Benefits, Harms, and Costs
- For ease of implementation, recommendations for preterm versus term infants have been kept distinct. Note that as the preterm period progresses, the risks of prematurity decrease substantially, such that the absolute benefits of deferred (delayed) cord clamping also decrease.
- a.In both preterm (<37 weeks) and extremely preterm (<28 weeks) singletons, deferred (delayed) cord clamping is recommended for 60 to 120 seconds because it decreases newborn mortality and morbidity and improves hematological outcomes after the newborn period. When cord clamping cannot be deferred for a full 60 to 120 seconds, then deferred (delayed) cord clamping for at least 30 seconds is superior to immediate clamping. Deferred (delayed) cord clamping should be performed with the infant at or below the level of the introitus or at the level of the cesarean incision (strong, high).
- b.In term singletons, deferred (delayed) cord clamping is recommended for 60 seconds because it improves hematological outcomes at birth and past the newborn period. Deferred (delayed) cord clamping beyond 60 seconds increases the risk of hyperbilirubinemia requiring phototherapy. Deferred (delayed) cord clamping can be performed with the infant at or below the level of the introitus, or at the level of the cesarean incision (strong, high), or on the mother’s abdomen (conditional, low).
- 2.Stabilization or resuscitation with an intact cord for longer durations in preterm and term infants is feasible for centres with appropriate experience and equipment, although larger trials are needed to understand benefits and risks (strong, moderate).
- 3.For maintenance of temperature during deferred (delayed) cord clamping:
- a.Preterm infants should be placed in warm towels, medical grade plastic bags, or medical grade plastic wrap to maintain temperature (strong, high).
- b.Term infants can be placed in warm towels or on the mother’s abdomen (conditional, low).
- a.In preterm twins, deferred (delayed) cord clamping is associated with some benefits and should be considered, except when contraindicated (conditional, low).
- b.In term twins, deferred (delayed) cord clamping may be considered based on presumed extrapolation of benefits in term singletons, except when contraindicated (conditional, low).
- c.The evidence regarding optimal duration of deferred (delayed) cord clamping in twins is insufficient. Deferred (delayed) cord clamping for 30 to 60 seconds can be considered (conditional, low).
- d.When deferred (delayed) cord clamping is performed, not delaying delivery of the second twin is recommended (conditional, low).
- 5.Uterotonic medications increase uterine tone to prevent postpartum hemorrhage:
- a.In preterm pregnancies, due to concerns about a potential bolus of blood to preterm infants, it is recommended that intravenous uterotonic medications be administered after clamping the cord (conditional, low).
- b.In term pregnancies, with lower risk for bolus effects of blood, lower benefits of deferred cord clamping, and higher risk for maternal postpartum hemorrhage, it is recommended that intravenous uterotonic medications be administered with delivery of the anterior shoulder of the final infant (conditional, low).
- 6.Absolute contraindications to deferred (delayed) cord clamping are few, and include (but are not limited to) fetal hydrops, the need for immediate resuscitation of mother or infant (except in centres with appropriate experience and equipment), disrupted utero-placental circulation (e.g., bleeding vasa previas), and known twin-to-twin transfusion syndrome or twin anemia polycythemia sequence (strong, high).
- 7.Relative contraindications to deferred (delayed) cord clamping are few but include (in term infants) risk factors for significant hyperbilirubinemia (e.g., significant polycythemia, severe intrauterine growth restriction, pregestational diabetes), and cases where maternal antibody titres are high or when the first infant in a pair of monochorionic twins is delivered. In all these circumstances, immediate cord clamping should be considered. (conditional, low).
- 8.Cautions regarding deferred (delayed) cord clamping are few but include (in preterm infants) risk factors for significant hyperbilirubinemia (e.g., significant polycythemia, severe intrauterine growth restriction, and cases where maternal antibody titres are high or when the first infant in a pair of monochorionic twins is delivered. In all these circumstances, discussion with the newborn’s care providers regarding benefits and risks and the duration of deferred (delayed) cord clamping is encouraged. The infant’s gestational age should be taken into account, with consideration of deferral for 30 seconds (conditional, low).
- 9.Umbilical cord milking:
- a.Umbilical cord milking is not recommended in very preterm infants <32 weeks, due to increased risk for severe intraventricular hemorrhage (strong, moderate).
- b.In preterm and term infants, deferred (delayed) cord clamping should be performed instead of umbilical cord milking (strong, high).
Abbreviations:DCC (deferred (delayed) cord clamping), GA (gestational age), ICC (immediate cord clamping), IVH (intraventricular hemorrhage), IUGR (intrauterine growth restriction), NEC (necrotizing enterocolitis), RCT (randomized controlled trial), SGA (small for gestational age), TAPS (twin anemia polycythemia sequence), TTTS (twin-to-twin transfusion syndrome), UCM (umbilical cord milking)
The Rationale for Umbilical Cord Management
- 1.Deferred cord clamping benefits most infants, especially preterm infants, and is recommended best practice in most cases. Deferred cord clamping is advised for 60 to 120 seconds with preterm infants, and for 60 seconds with term infants. Umbilical cord milking is not recommended for very preterm infants (<32 weeks).
- Beltempo M.
- Shah P.
- Yoon E.W.
- et al.
Method and approach
The Appraisal of Guidelines Research and Evaluation—Recommendation EXcellence (AGREE-REX).
Benefits of Delayed Cord Clamping
Preterm Singleton Births
In the newborn period
- Beltempo M.
- Shah P.
- Yoon E.W.
- et al.
Beyond the newborn period
Term Singleton births
In the newborn period
Beyond the newborn period
Preterm Twin Births
In the newborn period
Term twin births
Performance of Umbilical Cord Management
- Beltempo M.
- Shah P.
- Yoon E.W.
- et al.
Duration of Delayed Cord Clamping
Positioning of the Infant
Mode of Birth
Contraindications to DCC
Umbilical Cord Milking
Implementation Initiatives in Canada
Evidence for Improving DCC Implementation
- 1.General change management factors (e.g., lack of staff awareness, resistance to change),
- 2.Obstetrical care provider concerns (e.g., risk of hemorrhage),
- 3.Paediatrician concerns (e.g., duration of deferral, polycythemia), and
- 4.Environmental factors (e.g., bags to minimize infant hypothermia).
|Strength of recommendation|
|Strong||High level of confidence that the desirable effects outweigh the undesirable effects (strong recommendation for) or the undesirable effects outweigh the desirable effects (strong recommendation against)|
| Conditional |
|Desirable effects probably outweigh the undesirable effects (weak recommendation for) or the undesirable effects probably outweigh the desirable effects (weak recommendation against)|
|Quality of evidence|
|High||High level of confidence that the true effect lies close to that of the estimate of the effect|
|Moderate||Moderate confidence in the effect estimate:|
The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
|Low||Limited confidence in the effect estimate:|
The true effect may be substantially different from the estimate of the effect
|Very low||Very little confidence in the effect estimate:|
The true effect is likely to be substantially different from the estimate of effect
|Authors||The net desirable effects of a course of action outweigh the effects of the alternative course of action.||It is less clear whether the net desirable consequences of a strategy outweigh the alternative strategy.|
|Patients||Most individuals in the situation would want the recommended course of action, while only a small proportion would not.||The majority of individuals in the situation would want the suggested course of action, but many would not.|
|Clinicians||Most individuals should receive the course of action. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator.||Recognize that patient choices will vary by individual and that clinicians must help patients arrive at a care decision consistent with the patient’s values and preferences.|
|Policymakers||The recommendation can be adapted as policy in most settings.||The recommendation can serve as a starting point for debate with the involvement of many stakeholders.|
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This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Patients have the right and responsibility to make informed decisions about their care in partnership with their health care provider. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate, and personalized. The values, beliefs and individual needs of each patient in the context of their personal circumstances should be considered and the final decision about care and treatment options chosen by the patient should be respected.
Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral language will be used. In other circumstances, we continue to use gendered language because of our mission to advance women’s health. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person’s needs.