The American College of Obstetricians and Gynecologists (ACOG) has issued new guidelines on deferred umbilical cord clamping in preterm babies, based on evidence showing that such delays save lives.
The Clinical Practice Update recommends clinicians wait at least 60 seconds to clamp the cord for babies born before 37 weeks of gestation who do not require immediate resuscitation. In cases where infants born at 28 0/7-36 6/7 weeks can’t receive the deferral, umbilical cord milking can be used as an alternative to “improve neonatal hematologic outcomes,” the authors wrote.
The guidance incorporates evidence from two systematic reviews and individual participant data meta-analyses published in Lancet in 2023. Containing 48 and 47 randomized controlled trials each and a combined total of 12,461 babies born before 37 weeks of gestation, the research compared immediate with delayed clamping or milking and found dramatic differences in death rates before hospital discharge.
Premature infants whose umbilical cords were clamped between 30 and at least 180 seconds after birth had a 32% lower risk for death before discharge than those whose cords were immediately clamped, defined as within 15 seconds (odds ratio [OR], 0.68; 95% CI, 0.51-0.91).
The research showed that “delayed clamping doesn’t just help with the baby’s transfusion, it actually improves mortality, which is pretty huge,” said Ilina Pluym, MD, a health sciences assistant clinical professor of obstetrics and gynecology at the University of California Los Angeles Health who was not involved in the studies or writing of the Clinical Practice Update.
The reviews included breakdowns of varying cord clamping deferral times, with waits of 120 seconds or more having the best results. The odds of death before discharge were 69% lower in these patients than in those whose cords were immediately clamped (OR, 0.31; 95% CI, 0.11-0.80).
However, evidence demonstrating the benefits of this deferral length occurred in carefully selected clinical trial settings and “may not be generalizable to neonates assessed at birth as requiring immediate resuscitation or to settings in which adequate newborn assessment and support are not available while the cord is intact,” the authors wrote.
Given the limited generalizability of the 120-plus second deferral time, ACOG recommends waiting at least 60 seconds. The guidance is based on a post hoc analysis performed by the International Liaison Committee on Resuscitation Advanced Life Support Task Force.
In the two Lancet reviews, lengths of 15-45 seconds and 45-120 seconds delays in cord clamping did not result in a lowered death rate before discharge compared with immediate clamping. The 60-second plus time frame wasn’t specifically studied.
However, in the post hoc analysis, the task force found that waiting at least 60 seconds reduced mortality by 37% (OR, 0.63; 95% CI, 0.44-0.88).
Deferred clamping of any duration reduced blood transfusion needs in babies born before 32 weeks by 41% (OR, 0.59; 95% CI, 0.47-0.73). No differences were found in rates of intraventricular hemorrhage.
“Now we actually have good, evidence-based recommendations about what to do for delayed cord clamping in preterm babies,” Pluym said. “I think this is something that we’ve all been starting to do more and more regularly but we now have specific ACOG-recommended guidelines.”
The recommendations also reinforce the benefits of cord milking, said Pluym. In the trials, this practice did not result in lower death rates but did reduce the need for blood transfusions in babies born before 32 weeks by 31% (OR, 0.69; 95% CI, 0.51-0.93).
The guidelines show that “if you cannot do the full minute of being patient and just letting the gentle passage of blood happen through regular delayed cord clamping because of the issues listed in the guidelines — like the baby isn’t breathing, the mom is bleeding, the baby really doesn’t have good tone — then you can do cord milking,” she said.
The guidance lists additional circumstances in which clinicians should consider immediate clamping or individualize care, including when the baby is nonvigorous or there are fetal congenital malformations, multiple gestations, fetal growth restriction, or placenta previa, among others.
The authors said that “though these results may prompt changes in clinical protocols guiding duration of cord clamping for selected preterm neonates, such alterations require careful and multidisciplinary collaboration to ensure safe and high-quality care. More evidence is needed before recommending the routine practice of long deferral of cord clamping for 120 seconds or more in preterm newborns.”
Brittany Vargas is a journalist covering medicine, mental health, and wellness.