A physiologic approach to cord clamping: Clinical issues

Susan Niermeyer, Susan Niermeyer

Abstract

Background: Recent experimental physiology data and a large, population-based observational study have changed umbilical cord clamping from a strictly time-based construct to a more complex equilibrium involving circulatory changes and the onset of respirations in the newly born infant. However, available evidence is not yet sufficient to optimize the management of umbilical cord clamping.

Findings: Current guidelines vary in their recommendations and lack advice for clinicians who face practical dilemmas in the delivery room. This review examines the evidence around physiological outcomes of delayed cord clamping and cord milking vs. immediate cord clamping. Gaps in the existing evidence are highlighted, including the optimal time to clamp the cord and the interventions that should be performed before clamping in infants who fail to establish spontaneous respirations or are severely asphyxiated, as well as those who breathe spontaneously.

Conclusion: Behavioral and technological changes informed by further research are needed to promote adoption and safe practice of physiologic cord clamping.

Keywords: Infant, Newborn; Infant, Premature; Umbilical cord, Placental transfusion, Resuscitation, Respiration.

Figures

Fig. 1
Fig. 1
Schematic of the fetal circulation (http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/SymptomsDiagnosisofCongenitalHeartDefects/Fetal-Circulation_UCM_315674_Article.jsp)
Fig. 2
Fig. 2
Various lines of evidence (a residual placental blood volume, b umbilical blood flow by dye dilution, c infant weight) demonstrating continuation of umbilical blood flow for several minutes after birth (permission requested) [57, 18, 17]
Fig. 3
Fig. 3
Change in appearance of the umbilical cord from birth, to 12 and 23 min after birth, with umbilical cord intact and completion of third stage of labor at 30 min (appleblossomfamilies.com, Morag Hastings, photographer)
Fig. 4
Fig. 4
Platform for resuscitation at the beside with umbilical cord intact (LifeStart, Inditherm plc, Rotherham, United Kingdom)

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