Overview
Definition:
Delayed cord clamping (DCC) involves waiting 30 seconds to 3 minutes or more before clamping the umbilical cord after birth, allowing for placental transfusion
Umbilical cord milking (UCM) is an alternative technique where blood is manually squeezed from the umbilical cord towards the neonate in a series of strokes, typically performed when DCC is not feasible or to achieve a rapid placental transfusion
Both aim to maximize hemoglobin and iron stores in the newborn.
Epidemiology:
The incidence of utilizing DCC or UCM varies significantly by institution and region
International guidelines increasingly recommend DCC for term and preterm infants, with estimates suggesting it is practiced in a substantial proportion of births in developed countries, though full adherence remains a challenge
UCM is often employed in specific scenarios, particularly when immediate cord clamping is necessary for maternal or fetal reasons.
Clinical Significance:
Optimizing placental transfusion through DCC or UCM can lead to increased hemoglobin levels, improved iron status in infancy, reduced risk of neonatal anemia, and potentially better neurodevelopmental outcomes
It is a critical intervention in modern neonatal care, directly impacting infant health and long-term well-being, making it a key area for DNB and NEET SS preparation.
Evidence For Dcc
Benefits Term Infants:
Increased hemoglobin at 24-48 hours of life
Improved iron stores at 3-6 months of age, leading to a reduced incidence of iron deficiency anemia
Lower rates of intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) in preterm infants
Potential for improved motor and cognitive development in later childhood.
Benefits Preterm Infants:
Significant reduction in mortality
Decreased need for blood transfusions
Lower incidence of IVH, NEC, and late sepsis
Improved cardiopulmonary adaptation at birth
Studies consistently show improved iron status and reduced anemia in the first year.
Risks And Contraindications:
Transient increase in polycythemia and hyperbilirubinemia
Increased risk of postpartum hemorrhage (PPH) in mothers if cord is clamped too late and manual removal of placenta is needed
Contraindicated in cases of non-vigorous infant requiring immediate resuscitation, or if the mother has placenta previa or abruption, or cord prolapse.
Evidence For Ucm
Rationale And Technique:
UCM is considered when DCC is not possible or as a rapid alternative
The technique involves milking the cord from the placental end towards the neonate 2-4 times, with each milking lasting 1-2 seconds, transferring approximately 15-30 ml of blood per milking
It aims to achieve a similar or even greater transfusion effect than DCC in a shorter timeframe.
Comparative Studies:
Studies comparing UCM to DCC suggest similar benefits in terms of increased hemoglobin and iron stores
Some studies indicate that UCM may lead to higher hemoglobin concentrations than DCC, possibly due to the more directed transfer of blood
However, data is less extensive than for DCC.
Safety And Considerations:
Generally considered safe when performed correctly
Potential risks include excessive polycythemia or hyperbilirubinemia if performed too vigorously or too many times
It should be avoided in infants requiring immediate resuscitation, or if there are concerns about cord integrity or placental separation.
Comparison Dcc Vs Ucm
Timing And Feasibility:
DCC is a passive waiting period, ideal in uncomplicated vaginal births and stable C-sections
UCM is an active procedure, suitable when immediate clamping is required but placental transfusion is still desired, or when there are concerns about excessive blood volume with prolonged DCC
UCM can be performed more rapidly than waiting for standard DCC durations.
Effectiveness Of Transfusion:
Both aim to maximize placental transfusion
DCC allows gradual physiological transfer
UCM provides a more rapid, manual transfer
Evidence suggests both are effective, with UCM potentially achieving higher initial hemoglobin levels in some instances due to the milking action.
Ideal Scenarios For Each:
DCC is the preferred method in most term and stable preterm infants
UCM is an option for situations where DCC is challenging or contraindicated, such as maternal conditions requiring rapid intervention, or in some preterm infants where immediate stabilization is paramount but placental transfusion is still desired.
Implementation And Practice
Guideline Recommendations:
WHO recommends DCC for all births, delaying cord clamping for at least 1 minute and ideally 3 minutes
ACOG and AAP also support DCC for term and preterm infants
UCM is considered a safe and effective alternative when DCC is not feasible, as per WHO and other guidelines.
Institutional Protocols:
Healthcare institutions should establish clear protocols for DCC and UCM, including training for obstetric and neonatal staff
Protocols should address timing, technique, contraindications, and monitoring of neonates receiving these interventions.
Resident Training:
Pediatric residents must be familiar with the evidence supporting DCC and UCM, understand the techniques, and recognize indications and contraindications
Proficiency in performing UCM correctly is essential for situations where DCC is not feasible, preparing them for diverse clinical scenarios encountered in DNB and NEET SS examinations.
Key Points
Exam Focus:
DCC recommended for all neonates (term and preterm) unless contraindications exist
UCM is an active alternative to DCC when indicated
Both improve iron stores and reduce anemia
UCM involves manual squeezing of the cord towards the neonate.
Clinical Pearls:
In emergencies, UCM can be performed quickly to deliver a significant blood volume
Always assess maternal and fetal stability before deciding on DCC or UCM
Monitor for polycythemia and hyperbilirubinemia post-intervention.
Common Mistakes:
Performing DCC/UCM in contraindicated situations
Inadequate or excessive milking in UCM
Not having clear institutional protocols
Failing to document the intervention and its timing
Overlooking the potential for postpartum hemorrhage with very delayed clamping in mothers needing manual placental removal.