Guideline sources The following summarized guidelines for the management of umbilical cord management are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022), the American Heart Association (AHA 2020), the American College of Obstetricians and Gynecologists (ACOG 2020), the World Health Organization (WHO 2018), the Enhanced Recovery After Surgery Society (ERASS 2018), and the Royal College of Obstetricians and Gynaecologists (RCOG 2015). 1 2 3 4 5 6 Guidelines 1. Medical management Uterotonics: As per SOGC 2022 guidelines: Administer IV uterotonic medications after clamping the cord in preterm pregnancies due to concerns about a potential bolus of blood to preterm infants. B Administer IV uterotonic medications with delivery of the anterior shoulder of the final infant in term pregnancies with lower risk for bolus effects of blood, lower benefits of deferred cord clamping and higher risk for maternal postpartum hemorrhage. B As per RCOG 2015 guidelines, recognize that IM uterotonic agents administered before cord clamping are unlikely to have a substantive effect on placental transfusion. E 2. Therapeutic procedures Timing of cord clamping: https://web.pathway.md/diseases/rec1UWXAkolzdS9Lm 1/3 6/29/23, 3:47 AM Umbilical cord management Pathway Timing of cord clamping: As per SOGC 2022 guidelines, delay cord clamping for 60-120 seconds in both preterm (< 37 weeks) and extremely preterm (< 28 weeks) singletons because it decreases newborn mortality and morbidity and improves hematological outcomes after the neonatal period. Delay cord clamping for at least 30 seconds over clamping immediately when cord clamping cannot be deferred for a full 60-120 seconds. Delay cord clamping with the infant at or below the level of the introitus or at the level of the Cesarean incision. A Show 6 more As per AHA 2020 guidelines, consider delaying cord clamping for > 30 seconds in preterm infants not requiring resuscitation at birth. C Show 2 more As per ERASS 2018 guidelines, delay cord clamping for at least 1 minute at term Cesarean deliveries B and for at least 30 seconds at preterm Cesarean deliveries. B As per WHO 2018 guidelines, delay umbilical cord clamping ( 1 minute after birth) for improved maternal and infant health and nutrition outcomes. A Considerations for delayed cord clamping: As per SOGC 2022 guidelines, recognize that stabilization or resuscitation with an intact cord for longer durations in preterm and term infants is feasible in centers with appropriate experience and equipment. B Show 6 more As per ACOG 2020 guidelines, perform delayed umbilical cord clamping in term infants as it increases Hgb levels at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes. E Show 4 more As per RCOG 2015 guidelines, delay umbilical cord clamping in healthy term infants, as this appears to improve iron stores in infancy. Recognize that jaundice may be more common after delayed umbilical cord clamping but this management is likely to be beneficial as long as phototherapy for jaundice is available. E Show 2 more Umbilical cord milking: As per SOGC 2022 guidelines: Do not perform umbilical cord milking in very preterm infants < 32 weeks due to increased risk for severe intraventricular hemorrhage. D Perform delayed cord clamping instead of umbilical cord milking in preterm and term infants. A As per AHA 2020 guidelines, do not perform cord milking in infants born at < 28 weeks of gestation. D As per RCOG 2015 guidelines, insufficient evidence regarding benefits and risks of the routine use of cord milking which is an alternative to delayed umbilical cord clamping. I Studies 2017 APTS https://web.pathway.md/diseases/rec1UWXAkolzdS9Lm 2/3 6/29/23, 3:47 AM Umbilical cord management Pathway In fetuses from women who were expected to deliver before 30 weeks of gestation, delayed cord clamping was not superior to immediate cord clamping with respect to death or major morbidity at 36 weeks of postmenstrual age. William Tarnow-Mordi et al. N Engl J Med. 2017 Dec 21. References 1. No authors listed. WHO recommendations: Intrapartum care for a positive childbirth experience. WHO. 2018. Open 2. No authors listed. Clamping of the Umbilical Cord and Placental Transfusion Scientific Impact Paper No. 14 . Scientific Impact Paper No. 14. Open 3. Sarah D McDonald, Michael Narvey, William Ehman et al. Guideline No. 424 Umbilical Cord Management in Preterm and Term Infants. J Obstet Gynaecol Can. 2022 Mar;44 3 313 322.e1. Open 4. Khalid Aziz, Henry C Lee, Marilyn B Escobedo et al. Part 5 Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S524 S550. Open 5. Aaron B Caughey, Stephen L Wood, George A Macones et al. Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations Part 2 . Am J Obstet Gynecol. 2018 Dec;219 6 533 544. Open 6. No authors listed. Delayed Umbilical Cord Clamping After Birth: ACOG Committee Opinion Summary, Number 814. Obstet Gynecol. 2020 Dec;136 6 1238 1239. Open https://web.pathway.md/diseases/rec1UWXAkolzdS9Lm 3/3