What is the recommended procedure and timing for cutting the umbilical cord in a healthy newborn?

Umbilical Cord Cutting: Timing and Procedure

For healthy term newborns who do not require immediate resuscitation, delay umbilical cord clamping for at least 60 seconds after birth, with the infant positioned at or below the level of the placenta. This recommendation is based on the most recent 2024 international consensus guidelines and provides significant hematological benefits without maternal harm 1.

Timing Recommendations by Gestational Age

Term Infants (≥37 weeks)

• Delay cord clamping for at least 60 seconds in vigorous infants who do not require immediate resuscitation 1, 2
• Optimal benefit occurs with delays of 2-3 minutes, which maximizes placental transfusion and iron stores 2, 3
• The 2021 ILCOR guidelines previously recommended at least 30 seconds, but the 2024 update strengthened this to 60 seconds minimum 1

Preterm Infants (<37 weeks)

• Defer cord clamping for at least 60 seconds in preterm infants not requiring immediate resuscitation (strong recommendation, moderate-certainty evidence) 1, 4
• This reduces mortality with a number needed to treat of 18 infants 1, 4
• For infants 28+0 to 36+6 weeks who cannot receive delayed clamping, umbilical cord milking is a reasonable alternative 1, 4
• Avoid intact cord milking in infants <28 weeks' gestation due to increased risk of severe intraventricular hemorrhage 1, 4

Infant Positioning During Delayed Clamping

• Position the infant at or below the level of the placenta (0-10 cm below or on mother's abdomen) for optimal placental transfusion 2
• Lowering the infant 30 cm below placental level may enhance transfusion effect 2
• This positioning is critical for gravity-assisted blood transfer from placenta to infant 2

Clinical Benefits

Hematological Outcomes

• Increases hemoglobin concentration by 1.17 g/dL within 24 hours compared to early clamping 1
• Reduces anemia risk by 47% in the first 4-6 months of life 2, 3
• Improves iron stores for up to 6 months after birth 2, 5
• Increases hematocrit by 3.38% within 24 hours 1

Benefits for Preterm Infants

• Reduces mortality (OR 0.31 for long deferral ≥120 seconds vs immediate clamping) 1
• Decreases intraventricular hemorrhage by 17% (all grades) 2, 3
• Reduces need for blood transfusions in first 6 weeks of life 2, 3
• Decreases necrotizing enterocolitis and sepsis 3, 5
• Improves mean systemic blood pressure and cardiac function 3

Special Circumstances

When Immediate Resuscitation is Required

• If resuscitation is needed, proceed immediately without delayed clamping 4
• However, if feasible, place infant between mother's legs and initiate positive pressure ventilation with cord intact, aiming for at least 60 seconds before clamping 2
• The decision about immediate resuscitation need must be made within seconds of delivery 4

Maternal Safety Considerations

• Combine delayed cord clamping with immediate oxytocin administration after delivery to reduce maternal blood loss 2, 5
• No increased risk of postpartum hemorrhage with delayed clamping 5
• No difference in maternal postpartum hemoglobin levels or need for transfusion 5

Potential Adverse Effects and Monitoring

Polycythemia Risk

• Increased risk of polycythemia (hematocrit >65%): 50 more infants per 1000 with delayed clamping 1
• This is generally asymptomatic and does not require treatment in most cases 1

Jaundice Monitoring

• Small increase in jaundice requiring phototherapy in term infants 3, 5
• Ensure mechanisms are in place to monitor and treat neonatal jaundice when implementing delayed cord clamping protocols 5
• Never rely on visual assessment alone—always measure total serum or transcutaneous bilirubin if any doubt exists 4

Common Pitfalls to Avoid

• Never delay the assessment of whether immediate resuscitation is needed—this decision must be made within seconds 4
• Do not clamp early "just in case" resuscitation might be needed—wait to see if infant is vigorous 1
• Avoid intact cord milking in extremely preterm infants (<28 weeks) due to hemorrhage risk 1, 4
• Do not position infant above placental level, as this negates the benefit of placental transfusion 2