What are the treatment options for cord signaling issues, including umbilical cord and spinal cord problems?

Umbilical Cord Management at Birth

For preterm infants <37 weeks' gestation who do not require immediate resuscitation, defer umbilical cord clamping for at least 60 seconds—this is a strong, evidence-based recommendation that reduces mortality. 1

Management Algorithm by Gestational Age and Clinical Status

Preterm Infants <28 Weeks' Gestation

• Defer cord clamping for at least 60 seconds as the primary strategy, based on high-certainty evidence showing reduced mortality across multiple subgroups including gestational age, mode of birth, and multiple births 1, 2
• Avoid intact umbilical cord milking in this population due to increased risk of severe intraventricular hemorrhage—one trial was stopped early specifically because of this finding in infants <28 weeks 1, 2
• There is insufficient evidence to recommend cut-cord milking as an alternative 1

Preterm Infants 28+0 to 36+6 Weeks' Gestation

• First-line approach: Defer cord clamping for at least 60 seconds to reduce mortality 1
• Alternative when delayed clamping is not feasible: Umbilical cord milking can be considered as a reasonable alternative to immediate cord clamping 1, 2
• Umbilical cord milking in this gestational age range shows moderate-certainty evidence for reduced red cell transfusion requirements and higher hemoglobin levels, with no evidence of adverse effects 1
• Technique for intact cord milking: Milk approximately 20 cm of umbilical cord toward the umbilicus, repeat 3 times, hold the infant at or below the level of the placenta, and complete before cord clamping 2

Preterm Infants Requiring Immediate Resuscitation

• There is insufficient evidence to make a firm recommendation for cord management in preterm infants <37 weeks who require immediate resuscitation at birth 1
• Individualized decisions should be made based on the severity of the infant's condition and assessment of maternal and neonatal risk 1
• Most trials allowed early cord clamping for infants perceived to require resuscitation, leaving optimal management unresolved until ongoing studies of resuscitation with cord intact are completed 1

Special Circumstances and Contraindications

Maternal, Fetal, or Placental Conditions

Insufficient evidence exists for cord management recommendations in the following conditions that were exclusion criteria in most studies 1:

• Monochorionic multiple fetuses
• Congenital anomalies
• Placental abnormalities
• Alloimmunization or fetal anemia
• Fetal compromise
• Maternal illness

Make individualized decisions based on severity of the condition and assessment of maternal and neonatal risk in these situations 1

Hypercoiled Umbilical Cord

• Implement weekly non-stress testing after viability and serial growth ultrasounds every 3-4 weeks to monitor for growth restriction 3
• For hypercoiled cord with fetal growth restriction, perform serial umbilical artery Doppler assessment 3
• Delivery timing: 39-40 weeks for isolated hypercoiled cord without FGR; 38-39 weeks when estimated fetal weight is between 3rd-10th percentile with normal Doppler; 37 weeks with FGR and abnormal umbilical artery Doppler 3

Hypocoiled Umbilical Cord

• Initiate umbilical artery Doppler assessment after 20 weeks 4
• Implement enhanced fetal surveillance including serial growth ultrasounds every 3-4 weeks and antenatal testing (NST/BPP) in the third trimester 4
• Prepare for potential intrapartum complications with continuous electronic fetal monitoring during labor and lower threshold for interventional delivery if fetal distress develops 4

Critical Practice Points

Timing and Communication

• The plan for umbilical cord management should be discussed between maternity and neonatal clinicians and parents before delivery whenever circumstances allow, taking into account individual maternal and infant circumstances 1
• This represents a good practice statement emphasizing the importance of shared decision-making 1

Evidence Quality Considerations

• The strong recommendation for deferred cord clamping is based on high-certainty evidence for reduced mortality that was robust across multiple participant-level and trial-level subgroups 1
• Parents report that deferred cord clamping provides a positive experience, with mothers feeling closer and more attached to their infants 1
• The overall certainty of evidence is moderate when considering all outcomes, though mortality evidence specifically is high-certainty 1

Common Pitfalls to Avoid

• Do not perform intact cord milking in infants <28 weeks' gestation due to the specific risk of severe intraventricular hemorrhage in this population 1, 2
• Do not assume that cord milking is equivalent to delayed clamping for mortality reduction—the evidence shows cord milking may not reduce death before discharge compared with immediate cord clamping 1
• Avoid immediate cord clamping in stable preterm infants <37 weeks when delayed clamping is feasible, as this represents a missed opportunity to reduce mortality 1