Guidelines on Deferred Cord Clamping and Cord Milking: A Systematic Review

Abstract

CONTEXT: Deferred cord clamping (DCC) saves lives. It reduces extremely preterm infants' mortality by 30%, yet a minority of eligible infants receive it. This may in part be due to lack of awareness or confidence in evidence, or conflicting or vague guidelines.OBJECTIVE: To systematically review clinical practice guidelines and other statements on DCC and cord milking.DATA SOURCES: Ten academic and guideline databases were searched.STUDY SELECTION: Clinical practice guidelines and other statements (position statements and consensus statements) providing at least 1 recommendation on DCC or umbilical cord milking among preterm or term infants were included.DATA EXTRACTION: Data from included statements were extracted by 2 independent reviewers, and discrepancies were resolved through consensus. Guideline quality was appraised with modified Appraisal of Guidelines for Research and Evaluation II and Appraisal of Guidelines for Research and Evaluation Recommendation Excellence tools.RESULTS: Forty-four statements from 35 organizations were included. All endorsed DCC for uncompromised preterm infants, and 11 cautiously stated that cord milking may be considered when DCC is infeasible. Only half (49%) of the recommendations on the optimal duration of DCC were supported by high-quality evidence. Only 8% of statements cited a mortality benefit of DCC for preterm infants.LIMITATIONS: Because systematic reviews of guidelines are relatively novel, there are few tools to inform study execution; however, we used the Appraisal of Guidelines for Research and Evaluation II and the Appraisal of Guidelines for Research and Evaluation Recommendation Excellence to assess quality and were methodologically informed by previous systematic reviews of guidelines.CONCLUSIONS: Statements worldwide clearly encouraged DCC. Their implementability would benefit from noting the preterm mortality benefit of DCC and more granularity.

A hybrid type I, multi-center randomized controlled trial to study the implementation of a method for Sustained cord circulation And VEntilation (the SAVE-method) of late preterm and term neonates: a study protocol

“…The implementation of delayed CC practice varies between countries, and international and national guidelines differ depending on mode of delivery and complications at birth [ 4 ]. Hence, more studies of specific clinical situations and different implementation settings are needed.…”

Umbilical cord clamping and management of the third stage of labor: A telephone-survey describing Swedish midwives’ clinical practice

“…During the last decade, research has demonstrated the benefits for the neonate of delaying CC [18][19][20] , and this finding has led to a change in the strategies for timing of umbilical CC and cutting, in Sweden and several other countries as well 21 . Several barriers for implementation exist, but a multidisciplinary approach is needed for practice to be adopted 22 .…”

Toward greater nuance in delayed cord clamping

“…A statewide California quality improvement (QI) collaborative reported inter-hospital variation in DCC from 0 to 74% and only 29% of newborns overall receiving DCC in 2016 [3]. A proliferation of clinical practice guidelines, which differ in their details and sometimes fail to reflect the most recent evidence, may actually add to uncertainty and reluctance to change existing practice [4].…”