Delayed Cord clamping : ACOG review

Number 543, December 2012

Committee on Obstetric PracticeThis Committee Opinion was developed by the Committee on Obstetric Practice with the assistance of the American Academy of Pediatrics. The American Academy of Pediatrics endorses this document. This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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Timing of Umbilical Cord Clamping After Birth

ABSTRACT: The optimal timing for clamping the umbilical cord after birth has been a subject of controversy and debate. Although many randomized controlled trials in term and preterm infants have evaluated the benefits of delayed umbilical cord clamping versus immediate umbilical cord clamping, the ideal timing for cord clamping has yet to be established. Several systematic reviews have suggested that clamping the umbilical cord in all births should be delayed for at least 30–60 seconds, with the infant maintained at or below the level of the placenta because of the associated neonatal benefits, including increased blood volume, reduced need for blood transfusion, decreased incidence of intracranial hemorrhage in preterm infants, and lower frequency of iron deficiency anemia in term infants. Evidence exists to support delayed umbilical cord clamping in preterm infants, when feasible. The single most important clinical benefit for preterm infants is the possibility for a nearly 50% reduction in intraventricular hemorrhage. However, currently, evidence is insufficient to confirm or refute the potential for benefits from delayed umbilical cord clamping in term infants, especially in settings with rich resources.

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Before the mid 1950s, the term “early clamping” was defined as umbilical cord clamping within 1 minute of birth, and “late clamping,” as umbilical cord clamping more than 5 minutes after birth. In a series of studies of blood volume changes after birth carried out by investigators in Sweden, the United States, and Canada, it was reported that in healthy term infants, more than 90% of blood volume was achieved within the first few breaths the infant took after birth (1). Because of these findings and the lack of specific recommendations regarding the optimal timing, the interval between birth and umbilical cord clamping began to be shortened. In most cases, umbilical cord clamping is performed within 15–20 seconds after birth, with the infant maintained at or below the level of the placenta. Although many randomized controlled trials of term and preterm infants have evaluated the benefits of immediate umbilical cord clamping versus delayed umbilical cord clamping (generally defined as umbilical cord clamping performed 30–60 seconds after birth) (2–26), the ideal timing for umbilical cord clamping has yet to be established and continues to be a subject of controversy and debate (21, 27–29).

Concerns exist regarding universally adopting delayed umbilical cord clamping. Delay in umbilical cord clamping may jeopardize timely resuscitation efforts, if needed, especially in preterm infants. However, because the placenta continues to perform gas exchange after delivery, sick and preterm infants are likely to benefit most from additional blood volume derived from a delay in umbilical cord clamping. Another concern has been raised that delay in umbilical cord clamping increases the potential for excessive placental transfusion, which can lead to neonatal polycythemia, especially in the presence of risk factors for fetal polycythemia, such as maternal diabetes, severe intrauterine growth restriction, and high altitude. Additionally, delayed umbilical cord clamping (with the infant placed at or below the level of the placenta) may be technically difficult in some circumstances. Another issue is that delayed umbilical cord clamping might interfere with attempts to collect cord blood for banking. However, the routine practice of umbilical cord clamping should not be altered for the collection of umbilical cord blood for banking (30).