Abstract
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.
Highlights
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, without evidence [1, 2]
This study provided high quality evidence that DCC reduced hospital mortality by 30%, in newborn ≤28 weeks gestational age (GA) (RR 0.70, 95% CI −0.09 to −0.01, number needed to benefit 20), compared to Immediate Cord Clamping (ICC) and reduced the proportion of infants having blood transfusion by 10%
MD and AL wrote the first draft of paragraphs on term newborns, twins, and gas analysis
Summary
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, without evidence [1, 2]. Great interest has been renewed on DCC and umbilical cord milking (UCM), an active maneuver by which the content of the umbilical cord is gently squeezed toward the newborn [3] 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 [4,5,6]. Available studies on placental transfusion strategies, 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 [42]
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