Placental Transfusion Confusion

Medical professional organizations cannot reach consensus regarding delayed cord clamping and umbilical cord “milking.”

Nearly every relevant professional organization has its own recommendations for placental transfusion techniques known as delayed umbilical cord clamping and milking. But it’s unclear whether additional research will lead to consensus. The American Congress of Obstetricians and Gynecologists and American Academy of Pediatrics say there’s insufficient evidence full-term infants benefit from delaying cord clamping at least 60 seconds to recommend for or against the practice. They do, however, advocate the practice for all preterm births, when feasible.

“I think it is unlikely that ACOG and AAP will change their recommendations until research strongly indicates that the short- and long-term benefits outweigh the potential risks in term babies,” says Carl H. Backes, Jr., MD, neonatologist at Nationwide Children’s Hospital and lead author of two recent studies on placental transfusion in premature infants.

The American College of Nurse-Midwives recommends delayed clamping for all babies and endorses cord milking (quickly stripping the cord toward the baby) in infants requiring resuscitation. The World Health Organization supports delayed clamping regardless of gestational age at delivery, even in certain cases requiring immediate resuscitation — highlighting another point of friction among professional organizations’ guidelines.

“There is very good data that, among preterm infants not requiring active resuscitation, delayed cord clamping or umbilical cord milking will improve outcomes, but there’s not a lot of good data to tell us how to combine resuscitation with delayed cord clamping,” explains Dr. Backes, who also is a principal investigator in the Center for Perinatal Research in The Research Institute. “At least in preterm infants, it sounds like the ideal scenario would be to delay cord clamping and provide active resuscitation at the bedside. But the logistics of that are difficult.”

He knows of several groups working to identify effective methods for delayed clamping when resuscitation is required. But that’s only one step toward resolving the controversy surrounding placental transfusion.

“We still have a lot to learn about subgroups among preterm and term infants who may respond differently to the delay, such as infants born at less than 26 weeks or those with heart disease,” says Dr. Backes, who is finalizing studies on both of these populations.High-quality investigations should shed light on when and how to implement placental transfusion strategies, he says. “Then we have to figure out how to get clinicians from multiple disciplines to translate that evidence-based medicine into clinical practice.”

References:

1. Backes CH, Rivera B, Haque U, Copeland K, Hutchon D, Smith CV.Placental transfusion strategies in extremely preterm infants: The next piece of the puzzle. Journal of Neonatal-Perinatal Medicine. 2014 Jan 1, 7(4):257-67.
2. Backes CH, Rivera BK, Haque U, Bridge JA, Smith CV, et al. Placental transfusion strategies in very preterm neonates: a systematic review and meta-analysis. Obstetrics and Gynecology. 2014 Jul, 124(1):47-56.
3. Committee on Obstetric Practice. Committee Opinion: Timing of umbilical cord clamping after birth. American College of Obstetricians and Gynecologists. 2012 Dec, 543.
4. Division of Standards and Practice Clinical Documents Section. Position statement: Delayed umbilical cord clamping. American College of Nurse-Midwives. 2014 May.
5. World Health Organization. Guideline: Delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes. Geneva, World Health Organization. 2014.