In term and preterm infants, should the umbilical cord be clamped after waiting at least 30 seconds (preferably 1–3 minutes) unless there is severe maternal hemorrhage, placental abruption, or the need for immediate neonatal resuscitation?

Delayed Cord Clamping in Term and Preterm Infants

Yes, the umbilical cord should be clamped after waiting at least 30–60 seconds in both term and preterm infants who do not require immediate resuscitation, as this practice reduces mortality in preterm infants and improves hematologic outcomes in term infants without increasing maternal risk. 1, 2, 3

Term and Late Preterm Infants (≥34 weeks)

For vigorous infants ≥34 weeks gestation who do not require resuscitation, delay cord clamping for at least 30–60 seconds. 1, 2, 3

Benefits in Term Infants

• Delayed clamping increases hemoglobin concentration by approximately 1.17 g/dL within 24 hours after birth and hematocrit by 3.38% compared with early clamping 1
• Iron stores are improved for at least 6 months, with higher serum ferritin levels and lower incidence of iron-deficiency anemia at 4–6 months 1, 4
• These hematologic benefits may have favorable effects on neurodevelopmental outcomes, as iron deficiency in young children is associated with impaired motor development, behavioral problems, and cognitive delays 1

Optimal Timing for Term Infants

• Delay clamping for at least 3 minutes when possible for maximum placental transfusion, with the infant positioned on the mother's abdomen or lower 1
• If circumstances do not allow 3 minutes, aim for at least 60 seconds with the infant placed between the mother's legs 1
• The 30–60 second window represents the evidence-based minimum duration across most clinical scenarios 2

Important Caveat: Polycythemia and Jaundice

• Delayed clamping increases the risk of polycythemia (hematocrit >65%) by approximately 50 additional cases per 1,000 infants 1, 2
• There is a small increase in jaundice requiring phototherapy in term infants 3, 5, 6
• Ensure mechanisms are in place to monitor and treat neonatal jaundice before adopting delayed cord clamping protocols 3, 5, 6

Preterm Infants (<34 weeks)

Infants 28–34 Weeks Gestation

For preterm infants 28–34 weeks who do not require immediate resuscitation, delay cord clamping for at least 30 seconds. 1, 2

• Moderate-certainty evidence from 16 RCTs involving 2,988 infants shows delayed clamping probably reduces mortality before discharge (RR 0.73,95% CI 0.54–0.98) 1
• Additional benefits include: 1, 2
  • Improved transitional circulation and cardiovascular stability
  • Reduced need for inotropic support for hypotension within 24 hours (125 fewer per 1,000 infants)
  • Better establishment of red blood cell volume with higher hemoglobin and hematocrit
  • Decreased need for blood transfusions (167 fewer per 1,000 infants)
  • Lower incidence of severe intraventricular hemorrhage (IVH grades 3–4)
  • Reduced necrotizing enterocolitis
  • Lower rates of late-onset sepsis

When delayed clamping cannot be performed in the 28–34 week group, intact cord milking may be used as a reasonable alternative. 1, 2

Extremely Preterm Infants (<28 weeks)

For infants <28 weeks gestation, delay cord clamping for at least 30 seconds but do NOT perform intact cord milking. 1, 2

• Intact cord milking is contraindicated in extremely preterm infants because it markedly increases the risk of severe IVH 1, 2
• A trial of 182 infants showed significantly higher rates of severe IVH with milking versus delayed clamping in this population 1

Absolute Contraindications to Delayed Clamping

Clamp the cord immediately (<30 seconds) in the following situations:

• Infant requires immediate resuscitation (apnea, gasping, or poor muscle tone requiring positive pressure ventilation) 1, 2
• Severe maternal hemorrhage 1
• Placental abruption 1

Critical Pitfall: Resuscitation Takes Priority

• Current evidence is insufficient to support delayed clamping in infants requiring resuscitation 1
• When immediate neonatal care is needed, the priority is prompt positive-pressure ventilation, and the cord should be clamped without delay 2
• One approach under investigation is placing the infant between the mother's legs and starting positive pressure ventilation with the cord intact, delaying clamping for at least 60 seconds, but this remains very low-certainty evidence 1

Maternal Safety

Delayed cord clamping does not increase maternal risk. 3, 5, 6, 4

• No association with increased postpartum hemorrhage ≥500 mL 1, 3
• No difference in postpartum hemoglobin levels or need for maternal blood transfusion 3, 5, 6
• Delayed cord clamping should be combined with administration of oxytocin immediately after delivery of the infant to reduce maternal blood loss 1

Special Populations with Insufficient Evidence

The following conditions were exclusion criteria in most studies, and individualized decisions are necessary based on severity and risk assessment: 1

• Multiple fetuses
• Congenital anomalies (particularly congenital heart or lung disease)
• Placental abnormalities
• Alloimmunization or fetal anemia
• Fetal compromise
• Maternal illness

Practical Implementation Algorithm

1. Assess infant immediately at birth:

   • Vigorous (good tone, breathing/crying)? → Proceed to step 2
   • Nonvigorous (apnea, gasping, poor tone)? → Clamp cord immediately and initiate resuscitation 2

2. Check for maternal contraindications:

   • Severe hemorrhage or placental abruption? → Clamp immediately
   • Otherwise → Proceed to step 3

3. Determine gestational age:

   • ≥34 weeks: Delay clamping 30–60 seconds (preferably up to 3 minutes) with infant on mother's abdomen or between legs 1, 2, 3
   • 28–34 weeks: Delay clamping ≥30 seconds; if not feasible, consider intact cord milking 1, 2
   • <28 weeks: Delay clamping ≥30 seconds; do NOT perform cord milking 1, 2

4. After clamping, proceed with controlled cord traction 1

5. Monitor for jaundice in all infants who received delayed clamping 3, 5, 6