Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants
Full set of recommendations*
WHO recommendations (1)
In summary:
Delayed umbilical cord clamping (not earlier than 1 min after birth) is recommended for improved maternal and infant health and nutrition outcomes.
From 2012 WHO guidelines on basic newborn resuscitation (2):
In newly born term or preterm babies who do not require positive-pressure ventilation, the cord should not be clamped earlier than 1 min after birth.
When newly born term or preterm babies require positive-pressure ventilation, the cord should be clamped and cut to allow effective ventilation to be performed.
Newly born babies who do not breathe spontaneously after thorough drying should be stimulated by rubbing the back 2–3 times before clamping the cord and initiating positive-pressure ventilation.
From 2012 WHO recommendations for the prevention and treatment of postpartum haemorrhage (3):
Late cord clamping (performed approximately 1–3 min after birth) is recommended for all births, while initiating simultaneous essential neonatal care.
Early umbilical cord clamping (less than 1 min after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation.
Remarks
- The evidence base for recommendations on the optimal timing of umbilical cord clamping for the prevention of postpartum haemorrhage includes both vaginal and caesarean births. The WHO guideline development group considered this recommendation to be equally important for caesarean sections.
- Delayed umbilical cord clamping should be performed during the provision of essential neonatal care.
- Recommendations for the optimal timing of umbilical cord clamping apply equally to preterm and term births. The guideline development group considered the benefits of delayed cord clamping for preterm infants to be particularly important.
- Some health professionals providing care for an HIV positive pregnant woman and/or working in high HIV prevalent settings have expressed concern regarding delayed cord clamping as part of the management of the third stage of labour. These professionals are concerned that, during placental separation, a partially detached placenta could be exposed to maternal blood and this could lead to a micro-transfusion of maternal blood to the baby. The evidence shows that the benefits of delaying cord clamping for 1-3 minute outweighs the risks of transmission of HIV. HIV testing should be offered intrapartum, if not already done. WHO recommends that all HIV positive pregnant and breastfeeding women and their infants should receive appropriate antiretroviral (ARV) drugs to prevent mother to child transmission of HIV. Thus, the proven benefits of at least a 1–3 minute delay in clamping the cord outweigh the theoretical, and unproven, harms. Delayed cord clamping is recommended even among women living with HIV or women with unknown HIV status. HIV status should be ascertained at birth, if not already known, and HIV positive women and infants should receive the appropriate ARV drugs.
- Delayed umbilical cord clamping should not be confused with milking of the cord. The terms are not necessarily synonymous (milking refers to physically expressing blood from the umbilical cord). There are various recent studies assessing the effect of cord milking, practised at different times after birth, with a variety of “milking” times, associated with early or delayed cord clamping. These studies need further analysis, as cord milking has been proposed as an alternative to delayed cord clamping, especially for preterm infants.
- The WHO guideline development group considered that the package of active management of the third stage of labour includes a primary intervention: the use of a uterotonic drug. In the context of oxytocin use, controlled cord traction may add a small benefit, while uterine massage may add no benefit for the prevention of postpartum haemorrhage. Early cord clamping is generally contraindicated.
- Clamping “not earlier than one minute” should be understood as the lower limit period supported by published evidence. WHO recommends that the umbilical cord should not be clamped earlier than is necessary for applying cord traction to reduce post-partum haemorrhage and speed expulsion of the placenta (3), which the guideline development group clarified would normally take around 3 min.
- For basic newborn resuscitation, if there is experience in providing effective positive-pressure ventilation without cutting the umbilical cord, ventilation can be initiated before cutting the cord (2).
* This is an extract from the relevant guidelines (1-3). Additional guidance information can be found in these documents.
References
1. WHO. Guideline: Delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes. Geneva, World Health Organization; 2014 (http://www.who.int/nutrition/publications/guidelines/cord_clamping/en/).
2. WHO. Guidelines on basic newborn resuscitation. Geneva, World Health Organization; 2012 (http://www.who.int/maternal_child_adolescent/documents/basic_newborn_resuscitation/en/).
3. WHO. WHO recommendations for the prevention and treatment of postpartum haemorrhage; 2012 (http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548502/en/).