved neurodevelopmental outcomes in limited-resource environments 5
- Better hemodynamic stability with improved cardiac output and cerebral oxygenation 5
Potential Concerns
- Increased phototherapy for hyperbilirubinemia (10 more per 1000 infants, number needed to harm = 100) 1
- However, more recent evidence suggests hyperbilirubinemia rates may no longer be significantly elevated 5
- No increase in maternal blood loss or postoperative infections during cesarean delivery 2, 4
- No adverse effects on Apgar scores or neonatal temperature 2
Common Pitfalls to Avoid
- Do not perform cord milking in infants <28 weeks gestational age due to severe intraventricular hemorrhage risk 3
- Do not assume delayed clamping increases maternal hemorrhage risk—evidence shows no significant difference in blood loss 2, 4
- Do not clamp early due to concerns about neonatal hypothermia—temperature is not adversely affected 2
- Avoid immediate clamping for cord blood banking when it conflicts with the infant's best interest for delayed clamping 7
Alternative: Cord Milking Technique
When delayed clamping is not feasible (≥28 weeks gestational age only):