Neonatal Resuscitation

Cord Management for Non-Vigorous Term and Late Preterm Newborns

Last Full Review: ILCOR 2025
Last Update: 2021

An International Liaison Committee on Resuscitation (ILCOR) systematic review in 2021 (Wyckoff et al. 2022, e645; Gomersall et al. 2021, e2020015404) supported deferred cord clamping for 60 seconds or longer as the preferred strategy for improving outcomes in term and late preterm newborns. However, non-vigorous newborns who require immediate assistance were excluded from the review. For this subgroup of newborns, management typically includes immediate umbilical cord clamping followed by moving the infant to a resuscitation area and providing assisted ventilation. A 2025 ILCOR review (Davis et al. 2024; Liley et al. 2025, S165) focuses on cord management strategies designed to improve fetal to neonatal cardiorespiratory transition in term and late preterm infants (34+0 weeks’ gestation or more) who are not vigorous at birth.

The International Liaison Committee on Resuscitation notes that terms and definitions have been revised or updated. The definitions used in the 2025 review (Davis et al. 2024; Liley et al. 2025, S165) are as follows:

• Immediate cord clamping: Performed usually in 15 or fewer seconds without the initiation of respiratory support.
• Early cord clamping: Performed usually in less than 60 seconds without the initiation of respiratory support and may include infants who had immediate cord clamping.
• Deferred cord clamping: Performed usually after 60 or more seconds and before respiratory support.
• Intact cord resuscitation: Includes any time to cord clamping (usually 60 or more seconds) when respiratory support (such as high-flow oxygen, continuous positive airway pressure, positive pressure ventilation) is provided before cord clamping.
• Physiologically based cord clamping: Cord clamping is not based on a specific time but on physiological observations, such as a defined duration of breathing or effective positive pressure ventilation.
• Intact umbilical cord milking: The repeated compression of the umbilical cord from the placental side toward the baby with the connection to the placenta intact.
• Cut umbilical cord milking: The drainage of the umbilical cord by compression from the cut end toward the baby after clamping and cutting a long segment.

 

 

Evidence Summary

A 2025 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Davis et al. 2024; Liley et al. 2025, S165) evaluated evidence in term and late preterm infants (34 weeks’ gestation or more) who were not vigorous at birth for any cord management strategy designed to improve fetal to neonatal cardiorespiratory transition. The potential interventions of interest in the systematic review question included:

• Deferred (delayed/later) cord clamping for any time greater than 60 seconds, before respiratory support (high-flow oxygen [O₂], continuous positive airway pressure (CPAP), intermittent positive pressure ventilation).
• Deferred (delayed/later) cord clamping for any time greater than 60 seconds with concurrent respiratory support (high-flow oxygen, CPAP, intermittent positive pressure ventilation).
• Intact umbilical cord milking.
• Cut cord umbilical cord milking.

 

Interventions were compared with immediate cord clamping without cord milking or initiation of respiratory support at 60 seconds or less, or as defined by the trialist and between-intervention comparisons. Critical outcomes included neonatal mortality and neurodevelopmental impairments at 18 to 24 months.

Of the studies ultimately included, two interventions were identified: intact cord milking and intact cord resuscitation. One cluster randomized crossover study (Katheria et al. 2023, 217.e1) compared intact umbilical cord milking with early cord clamping within 60 seconds of birth in 1730 infants born at 35 weeks’ gestation or more who had poor tone, pallor or lack of breathing despite stimulation in the first 15 seconds after birth. Mortality rates were low (4 per 1,730), with all occurring in the early cord clamping group (RR, 0.11; 95% CI, 0.01–2.03). Moderate certainty evidence from the same randomized control trial (RCT) (Katheria et al. 2023, 217.e1) suggested possible clinical benefit for intact umbilical cord milking on outcomes of moderate to severe hypoxic ischemic encephalopathy (RR, 0.49; 95% CI, 0.25–0.97) and hemoglobin at 24 hours of age. For intact umbilical cord milking, the infant was held at the level of the caesarean incision or, for vaginal births, the mother’s abdomen, while a 20-centimeter length of cord was milked for 2 seconds per time for a total of four times before cord clamping. Early cord clamping was performed within 60 seconds after birth. Findings for additional minor outcomes can be found in the online CoSTR.

For intact cord resuscitation, three studies met inclusion criteria (Andersson et al. 2019, 5; Badurdeen et al. 2022, e1004029; Raina et al. 2023, 54), providing very low-certainty evidence and no clear benefits. In the studies by Andersson et al. (Andersson et al. 2019, 5) and Raina et al. (Raina et al. 2023, 54), respiratory assistance was provided if needed using a T-piece resuscitator or self-inflating bag with the umbilical cord intact for at least 180 seconds before cord clamping. In the study by Badurdeen et al. (Badurdeen et al. 2022, e1004029), umbilical cord clamping was deferred until 2 or more minutes after birth and until 60 or more seconds after change in color of a carbon dioxide detector placed between the face mask and T-piece. For all three RCTs (total of 516 infants), a clinical benefit or harm could not be excluded for the critical outcome of in-hospital mortality (Davis et al. 2024; Liley et al. 2025, S165) encephalopathy. Evidence was downgraded for imprecision and risk of bias due to randomization before birth.

Two small nonrandomized feasibility studies were included in the review narrative but only evidence from the RCTs was used to derive the following ILCOR treatment recommendation (Davis et al. 2024; Liley et al. 2025, S165):

• In term and late preterm infants who remain non-vigorous despite stimulation, intact cord milking is suggested in preference to early cord clamping (weak recommendation, low-certainty evidence).

 

There is currently insufficient evidence to recommend either for or against intact cord resuscitation for term and late preterm infants who are non-vigorous at birth.

The authors of the ILCOR CoSTR (Davis et al. 2024; Liley et al. 2025, S165 note that one observational study (Kc et al. 2021, e001207) that was ultimately excluded (because the intervention was stimulation rather than cord management) reported that tactile stimulation of newborns who were not yet crying while the cord was intact (n=671) was associated with a higher proportion who breathed spontaneously (81% versus 69%, P<0.01), a decrease use of bag-mask ventilation (18% versus 32%, P<0.01) and fewer Apgar scores of 3 or less (8% versus 11%, P<0.01) compared to newborns who underwent cord clamping before stimulation (n=1,892). This demonstrates the importance of tactile stimulation during deferred cord clamping and implies that the previous Red Cross guideline for tactile stimulation to stimulate breathing should apply regardless of the umbilical cord management strategy:

• For newborn infants greater than 32+0 weeks’ gestation with absent, intermittent or shallow respirations immediately after birth, it is reasonable to use tactile stimulation in addition to initial care including drying, stimulation and additional care to maintain temperature. (See Red Cross Guidelines: Neonatal Advanced Life Support: Airway and Ventilation Management, Tactile Stimulation for Resuscitation Immediately After Birth.)

 

Insights and Implications

Although the evidence was limited, the recommendation for intact umbilical cord milking in preference to early cord clamping in infants who remain non-vigorous despite stimulation was considered by ILCOR to be justified by the reduction in moderate or severe hypoxic ischemic encephalopathy and improvement in early hemoglobin and in light of a lack evidence of adverse effects. For all vigorous infants, deferred cord clamping for at least 60 seconds continues to be the recommended cord management strategy at birth.

Preterm Infant Cord Management at Birth

Last Full Review: ILCOR 2021
Last Update: 2024

Placental transfusion of newborns has been shown to decrease mortality in preterm infants (Tarnow-Mordi et al. 2017,  2445) and to improve developmental outcomes in term infants (Andersson et al. 2015, 631). Umbilical cord management at birth impacts the volume of placental transfusion to the newborn and the cardiorespiratory adaptation after birth with the onset of breathing and/or ventilation (Bhatt et al. 2013, 2113; Yao et al. 1969, 871). Deferred, or delayed, clamping of the umbilical cord after the onset of breathing allows placental transfusion via the umbilical vein.

Deferred cord clamping for 60 or more seconds (El-Naggar et al. 2023) after birth is currently recommended for term and late preterm infants (Wyckoff et al. 2021, 229; Yamada et al. 2024, e2023065030; El-Naggar et al. 2024). Preterm infants, however, have a greater risk of mortality and major morbidities than term infants. In 2021, a systematic review (Seidler et al. 2021, e20200575) and Consensus on Science with Treatment Recommendations (CoSTR) (Wyckoff et al. 2021a, 229) by the International Liaison Committee on Resuscitation (ILCOR) suggested deferral of cord clamping for at least 30 seconds for preterm infants born at less than 34+0 weeks’ gestation who do not require immediate resuscitation after birth to improve outcomes. Intact-cord milking was suggested as a reasonable alternative to deferred cord clamping for infants born at 28+0 weeks’ to 33+6 weeks’ gestation who do not require immediate resuscitation after birth. Since this review, additional randomized controlled trials (RCTs) have been published, and data was compiled into a very large individual patient data pairwise meta-analysis and a network meta-analysis: the individual participant data on cord management at preterm birth (iCOMP) study (Seidler et al. 2020, e034595).

 

Evidence Summary

The adolopment process (Schünemann et al. 2017, 101) was used to guide the adaptation of a recent systematic review and network meta-analysis with individual participant data on cord management at preterm birth (Seidler et al. 2023, 2209; Seidler et al. 2023, 2223). The process included development of two Population, Intervention, Control, Outcomes, Study design and Timeframes (PICOSTs) questions and CoSTR (El-Naggar et al. 2024; Greif et al. 2024) statements. The first PICOST used an individual participant data pairwise meta-analysis of preterm infants born at less than 37+0 weeks’ gestation and their mothers to compare deferred cord clamping or umbilical cord milking with immediate (early) cord clamping. Between-interventions (deferred cord clamping versus umbilical cord milking) were also compared. Multiple infant and maternal outcomes were selected for assessment, including mortality before hospital discharge, major inpatient morbidities and maternal complications.

Definitions

Definitions used in this review included:

• Deferred cord clamping: Cord clamping without milking, with or without respiratory support, at more than 15 seconds after birth
• Umbilical cord milking:
  • Repeated compression of the cord from the placental side toward the infant, with the connection to the placenta intact, immediately after birth (intact-cord milking), or
  • Drainage of a long segment of the cord by compression from the cut end toward the infant with or without respiratory support after clamping and cutting of the long segment after birth (cut-cord milking)
  • NOTE: The individual participant data pairwise meta-analysis did not distinguish between the two methods of milking (intact cord and cut cord). The CoSTR authors noted that in most trials, the intact cord was milked 2 to 4 times, while a few trials milked the cut cord once (El-Naggar et al. 2024; Greif et al. 2024).

• Immediate cord clamping: Cord clamping, without milking or initiation of respiratory support, at 15 or less seconds after the birth of the infant or as defined by the trialist

 

The reader is encouraged to read the full online systematic review and CoSTR for the methodological details of this complex and comprehensive analysis (Seidler et al. 2023, 2209; Seidler et al. 2023, 2223; El-Naggar et al. 2024; Greif et al. 2024).

The following is a summary of the findings.

PICOST/CoSTR #1

For deferred cord clamping compared with immediate cord clamping, the individual participant data pairwise meta-analysis included 3292 infants from 21 eligible studies. The median gestational age at birth was 29 (IQR, 27 to 33) weeks. The deferred cord clamping interval ranged between 30 to 180 or more seconds while immediate cord clamping was specified by most trials as within 10 seconds.

Key results included (Seidler et al. 2023, 2209; El-Naggar et al. 2024; Greif et al. 2024):

• A reduction in mortality before hospital discharge with deferred cord clamping compared with immediate cord clamping (OR, 0.68; 95% CI, 0.51–0.91; risk difference, 25 fewer infants died per 1000 [95% CI, 38 to 7 fewer infants] with deferred umbilical cord clamping).
• Fewer red cell transfusions and higher hemoglobin concentrations in infants less than 32 weeks’ gestation with deferred cord clamping compared with immediate cord clamping.
• There was a slightly greater risk of developing hypothermia by admission with deferred cord clamping for infants less than 32 weeks’ gestation (OR 1.28, 95% CI, 1.06–1.56; 62 more infants per 1000 were hypothermic on admission [95% CI, 14 more to 111 more]).

 

For umbilical cord milking compared with immediate cord clamping, the individual participant data pairwise meta-analysis included 1565 infants from 18 trials, with a median gestational age of 29 weeks. Techniques for cord milking varied between trials. For preterm infants less than 37+0 weeks’ gestation, there was not a significant reduction in mortality before hospital discharge with umbilical cord milking compared with immediate cord clamping (OR 0.73, 95% CI, 0.44–1.20; 14 fewer infants died per 1000 [95% CI, 30 fewer to 10 more/1000]) (Seidler et al. 2023, 2209; Seidler et al. 2023, 2223; El-Naggar et al. 2024; Greif et al. 2024). Hemoglobin levels were marginally higher within the first 24 hours after birth with umbilical cord milking in infants less than 32 weeks’ gestation, and there was a reduced need for red blood cell transfusions.

For umbilical cord milking compared with deferred cord clamping, the individual participant data pairwise meta-analysis included 1655 infants from 15 identified trials with a median gestational age at birth of 30 weeks. Time to cord clamping in the deferred cord clamping group ranged from 30 to 120 seconds. For preterm infants less than 37+0 weeks’ gestation, a significant reduction in mortality before hospital discharge was not shown with umbilical cord milking compared with deferred cord clamping (OR, 0.95; 95% CI, 0.59–1.53) (Seidler et al. 2023, 2209; Seidler et al. 2023, 2223; El-Naggar et al. 2024; Greif et al. 2024). However, among preterm infants less than 32 weeks’ gestation, there appeared to be a higher risk of severe intraventricular hemorrhage following intact umbilical cord milking (OR 2.20, 95% CI, 1.13–4.31; Number needed to harm, 24 [95% CI, 9 to 200 infants more have severe intraventricular hemorrhage after umbilical cord milking compared with delayed cord clamping]). One RCT was stopped early due to increased rates of severe intraventricular hemorrhage in preterm infants less than 28 weeks’ gestation (Katheria et al. 2019, 1877).

PICOST/CoSTR #2

The second PICOST used an individual participant data network meta-analysis of preterm infants born at less than 37+0 weeks’ gestation and their mothers to compare different intervals of cord clamping and intact-cord milking immediately after birth.

For this meta-analysis, 47 eligible studies were identified with 6094 infants and a median gestational age at birth of 29.6 weeks. The number of trials for each comparison varied (Seidler et al. 2023, 2223). Key findings included (El-Naggar et al. 2024; Greif et al. 2024):

• For the outcome of death before discharge, compared with immediate cord clamping, long deferral (120 or more seconds) reduced death (OR 0.31; 95% credible intervals 0.11 to 0.80, number needed to treat to benefit, 18; 95% credible intervals 4 to 143).
• For the outcome of receiving red cell transfusions, compared with immediate cord clamping, all medium and short deferral of cord clamping and intact-cord milking reduced the receipt of red cell transfusions by about 50%. There was insufficient evidence for long deferral compared with immediate cord clamping.
• The network meta-analysis ranked the probabilities of different cord management interventions to prevent death before discharge (Seidler et al. 2023, 2223). Long deferral of cord clamping had a 91% probability of being the highest-ranked treatment to prevent death before discharge. Immediate clamping had less than a 1% probability of being the best treatment to prevent death before discharge, and a 53% probability of being the worst treatment. Medium-length deferral and intact-cord milking had a high probability of being second or third best treatments to prevent death before discharge.

 

New ILCOR treatment recommendations include (El-Naggar et al. 2024; Greif et al. 2024):

• A strong recommendation based on moderate-certainty evidence for deferring clamping of the umbilical cord for at least 60 seconds in preterm infants born at less than 37 weeks’ gestation who are deemed to not require immediate resuscitation at birth.
• A conditional recommendation that suggests umbilical cord milking as a reasonable alternative to immediate cord clamping to improve infant hematological outcomes in preterm infants born at 28+0 weeks’ to 36+6 weeks’ gestation who do not receive deferred cord clamping. Individual maternal and infant circumstances should be taken into account.
• A weak recommendation based on low-certainty evidence that suggests against intact-cord milking for infants born at less than 28 weeks’ gestation. There is insufficient evidence to make a recommendation regarding cut-cord milking in this gestational age group.
• There was insufficient evidence to make a recommendation with respect to cord management in preterm infants born at less than 37 weeks’ gestation who are deemed to require immediate resuscitation at birth.
• There is insufficient evidence to make recommendations on cord management for maternal, fetal or placental conditions that were considered exclusion criteria in many studies (monochorionic fetuses, congenital anomalies, placental abnormalities, alloimmunization and/or fetal anemia, fetal compromise, maternal illness). In these situations, ILCOR makes a weak recommendation suggesting individualized decisions based on the severity of the condition, and assessment of maternal and neonatal risk.
• A good practice statement was made that whenever circumstances allow, the plan for umbilical cord management should be discussed between maternity and neonatal providers and parents before delivery, and should take into account individual maternal and infant circumstances.

 

Insights and Implications

This comprehensive systematic review with meta-analysis was reviewed by the American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2024). The Red Cross guidelines are informed by the ILCOR review and the American Red Cross Scientific Advisory Council considerations of the treatment recommendations. The evidence for reduced mortality after deferred cord clamping compared with immediate cord clamping was considered high certainty, with reduced mortality across multiple subgroups, including:

• Gestational age at birth
• Mode of birth
• Multiple birth
• Sex 
• Year of the trial 
• Perinatal mortality

 

The specific 60-second minimum interval for deferred cord clamping was recommended by ILCOR, because that threshold defined 80% of infants who received deferred clamping in the combined studies (El-Naggar et al. 2024; Greif et al. 2024). The ILCOR CoSTR notes that there were fewer infants and trials providing evidence for medium (60 to 119 seconds) or long (more than 120 seconds) deferral of cord clamping, and that medium or long delay may be justified for infants who are coping well without resuscitation, or where appropriate newborn stabilization can be provided before umbilical cord clamping.

The recommendation to consider umbilical cord milking as an alternative to immediate cord clamping in infants born at 28+0 to 36+6 weeks’ gestation was based on (El-Naggar et al. 2024; Greif et al. 2024): 

• Evidence for reduced red cell transfusion and higher hemoglobin after umbilical cord milking compared with immediate cord clamping in infants both less than 32 weeks’ gestation and 32 or more weeks’ gestation.
• Low-certainty evidence that umbilical cord milking may not reduce death before discharge compared with immediate cord clamping. 

 

In addition, no evidence was identified for adverse effects in preterm infants less than 37 weeks’ gestation or their mothers after umbilical cord milking compared with immediate cord clamping. There was no evidence for adverse effects after umbilical cord milking compared with deferred cord clamping in preterm infants born at 28+0 to 36+6 weeks’ gestation. 

The suggestion against intact-cord milking in infants less than 28 weeks’ gestation was based on low-certainty evidence for increased severe intraventricular hemorrhage after intact-cord milking compared with deferred cord clamping (El-Naggar et al. 2024; Greif et al. 2024). Evidence informing this guideline was from a randomized clinical trial of preterm infants (born at 23 weeks’ to 32 weeks’ gestation) that sought to determine whether the rates of death or severe intraventricular hemorrhage differ among preterm infants receiving placental transfusion with umbilical cord milking versus delayed umbilical cord clamping (Katheria et al. 2019, 1877). The trial was terminated early due to a signal for harm, with an imbalance in the number of severe intraventricular hemorrhage events by study group. A post-hoc comparison was performed. There were 474 infants enrolled who completed the trial. No statistically significant difference was found for death, but severe intraventricular hemorrhage was significantly higher in the umbilical cord milking group than in the delayed umbilical cord clamping group (8% [20/236] versus 3% [8/238], respectively; risk difference, 5% [95% CI, 1%–9%]; P=0.02). When analyzed by gestational age status, among infants born at 23 to 27 weeks’ gestation, a significant difference was seen with severe intraventricular hemorrhage in more infants with umbilical cord milking than with delayed umbilical cord clamping (22% [20/93] versus 6% [5/89], respectively; risk difference, 16% [95% CI, 6%–26%];P=0.002) (Katheria et al. 2019, 1877).

Future studies that are underway will address the provision of some resuscitation measures while cord clamping is deferred. Studies are needed to determine long-term neurodevelopmental and health outcomes following the various cord management strategies used, and measures that may be taken to prevent hypothermia during deferred cord clamping.

Term Infant Cord Management at Birth

Last Full Review: ILCOR 2021

How the umbilical cord is managed at birth can potentially impact a newborn’s initial cardiovascular transition with the onset of breathing, as well as the volume of placental transfusion to the infant, with implications for development of iron deficiency anemia. Research into cord management has focused on immediate cord clamping, delayed cord clamping for up to 60 seconds or more, clamping with the onset of respirations, and milking or stripping of the intact or cut cord. Which cord management strategy is currently supported by the literature?

 

Evidence Summary

Red Cross guidelines are informed by a 2021 International Liaison Committee on Resuscitation (ILCOR) systematic review (Gomersall et al. 2021) and Consensus on Science with Treatment Recommendations (CoSTR) (El-Naggar et al. 2021) that sought to evaluate the use of delayed cord clamping for 30 or more seconds, intact cord milking and cut cord milking in term and late preterm infants (34+0 week’s or more gestation) compared with:

• Early clamping of the cord (less than 30 seconds after birth) without cord milking or initiation of respiratory support and compared to each of the above interventions.
• Between-intervention comparisons.
• Delayed cord clamping at less than 60 seconds compared with 60 seconds or greater.
• Delayed cord clamping based on time since birth compared with physiologic approach to cord clamping (until cessation of pulsation or based on vital signs monitoring/initiation of breathing).

 

Primary outcomes included survival without moderate to severe neurodevelopmental impairment in early childhood, anemia by 4 to 6 months after delivery or maternal postpartum hemorrhage (estimated blood loss of greater than or equal to 500 ml). Secondary outcomes included neonatal mortality, moderate to severe hypoxic ischemic encephalopathy, resuscitation and numerous others described in the online CoSTR publication (El-Naggar et al. 2021).

For delayed cord clamping at 30 or more seconds compared with early cord clamping at less than 30 seconds after birth, very low-certainty evidence from four trials including 537 infants evaluated the critical outcome of neonatal mortality (Gomersall et al. 2021). Meta-analysis was not able to demonstrate an impact on neonatal mortality (RR, 2.54; 95% CI, 0.50–12.74), the need for resuscitation (RR, 5.08; 95% CI, 0.25–103.58) or admission to the neonatal intensive care unit (NICU) (RR, 1.16; 95% CI, 0.69–1.95). The review noted that compared to early cord clamping, delayed cord clamping greater than or equal to 30 seconds may improve hematologic measures within 24 hours after birth and 7 days after birth but may make little to no difference to maternal postpartum hemorrhage greater than or equal to 500 ml (Gomersall et al. 2021).

A single study reported on the comparison of intact cord milking compared with early cord clamping, reporting no effect from intact cord milking on admission to the NICU, clinical jaundice or exchange transfusion. Intact cord milking in this study may improve hemoglobin and hematocrit values within the first 7 days after birth compared with early cord clamping (MD, 2.20; 95% CI, 0.48–3.92; and MD, 7.50; 95% CI, 2.30–12.70, respectively) (Gomersall et al. 2021).

For cut cord milking with early cord clamping, a single study was included; no impact of cut cord milking was shown for NICU admission, neonatal mortality or hyperbilirubinemia requiring phototherapy. Cut cord milking compared with early cord clamping was reported to possibly improve hematologic measures at 24 and 72 hours after birth (Gomersall et al. 2021).

For intact cord milking versus delayed cord clamping 30 or more seconds, a single study with 388 infants was included; no impact was shown for neonatal mortality (Gomersall et al. 2021).

For cut cord milking versus delayed cord clamping, no differences were observed in neonatal mortality (one study, 300 infants), NICU admission (one study, 200 infants) or phototherapy for hyperbilirubinemia (two studies, 500 infants). Lower hematologic measures were seen at 24 hours and 7 days after birth (two studies, 500 infants) with delayed cord clamping compared with cut cord milking (Gomersall et al. 2021).

For delayed cord clamping 60 or more seconds compared with less than 60 seconds, little or no difference was shown for neonatal mortality (one trial, 231 infants), resuscitation (one trial, 60 infants), NICU admission (two studies, 291 infants), moderate-to-severe hypoxic ischemic encephalopathy or respiratory support (one study, 60 infants) (Gomersall et al. 2021).

The systematic review concludes that delayed cord clamping or cord milking increases hemoglobin and hematocrit immediately after birth in infants at 34 or more week’s gestation when compared with early cord clamping (Gomersall et al. 2021). A weak recommendation by ILCOR suggests delayed clamping of the cord at 60 or more seconds for term and late preterm infants born at 34 or more week’s gestation who are vigorous or deemed not to require immediate resuscitation at birth (Wyckoff et al. 2021a; Wyckoff et al. 2021b; El-Naggar et al. 2021).

Insights and Implications

This comprehensive systematic review with meta-analysis was reviewed by the American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2024). The Red Cross guidelines are informed by the ILCOR review and the American Red Cross Scientific Advisory Council considerations of the treatment recommendations. The evidence for reduced mortality after deferred cord clamping compared with immediate cord clamping was considered high certainty, with reduced mortality across multiple subgroups, including: Definitions for delayed clamping varied among the included studies from 30 seconds to more than 3 minutes, while early clamping ranged from within 5 seconds to within 30 seconds. While there may had been some overlap between the early and delayed groups, most of the included studies for this review that compared delayed cord clamping with early cord clamping used a delay of 60 or more seconds.

• Gestational age at birth 

• Mode of birth 

• Multiple birth 

• Sex  

• Year of the trial  

• Perinatal mortality

 

The specific 60-second minimum interval for deferred cord clamping was recommended by ILCOR, because that threshold defined 80% of infants who received deferred clamping in the combined studies (El-Naggar et al. 2024; Greif et al. 2024). The ILCOR CoSTR notes that there were fewer infants and trials providing evidence for medium (60 to 119 seconds) or long (more than 120 seconds) deferral of cord clamping, and that medium or long delay may be justified for infants who are coping well without resuscitation, or where appropriate newborn stabilization can be provided before umbilical cord clamping.

The recommendation to consider umbilical cord milking as an alternative to immediate cord clamping in infants born at 28+0 to 36+6 weeks’ gestation was based on (El-Naggar et al. 2024; Greif et al. 2024):

• Evidence for reduced red cell transfusion and higher hemoglobin after umbilical cord milking compared with immediate cord clamping in infants both less than 32 weeks’ gestation and 32 or more weeks’ gestation.
• Low-certainty evidence that umbilical cord milking may not reduce death before discharge compared with immediate cord clamping.

 

In addition, no evidence was identified for adverse effects in preterm infants less than 37 weeks’ gestation or their mothers after umbilical cord milking compared with immediate cord clamping. There was no evidence for adverse effects after umbilical cord milking compared with deferred cord clamping in preterm infants born at 28+0 to 36+6 weeks’ gestation.

The suggestion against intact-cord milking in infants less than 28 weeks’ gestation was based on low-certainty evidence for increased severe intraventricular hemorrhage after intact-cord milking compared with deferred cord clamping (El-Naggar et al. 2024; Greif et al. 2024). Evidence informing this guideline was from a randomized clinical trial of preterm infants (born at 23 weeks’ to 32 weeks’ gestation) that sought to determine whether the rates of death or severe intraventricular hemorrhage differ among preterm infants receiving placental transfusion with umbilical cord milking versus delayed umbilical cord clamping (Katheria et al. 2019, 1877). The trial was terminated early due to a signal for harm, with an imbalance in the number of severe intraventricular hemorrhage events by study group. A post-hoc comparison was performed. There were 474 infants enrolled who completed the trial. No statistically significant difference was found for death, but severe intraventricular hemorrhage was significantly higher in the umbilical cord milking group than in the delayed umbilical cord clamping group (8% [20/236] versus 3% [8/238], respectively; risk difference, 5% [95% CI, 1%–9%]; P=0.02). When analyzed by gestational age status, among infants born at 23 to 27 weeks’ gestation, a significant difference was seen with severe intraventricular hemorrhage in more infants with umbilical cord milking than with delayed umbilical cord clamping (22% [20/93] versus 6% [5/89], respectively; risk difference, 16% [95% CI, 6%–26%];P=0.002) (Katheria et al. 2019, 1877).

Future studies that are underway will address the provision of some resuscitation measures while cord clamping is deferred. Studies are needed to determine long-term neurodevelopmental and health outcomes following the various cord management strategies used, and measures that may be taken to prevent hypothermia during deferred cord clamping

 

Family Presence During Neonatal Resuscitation

Last Full Review: ILCOR 2021

Many hospitals now have policies and protocols for allowing family presence during cardiopulmonary resuscitation. At birth, the mother is always present, and other family members are frequently present. What evidence supports policies and protocols that allow family presence during the resuscitation of children and infants?

 

Evidence Summary

The Red Cross guidelines are informed by a systematic review (Dainty et al. 2021b, 20) and Consensus on Science with Treatment Recommendations (CoSTR) (Wyckoff et al. 2021a; Wyckoff et al. 2021b; Dainty et al. 2021a) by the International Liaison Committee on Resuscitation (ILCOR) that sought to evaluate published evidence related to family presence during pediatric and neonatal resuscitation in any setting, compared with no family presence during resuscitation. Outcomes included short- and long-term patient outcomes, short- and long-term family-centered outcomes (including perception of the resuscitation), and healthcare provider-centered outcomes (such as perception of the resuscitation and psychological stress). Thirty-six studies were included for review, including seven involving family presence during neonatal resuscitation, with all eligible studies being either a survey design or an interview design, or a combination of both survey and interview designs (Dainty et al. 2021b, 20). Meta-analysis was not possible, and a narrative review was completed. Included studies focused on parental or family opinion of being present or absent during their child’s resuscitation, and on healthcare provider experience or opinion of family presence during resuscitation.

Findings from studies of parental or family opinion of their presence during resuscitation reflect opinions that their presence during the resuscitation experience was very helpful, brought their child comfort and helped them with adjusting to the loss of their child (Dainty et al. 2021b, 20). Prominent themes included the parents’ desire to be present and to understand what was happening, a need for physical contact with their child, and that their presence helped them to know that all had been done for their child. In over 80% of the included studies measuring hypothetical opinion of parents/families, parents believed it should be their decision whether to be present or not for the resuscitation of their child (Dainty et al. 2021b, 20).

Results of studies including healthcare providers with experience having parental/family present during resuscitation were mixed. The overall agreement with family presence was higher among clinically senior healthcare providers and those experienced with family presence. Overall, agreement was found to range from 85% disagreement to greater than 60% acceptance with family presence during resuscitation. Surveys of healthcare providers who disagreed with family presence described concern for psychological trauma for the parents, risk of interference with medical management, and potential stress on the care team, such as anxiety related to performance (Dainty et al. 2021b, 20).

Studies specifically related to family presence during immediate neonatal resuscitation were limited to six qualitative and one survey study (Dainty et al. 2021b, 20). The focus of the papers was on the experience of fathers during their infant’s resuscitation, the experience of both parents, provider opinion, and one paper focused on both parent and provider opinions. In summary, the studies found: (Dainty et al. 2021b, 20)

• A father’s experience is unique. At the time of the resuscitation, fathers/partners focus on their partner.
• Although parents reported reservations about the emotional toll of their presence during resuscitation, they felt that their presence provided reassurance and the opportunity to be involved and to communicate.
• Education and training are needed for healthcare and nonhealthcare providers assigned to support family presence during resuscitation.
• Parental presence at birth was described as intense and ranged from desperation to immediately see their baby to the opposite end of the spectrum with fear of observing a situation involving their baby that they would prefer to have avoided.

 

The systematic review concludes that parents wish to be offered the opportunity to be present during resuscitation of their child, but perspectives on family presence vary greatly among healthcare providers (Dainty et al. 2021b, 20). The ILCOR treatment recommendation suggests it is reasonable for mothers/father/partners to be present during the resuscitation of neonates where circumstances, facilities and parental inclination allow (weak recommendation based on very low-certainty evidence) (Wyckoff et al. 2021a; Wyckoff et al. 2021b; Dainty et al. 2021a).

Insights and Implications

While this review offers parental and healthcare provider perspectives on the topic of family presence during resuscitation, most of the included studies were surveys, using investigator-designed tools. Well-designed comparative studies are needed to measure the impact of family presence on patient-, family- or provider- centered outcomes. In addition, the included studies were conducted in multiple countries without consideration for cultural differences regarding family presence during resuscitation. Aspects that may influence parental and healthcare provider acceptance need further research, such as the impact of having trained support staff as part of an organized approach to family presence. Parents from some cultures may not feel comfortable with being present during resuscitation. In practice, parental presence, if offered, needs to be the choice or personal preference of the parent.

Duration of Resuscitation at Birth

Posted May 22, 2023; Last Reviewed November 17, 2020

In newborn infants presenting with at least 10 minutes of asystole, bradycardia (less than 60 beats per minute) or pulseless electrical activity after birth for which CPR is indicated, does ongoing CPR for incremental time intervals beyond 10 minutes after birth compared with CPR discontinued at 10 minutes after birth change survival or neurodevelopmental outcomes?

Evidence Summary

An ILCOR systematic review (Foglia et al. 2020) and CoSTR (Wyckoff et al. 2020, S185) evaluated if, in newborn infants presenting with at least 10 minutes of asystole, bradycardia (heart rate less than 60 beats per minute) or pulseless electrical activity after birth for which CPR is indicated, continuing CPR for incremental time intervals beyond 10 minutes after birth compared with discontinuing CPR at 10 minutes after birth changes survival or long-term neurodevelopmental outcomes. Evidence included was from observational studies, including retrospective record reviews, and of very low certainty due to risk of bias and inconsistency.

Outcomes were reported in 16 identified studies with 579 newborns, with individual studies reporting 2% to 100% of infants surviving to last follow-up (hospital discharge through 12 years) (Foglia et al. 2020). Among 579 newborns reported across studies, 237 (40%) survived to last follow-up (Foglia et al. 2020).

Neurodevelopmental outcomes among survivors were assessed in 13 observational studies, including 277 infants. Of these infants, 30 (10.8%) survived without moderate or severe neurodevelopmental impairment (Foglia et al. 2020). The reviewers concluded that failure to achieve ROSC in newborns after 10 to 20 minutes of intensive resuscitation is associated with a high risk of mortality and moderate to severe neurodevelopmental impairment among survivors, but there is no evidence that any specific duration of resuscitation predicts mortality or moderate-severe neurodevelopmental impairment among survivors (Wyckoff et al. 2020, S185).

If a newborn infant requires ongoing CPR after birth despite completing all the recommended steps of resuscitation and excluding reversible causes, ILCOR suggests initiating discussion of discontinuing resuscitative efforts with the clinical team and family (Wyckoff et al. 2020, S185). A reasonable time frame for this change in goals of care is around 20 minutes after birth (Wyckoff et al. 2020, S185).

 

Insights and Implications

The reviewers recognized the need to balance the risk of ceasing resuscitation too early, when ROSC and long-term survival may be achievable, and continuing resuscitation for too long, when ROSC may occur, but survival is associated with a high risk of severe neurologic injury. The review discussed the number of survivors without moderate or severe neurodevelopmental impairment after 10 minutes or more of resuscitation and case series of favorable outcomes among newborn infants with Apgar scores of 0 to 1 at 10 minutes after birth who achieved ROSC and received therapeutic hypothermia (Wyckoff et al. 2020, S185).