Edited by: Michael P. Meyer, Middlemore Hospital, New Zealand
Reviewed by: Salvatore Andrea Mastrolia, Ospedale dei Bambini Vittore Buzzi, Italy; María Gormaz, Agencia Valenciana de Salud, Spain
This article was submitted to Neonatology, a section of the journal Frontiers in Pediatrics
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At delivery, if the cord is not clamped, blood continues to pass from the placenta to the newborn during the first minutes of life, allowing the transfer of 25–35 ml/kg of placental blood to the newborn, depending on gestational age, the timing of cord clamping, the position of the infant at birth, the onset of respiration, and administration of uterotonics to the mother. However, deriving benefits from delayed cord clamping (DCC) are not merely related to placental-to-fetal blood transfusion; establishing spontaneous ventilation before cutting the cord improves venous return to the right heart and pulmonary blood flow, protecting the newborn from the transient low cardiac output, and systemic arterial pressure fluctuations. Recent meta-analyses showed that delayed cord clamping reduces mortality and red blood cell transfusions in preterm newborns and increases iron stores in term newborns. Various authors suggested umbilical cord milking (UCM) as a safe alternative when delayed cord clamping is not feasible. Many scientific societies recommend waiting 30–60 s before clamping the cord for both term and preterm newborns not requiring resuscitation. To improve the uptake of placental transfusion strategies, in 2016 an Italian Task Force for the Management of Umbilical Cord Clamping drafted national recommendations for the management of cord clamping in term and preterm deliveries. The task force performed a detailed review of the literature using the GRADE methodological approach. The document analyzed all clinical scenarios that operators could deal with in the delivery room, including cord blood gas analysis during delayed cord clamping and time to cord clamping in the case of umbilical cord blood banking. The panel intended to promote a more physiological and individualized approach to cord clamping, specifically for the most preterm newborn. A feasible option to implement delayed cord clamping in very preterm deliveries is to move the neonatologist to the mother's bedside to assess the newborn's clinical condition at birth. This option could safely guarantee the first steps of stabilization before clamping the cord and allow DCC in the first 30 s of life, without delaying resuscitation. Contra-indications to placental transfusion strategies are clinical situations that may endanger mother ‘s health and those that may delay immediate newborn's resuscitation when required.
Until 1960, delayed umbilical cord clamping (DCC) to promote placental transfusion was common; afterward, cord clamping immediately after birth became standard practice to reduce the risk of postpartum hemorrhage, although without evidence (
Both techniques, referred in the text as placental transfusion strategies, allow transferring a similar amount of fetal blood, between 25 and 35 ml/kg, from the placenta to the newborn, increasing neonatal volemia, hemoglobin concentration, and blood pressure in the first days of life (
The amount of blood transferred to the newborn during DCC depends on various factors: the time of cord clamping, the mode of delivery, the position of the newborn, the beginning of spontaneous breathing and respiration, and uterine contractions (
Milking the umbilical cord is considered a valid alternative to DCC, as it takes 10–20 s to be performed, allowing rapid neonatal resuscitation when required. It consists of squeezing gently 20–30 cm of umbilical cord three to five times from the placenta to the newborn at a velocity of 10 cm/s (
In the last years, research studies and meta-analysis highlighted the favorable impact of placental transfusion strategies on short-term neonatal outcomes. Both have been associated with a lower incidence of iron deficiency at 3–6 months in term newborns (
The reported long-term effects of placental transfusions are still scarce; a recent neuro-cognitive follow-up study of term newborns associated DCC to improved fine motor and social domains scores at 4 years of age, particularly in males (
Recent studies on animal models (
Scientific societies and neonatal resuscitation guidelines (
Therefore, “newborns requiring resuscitation” have been excluded by most research protocols and a significant percentage of infants included in DCC trials were clamped earlier than scheduled, mostly due to clinical concerns about delaying ventilation in non-vigorous infants (
When stimulation of the newborn occurs before clamping the cord, as suggested by WHO guidelines (
A feasible option to promote placental transfusion in the most compromised newborns is to provide neonatal resuscitation during DCC. Recently Katheria et al. (
Umbilical cord milking could offer an advantage over DCC in preterm newborns who are deemed too unstable to wait for DCC and who are at the highest risk of severe IVH and death. Compared to DCC, UCM have been associated with higher blood pressure in the first day of life (
A recent Italian survey (
The study showed a significant correlation between the implementation of DCC and UCM and the knowledge of related benefits, the availability of obstetric-neonatal guidelines and the engagement across professions within the delivery team.
In 2016 the Italian Task Force for the Management of Umbilical Cord Clamping has been constituted to draft recommendations for the management of cord clamping in term and preterm newborns.
The aim of this document (first edition) is to provide operators involved in childbirth assistance with an updated consultation tool for optimal management of umbilical cord clamping in term and preterm newborns to standardize placental transfusion strategies in different clinical scenarios. Attention was paid to the application of DCC and UCM in extremely premature infants, according to guidelines for newborn's resuscitation (
Preterm deliveries are classically categorized, depending on gestational age at birth, in extremely preterm (<28 weeks), very preterm (<32 weeks), moderate (32–33 + 6/7 weeks), and late preterm (34–36 + 6/7 weeks) birth.
Available studies on placental transfusion strategies, however, showed a significant overlap among these categories. For this reason, the panel decided to elaborate recommendations tailored to a unique group of patients that included extreme, very and moderate preterm newborns for whom immediate post-partum medical assistance was expected. Late preterm newborns have been considered separately because, in most cases, they do not necessitate medical interventions at birth, except for the presence of a skilled operator in neonatal resuscitation, as recommended by resuscitation guidelines in 2010 (
The working group consists of obstetricians, midwifes, and neonatologists with experience in delivery room resuscitation, neonatal hematology, and cardiology, belonging to the Italian Society of Neonatology (SIN), the Italian Society of Perinatal Medicine (SIMP), and the National Federation of Midwifes (FNCO).
The Italian version of the document derives from a detailed review of the English literature until December 2017 and a summary of the recommendations already published on the subject by scientific societies and expert panels. Articles' search was performed in 2 online databases (PubMed and the Cochrane Library).
Recommendations have been drawn using the methodological approach proposed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group (
After identification and prioritization of the questions to be addressed, articles were screened for further evaluation. GRADE is a consensus process that rates the quality of evidence and strength of recommendations along with values and preferences. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high (where one has high confidence in the estimate of effect as reported in a synthesis of the literature), moderate (where one has moderate confidence, but there may be differences from a further elucidated truth), low (where one has low confidence in the estimate of the effect that may be substantially different from the true effect), or very low (where it is possible that the estimate of the effect is substantially different from the true effect) (
Recommendations were based on the evaluation of the expected benefits and risks connected to placental transfusion practices and the clinical context in which they could be applied. The safety for the mother and the newborn guided the drafting of the recommendations when evidence from the literature was not conclusive. The panel discussed and approved each statement unanimously during quarterly meetings held between 2016 and 2017.
The original document has been externally reviewed and accepted by a panel of neonatologists, obstetricians, and midwifes (see Acknowledgment).
Quality of evidence and strength of recommendations are summarized in Table
Quality of evidence and strenght of recommendations.
High quality | A |
Moderate quality | B |
Low quality | C |
Very low quality | D |
Strong recommendation: the desirable effects of adherence outweigh the undesirable effects | 1 |
Weak recommendations: the desirable effects of adherence probably outweigh the undesirable effects, although the trade-offs are uncertain | 2 |
The meta-analysis by McDonald et al. (
These positive results last up to the end of the first year of life in the case of infants born to mothers with low serum ferritin concentration at delivery (
The position (relative to perineum) of the newborn during DCC did not seem to affect the volume of placental transfusion (
Delayed clamping has been associated with a slight increase in the need for phototherapy (2.74 vs. 4.36%; RR < 2%). This result was much debated, as it originates from the inclusion of unpublished data (McDonald, 1996). No differences between early and delayed clamping were found in mortality rate, Apgar score, admission to NICU, respiratory distress, breastfeeding at discharge and up to 6 months. The incidence of asymptomatic polycythemia was similar between DCC and ICC in the review by McDonald et al. (
Delayed cord clamping improves iron stores in the first months of life in term, vaginally delivered newborns with a high quality of evidence.
In vaginally delivered newborns, DCC is recommended for at least 60 s to optimize cardio-pulmonary transition at birth and to promote placental transfusion
It is recommended to dry and stimulate non-breathing infants by rubbing the back two to three times to encourage spontaneous breathing before clamping, and to clamp the cord in cases of persistent apnea
It is suggested to clamp the umbilical cord by 3 min after delivery to improve iron stores in the first 3–6 months of life, although the optimal clamping time has not been defined
Clamping the umbilical cord at 3 min is not mandatory; a longer DCC is suggested (up to 5 min, until pulsations stop, etc.) if requested by parents
During DCC, newborns may be placed on the mother's abdomen or chest or kept below the perineal plane
A recent meta-analysis (
Zhou et al. (
At present, recommendations on DCC in term newborns do not distinguish between vaginal and cesarean deliveries even though no studies explored the effects of DCC in exclusively CD newborns and only a few of them included this category of patients (
Ceriani et al. (
There are few data supporting DCC longer than 1 min in cesarean-delivered newborns to improve iron stores in infancy; the higher rate of NICU admission associated to 3 min DCC in the study by Ceriani et al. (
No studies compared different positions of the newborn during DCC; infants can be placed between maternal legs or beside the maternal abdomen.
Overall, DCC by 30–60 s in CD term newborns is associated with improved iron stores in the first weeks after birth, with a moderate quality of evidence.
It is suggested to delay cord clamping for at least 30 s and up to 60 s after birth to improve iron stores in newborns not requiring resuscitation
It is recommended to dry and stimulate non-breathing infants by rubbing the back two to three times to encourage spontaneous breathing before clamping, and to clamp the cord in cases of persistent apnea
In the case of DCC longer than 1 min, it is recommended to ensure the presence of a skilled operator in neonatal resuscitation to evaluate the feto-neonatal transition
There are only a few studies (
Cord milking was associated to improved iron stores in the first weeks of life (
Erickson-Owens et al. (
Upadhyay et al. (
The positive effects of c-UCM on iron stores lasted up to 6 months of age in a prospective study on 200 term newborns (
The comparison of different placental transfusion strategies in term newborns was inconclusive.
Jaiswal et al. (
Yadav et al. (
None of the previous studies provided a separate analysis by type of delivery.
Some authors suggested to milk the uncut cord if this is still full at the end of the time allotment (
To our knowledge, the uncut UCM technique has not been compared to DCC in VD term newborns. The panel estimated that UCM (both techniques) in healthy vaginally-delivered term newborns should not replace a more physiological placental transfusion obtained by DCC.
Overall, c-UCM improves iron stores in CD term newborns in the first weeks of life, compared to immediate cord clamping, with a very low quality of evidence.
It is not possible to recommend the best milking technique to adopt. The uncut UCM technique may probably result in better transfusion performance but required further evaluation, both in VD and CD term newborns.
Umbilical cord milking (both techniques) is not suggested as an equal alternative to delayed cord clamping in VD newborns not requiring resuscitation at birth
In CD newborns, if delayed cord clamping is not feasible, umbilical cord milking is suggested as a valid alternative to promote placental transfusion and improve iron stores in the first weeks of life.
Delayed cord clamping in late preterm infants (34 0/7–36 6/7 weeks of gestational age) varied from 30 to 180 s after birth (
During DCC, infants were positioned on the mother's abdomen (
Strauss et al. (
Ranjit et al. (
Most of the studies included late preterm newborns, but only a few of them addressed to this specific category, with a very low number of patients recruited (
In vaginal and cesarean-delivered infants not breathing at birth, it is recommended to dry and stimulate by rubbing the back two to three times to encourage spontaneous breathing before clamping, and to clamp the cord if the baby continues not to breath
It is recommended the presence of personnel with neonatal resuscitation skills to evaluate the newborn in the transition phase
It is suggested clamping the cord between 60 and 180 s in vaginally delivered newborns, not requiring resuscitation at birth, to improve hemoglobin concentration and iron stores in the first weeks after birth
It is suggested placing newborns from vaginal delivery at the perineal level or below for the first 30 s of DCC, then on maternal abdomen
It is suggested clamping the cord between 30 and 60 s in cesarean-delivered late preterm newborns not requiring resuscitation
Only one study that included late preterm infants evaluated the effects of UCM (
Kumar et al. (
No data are available on the extent of placental transfusion with milking techniques, differentiated by mode of delivery.
Umbilical cord milking improves iron stores in the first weeks after birth in late preterm infants, with a very low quality of evidence.
Delayed cord clamping and milking were not associated with adverse events both in newborns and in the mother.
In vaginally and cesarean-delivered late preterm newborns, when DCC is not feasible, UCM is suggested as a valid alternative to improve iron stores
Delayed cord clamping in very preterm infants is defined as a clamping that occurs between 30 and 120 s after birth; DCC longer than 120 s has not been tested.
The most recent results on the effect of DCC in preterm infants were published in 2017.
The Australian APTS trial (
This study did not foresee interventions to promote breathing during DCC and may explain the high protocol violation rate (about ¼ of subjects randomized to DCC received ICC) mostly due to medical concern about the infant. The exclusion of the most critical newborns may have affected the results. Indeed, statistical analysis has not been performed on the effective treatment received by the patient but based on the treatment expected by randomization, which may have introduced an attrition bias, caused by the unequal loss of patients in the DCC group.
The second significative study was the meta-analysis by Fogarty et al. (
The authors explained the positive impact of DCC in preterm newborns with the reduction of unnecessary and potentially harmful medical interventions in the first hours and days of life that could influence short and long-term outcomes through the activation of the inflammatory cascade and oxidative stress, the increased risk of infections and lengthening of hospitalization.
Many authors observed that cord clamping should be individualized and based on clinical conditions, rather than on a pre-defined ideal clamping time (
Ventilation is the key strategy of neonatal resuscitation (
Indeed, first steps of stabilization at birth have been associated with reduced peripartum mortality and mask ventilation (
According to these concepts, the working group proposed a flow chart (Figure
Bedside evaluation flow-chart in the case of very preterm newborns (<34 weeks). *Milking the umbilical cord is suggested when clinical evaluation bedside is not feasible, (weak recommendation). **It is suggested to clamp the cord between 90 and 120 seconds in vaginally delivered newborn with gestational age between 29 + 0 and 33 +6 weeks_(Weak recommendation).
Delayed cord clamping increased the incidence of polycythemia in preterm newborns [risk difference 3% (95% CI: 2 to 5%)], and the incidence of jaundice (mean difference in peak bilirubin +4 μmol/l) without increasing morbidity or the need for exchange transfusion (
Preliminary results of long-term follow-up showed a positive correlation between DCC and improved motor function at 18–22 months of corrected age, compared to ICC (
Delayed cord clamping, compared to ICC, in moderate, very and extremely preterm deliveries improved outcomes with a high level of evidence.
Milking the umbilical cord in very and extremely premature newborns was associated with a significant decreased risk of intracranial hemorrhage of all grade IVH all grade (RR 0.62; CI 0.41–0.93) and bronchopulmonary dysplasia (RR, 0.42 [95%CI: 0.21–0.83]) in newborns with gestational age < 33 weeks, compared to ICC (
When UCM was compared to DCC, results are contradictory. Rabe et al. (
The follow-up study of the cohort by Rabe et al. (
In moderate, very and extreme preterm newborns, especially if cesarean-delivered, cord milking improved short-term outcomes with a moderate level of evidence, and long-term outcomes with very low quality of evidence, without undesirable effects, except for a low risk of symptomatic hyperviscosity (
In vaginal and cesarean-delivered newborns with gestational age < 34 weeks, it is recommended to delay cord clamping for at least 30”. During this period, it is recommended to ensure the maintenance of body temperature, to perform tactile stimulation, to ensure airway patency and possibly their aspiration
At 30 s of life, it is recommended to evaluate tone and breathing activity by visual inspection and heart rate by stethoscope: if the newborn is bradycardic (heart rate is < 100 bpm) apnoeic or gasping, it is recommended to clamp the cord and start ventilatory assistance maneuvers according to neonatal resuscitation procedures
At 30 s of life, if the heart rate is > 100 bpm and active breathing or efforts to breath are present, it is recommended to clamp the cord at 60 s
In vaginally delivered newborns with gestational age between 29 + 0 and 33 + 6 weeks, that do not require ventilatory assistance, the umbilical cord may be clamped at 90–120 s of life
The obstetrical-neonatological team should ensure sterility during bedside maneuvers, especially in the operating room
It is suggested to place vaginally delivered newborns at or below the perineal plane to promote placental transfusion
It is recommended to identify within the obstetric-neonatology team a professional figure responsible for checking and communicating the time elapsed from birth
When bed-side neonatological assistance could not be implemented, milking the uncut umbilical cord three to four times before clamping the cord is suggested
Rhesus disease and, generally, feto-maternal red blood cell alloimmunization, were excluded from DCC research protocols, as it was likely that delaying clamping may increase the risk for significant hyperbilirubinemia due to the higher amount of opsonized red blood cells (RBC) transfused from the placenta to the newborn that could undergo hemolysis.
There is a single retrospective study (
In newborns at risk of anemia due to feto-maternal alloimmunization, it is suggested clamping the cord within 30 s from birth, after the first breaths if these occur before 30 s from birth
Antiretroviral therapy during pregnancy together with intrapartum and postnatal prophylaxis can prevent perinatal transmission of HIV-infection from the mother to the newborn (
WHO guidelines (
Vaginal delivery is considered appropriate for HIV-infected pregnant women who have been maintained on combined antiretroviral therapy and who have viral loads <1,000 copies/ml at or near delivery (
The following recommendations are intended for HIV pregnancies in high-income countries with scheduled cesarean delivery.
In newborns from HIV-positive mothers with adequate antiretroviral therapy during pregnancy and HIV-RNA near or at delivery ≤ 1,000 copies/ml it is suggested to delay cord clamping for at least 30 s and up to 60 s to improve iron stores, similarly to what suggested for healthy term and late preterm CD newborns
Immediate cord clamping is suggested in all other cases
Various studies (
The higher hemoglobin concentration in the second-born from monochorionic twin has been addressed to the presence of vascular anastomoses allowing either intrapartum inter-twin blood transfusion or placenta-fetal transfusion (
Lopriore et al. (
In twins delivered through cesarean section, no intertwin differences in hemoglobin levels were detected.
Very few studies on placental transfusion strategies included dichorionic twin pregnancies, and none included monochorionic twins.
Mc Donnel et al. (
Kugelman et al. (
In the recent study by Katheria et al. (
The APTS trial (
The quality of evidence has been considered low or very low, due to the paucity of data on this subset of patients; however, the panel considered delayed cord clamping in twin pregnancies safe for mother and the child.
No studies evaluated the effect of milking in this group of patients.
Delayed cord clamping is not recommended in monochorionic twins because the risk of acute intertwin transfusion at birth outweighs the undetermined benefit of delayed cord clamping in this population.
In vaginally and cesarean-delivered term or preterm twin newborns from dichorionic pregnancy, it is suggested delaying cord clamping for at least 30 s up to 60 s
In vaginally and cesarean-delivered infants not breathing at birth, it is recommended to dry and stimulate by rubbing the back two to three times to encourage spontaneous breathing before clamping, and to clamp the cord if the baby continues not to breath
The hemodynamic and hematological improvements associated with DCC could theoretically advantage newborns with CHD. Indeed, the increased blood volume and hematocrit may have a positive effect, especially in cyanotic CHD, through the improvement of tissue oxygenation and increased blood flow at the level of Foramen Ovale and Ductus Arteriosus.
There is a single randomized study (
Based on the prediction of hemodynamic conditions at birth (
CHD without prediction of hemodynamic instability at birth: interatrial and interventricular septal defects, mild to moderate degree of valvular abnormalities.
CHD with a slight risk of hemodynamic instability at birth: obstructions to the right or left efflux with arterial duct dependence. In these conditions, the patency of the arterial duct in the first hours after birth generally allows a physiologic cardiorespiratory and hemodynamic transition at birth.
CHD with a high probability of hemodynamic instability at birth could compromise postnatal transition and required immediate resuscitation:
- Transposition of great vessels with a restrictive foramen ovale
- Hypoplastic left heart syndrome with a restrictive foramen ovale
- Total abnormal pulmonary venous return obstructed
- Ebstein disease with hydrops
- Tetralogy of Fallot with absent pulmonary valve
- Heart rhythm disorders with decompensation.
DCC between 1 and 2 min is suggested in the case of vaginally delivered CHD newborns
It is suggested clamping the cord at 1 min in the case of cesarean-delivered CHD newborns
In the case of mild or severe risk of hemodynamic instability, (group 2 and 3), it is recommended to foresee the presence of personnel with resuscitation skills to evaluate the newborn during the transition phase
The management of cord clamping in the case of severe CHD (group 3) should be discussed prenatally by a multidisciplinary team (obstetrician, neonatologist, and cardiologist) according to the predictable resuscitation needs.
Blood gas analysis from the umbilical artery is a tool to assess the metabolic status of the fetus (
Scientific Societies (
Wiberg et al. (
De Paco et al. (
All these studies included infants who did not require resuscitation at birth; whether the effect of DCC on arterial cord pH in non-vigorous infants would be similar is an important question requiring further investigations.
A possible solution that takes both needs into account (blood gas determination immediately after birth and delayed cord clamping in vigorous infants) is to perform blood gas analysis on the unclamped umbilical cord. Andersson et al. (
Di Tommaso et al. (
The quality of evidence was considered high for the outcome “reliability of cord blood gas analysis during delayed cord clamping.”
It is recommended performing umbilical artery gas analysis on double-clamped cord immediately after birth when neonatal asphyxia is expected, to obtain the most objective determination of the neonatal metabolic condition at of birth
When cord gas analysis is recommended immediately after birth, but the newborn is vigorous and does not require resuscitation, umbilical artery gas analysis on the unclamped cord is a feasible alternative method
Umbilical Cord Blood (UCB) is currently an established source of stem cells, especially in pediatric settings, in very urgent cases and for patients with no HLA matched donor (
In recent years, the cellularity threshold for banking has been augmented from 1.2 × 109 to 1.5 × 109; consequently, discarded units are increased up to over 75% (
Numerous factors may condition the collection of adequate UCB units; 1. weight of the newborn, 2. weight of the placenta, 3. ethnicity, and 4. collection methods (
Early cord clamping within 30 s from delivery is associated with optimal volume and progenitor cells for UCB collection while DCC for 1 to 3 min significantly reduces cord blood volume available for collection (
A study from the Canadian Blood Bank Service (
Differently, the National Swedish Cord Blood Bank (
Recent recommendations (
Scientific societies (
The following recommendations are intended for altruistic and dedicated umbilical cord blood (UCB) donations. Private cord blood banks are not allowed in Italy. Cord blood may be collected with special permission from the hospital, but units must be stored in foreign cord blood banks; transport and costs are not borne by national health service.
In the case of altruistic cord blood donation, it is suggested to clamp the umbilical cord after 60 s and before 120 s after birth
In the case of directed donation for at-risk families, with the goal of maximizing the content of hematopoietic progenitors through the volume collected, it is recommended to clamp the cord immediately after birth
Health care professionals should give written information to pregnant women and their partners of the benefits of DCC and its impact on cord blood collection and banking
Although there are no maternal contraindications to DCC or UCM, there are some emergent conditions (such as massive uterine bleeding) that required immediate cord clamping to safeguard mother's health.
Fetal conditions for which DCC and UCM are contra-indicated include all cases of perinatal asphyxia when immediate resuscitation is required; other exclusion criteria include clinical situations for which concerns exist about the possible benefits deriving from a placental transfusion, and results from research studies, when present, are inconclusive.
For the following clinical situations, immediate cord clamping is recommended, although based on experts' opinions.
Birth asphyxia secondary to hypoxic-ischemic events: placental detachment, cord prolapse, uterine rupture, shoulder dystocia, vasa previa rupture, maternal collapse, amniotic embolism, maternal cardiac arrest.
Twin to twin transfusion (TTTS)
Newborn from HIV-positive mother (see dedicated paragraph)
Fetal hydrops with evidence of fetal hearth decompensation
Doubt about the integrity of the umbilical cord
Cesarean delivery under general anesthesia.
Theoretically, when a hypovolemic shock is suspected (i.e., shoulder dystocia, placental detachment, cord prolapse, uterine rupture) c-UCM may be an immediate source of fetal blood to be transfused while initiating resuscitations ‘maneuvers (
Intrauterine growth restriction refers to a fetus with an estimated fetal weight <10th percentile on ultrasound that, because of a pathologic process, has not attained its growth potential (
Delayed cord clamping and cord milking have not been tested in this specific population; for this reason, the panel could not issue a recommendation on the subject. Theoretically, both techniques may worsen polycythemia (
A summary of all recommendations is given in Table
Summary of recommendations.
Newborns ≥ 34 weeks GA | - Always dry and stimulate apnoeic infants before clamping, to encourage spontaneous breathing, and to clamp the cord in cases of persistent apnea |
Vaginally delivered | - In term and late preterm newborns, delay cord clamping for at least 30 (late preterm) or 60 s (term) and up to 3 min to optimize cardiopulmonary transition and improve iron stores |
Cesarean-delivered | - Delay cord clamping for at least 30 (late preterm) or 60 (term) s |
Newborns < 34 weeks GA | - Ensure the neonatologist is at the bedside |
HIV pregnancy | - Clamp the cord between 1 and 2 min in CD newborns from HIV-positive mothers with HIV-RNA ≤ 1,000 copies/mL and adequate antiretroviral therapy during pregnancy |
Twin pregnancy | - In monochorionic twin, delayed cord clamping is not recommended |
Fetus with congenital heart disease (CHD) | - DCC between 1 and 2 min is suggested in VD newborns |
Cord blood banking | - In the case of altruistic cord blood donation, it is recommended clamping the cord after 60 s and before 120 s |
Blood gas analysis | - Perform umbilical artery gas analysis on double-clamped cord immediately after birth when neonatal asphyxia is expected |
Contra-indications to DCC and UCM | - Birth asphyxia secondary to hypoxic-ischemic events: placental detachment, cord prolapse, uterine rupture, shoulder dystocia, vasa previa rupture, maternal collapse, amniotic embolism, maternal cardiac arrest |
SG conceived the project, coordinated the work of the panel between 2015 and 2016, wrote the introduction and the material and methods paragraphs, wrote and reviewed the final version of the manuscript. MD and AL wrote the first draft of paragraphs on term newborns, twins, and gas analysis. BP wrote the first draft of paragraphs on late preterms, pregnancy with feto-maternal alloimmunization, HIV-positive pregnancy and contraindications. SF contributed to writing the first draft of the paragraph on congenital heart disease. PS contributed to writing the first draft on cord blood banking. SP contributed to writing the first draft on preterm < 34 weeks and together with SG and BP conceptualize the Flow-chart. All authors approved the final version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The Authors would thank Daniele Merazzi for his helpful revision of methodology; Daniele Trevisanuto, Antonello Del Vecchio, Gaetano Chirico, Giuseppe Battagliarin, Tullia Todros, Davide de Vita, Maurizio Silvestri, Elsa Viora, Marilisa Coluzzi, Iolanda Rinaldi for their revisions of the Italian version of the document.
Bronchopulmonary dysplasia
Cesarean Delivered
Congenital hearth defect
Cesarean Section
Delayed Cord Clamping
Gestational Age
Immediate Cord Clamping
Intraventricular Hemorrhage
Necrotizing Enterocolitis
Umbilical Cord Milking
cut-cord Umbilical Cord Milking
Vaginal Delivery
World Health Organization.