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UMBILICAL CORD MILKING

INTRODUCTION
1949,McCauslandetal surveyedmembersoftheAmericanBoardofObstetricsand
Gynecologyandreportednouniformityofpracticeintheirmanagementofumbilicalcord
andplacentalblood.Thebenefitsofdelayedcordclamping(DCC)andotherstrategiesto
influenceplacentaltransfusionatbirthhavebeenunderinvestigationfordecades. Recently,
interestintheevidentlyoldproceduresoftransferringresidualbloodfromtheplacentatothe
infantbymeansofDCCorumbilicalcordmilking(UCM)hasshownaresurgence.However,
practiceamongobstetriciansvaries7decadeslater.1
Recentlythe2012ACOGguidelinesrecommendeddelayedcordclamping(DCC)for
at least 30 seconds and up to one minute in preterm infants. Despite the evidence and
recommendationsforDCC,thereisstillreluctancebytheneonatal/obstetricalcommunityto
adopt this therapy because of possible conflict with immediate newborn resuscitation.
Umbilical cord milking (UCM), in which the unclamped umbilical cord is immediately
milked and clamped, results in rapid blood transfer from the placenta to the newborn
allowingresuscitationoftheprematureinfanttoproceedwithoutdelay. 2This procedure can
be performed within 20 seconds.6 A recent meta-analysis of 7 randomized controlled trials of
UCM in infants delivered at ,33 weeks demonstrated that infants who undergo UCM have
higher hemoglobin (Hb) and a lower risk for oxygen requirement at 36 weeks and IVH of all
grades compared with those who undergo immediate cord clamping (ICC).3
Thestrippingofbloodfromtheumbilicalcord,orUCM,wasponderedforyearsand
suspectedtobebeneficial.Nevertheless,methodologiclimitationsofolderstudieshindered
theadoptionofUCMasastandardofcare.Amorerecentseriesofstudiesassessedthesafety
andefficacyofUCM.ThekeydifferencebetweenDCCandUCMisthemechanismofcord
bloodtransfertotheinfant.InDCC,apassivetransferofadditionalbloodvolumeoccursata
slowrate,mostlybyuterinecontractions,whereasinUCManactivetransferofadditional
bloodvolumeoccursatarapidrateandwithinashorttime,whichmayormaynotbe
beneficialtoneonates,especiallypretermneonates.1

UMBILICALCORDMILKING
Afterbirth,thetimingofcordclampingmayhaveasubstantialimpactontheamountof
bloodtransfusedtothenewbornfromtheplacenta.Duringthefirst5to15safterdelivery,
bloodvolumeincreasesby5to15mlkg 1 asaresultofuterinecontractions.Thisearly
placental transfusion does not occur if the cordis clamped immediately after birth orif
uterinecontractionsdonotoccur.Inpretermneonates,randomizedtrialsandmetaanalyses
haveshownthatdelayingcordclampingforatleast30scomparedwithimmediatecord
clampingresultsinincreasedcirculatingbloodvolumeinthefirst24hoflife,andalower
incidence of red blood cell transfusion, necrotizing enterocolitis and intraventricular
hemorrhage.4
Despitetheseadvantages,adelayincordclampingof30sormoremaytheoretically
interfere with neonatal resuscitation and potentially increase the risk of neonatal
hyperbilirubinemia. An alternative method, active placental transfusion (milking the
umbilicalcordtowardthebabybeforeclamping),shouldtakelessthan5sandtherefore
shouldnotinterferewithneonatalresuscitation.Onepublishedrandomizedcontrolledtrial
hascompareddelayingcordclampingfor30stocordmilkinginpreterminfantsandfound
thatthetwointerventionsresultedinasimilaramountofplacentofetalbloodtransfusion.A
recentstudyofcordmilkingcomparedwithimmediateclampinginterminfantsdeliveredby
cesareansectionshowedanincreaseinhematocritat36to48hofage.Althoughsome
practitionershaveadoptedthispracticeofactivemilkingoftheumbilicalcordinpreterm
deliveries,thereisapaucityofdatatosupportthispractice.4

UmbilicalCordMilkinginPretermInfants
ArecentlypublishedstudycomparedUCMwithDCC(n=58)ininfantsdeliveredat
33weeksgestationalage.AlthoughnomajorclinicaldifferenceswerefoundbetweenUCM
andDCC,thistrialdidnotanalyzeanyoutcomesbymodeofdelivery.Todatetherehave
beennotrialscomparingUCMandDCCatcesareandelivery(CD).Giventhatupto90%of
preterminfants aredeliveredbyCD,thereis acriticalneedtodeterminewhichtherapy
shouldbegiventopreterminfants.3
AsystematicreviewandmetaanalysisoftheefficacyandsafetyofUCMinfullterm
andpretermneonatesthatheldbyHeidiAlWassiaandPrakeshS.Shahfoundheterogeneity
inthemethodofactualimplementationofUCMbetweenstudies.IninfantswithaGAofless
than33weeks,UCMwasnotassociatedwithadifferenceintheprimaryoutcomeoftherisk
formortalitybeforedischarge;however,UCMwasassociatedwithhigherinitialhemoglobin
values,alowerriskforoxygenrequirementatapostmenstrualageof36weeks,andalower
riskforIVHofallgrades.Theseimprovementsdidnottranslateintoareductionintheneed
forbloodtransfusionorintheriskforsevereIVHorperiventricularleukomalacia.1

HeartRate
AccordingtotheNeonatalResuscitationProgramguidelines,heartrateisthemost
importantindicatorofinfantwellbeingduringneonatalresuscitation.In1962,Bradyetal
demonstrated that afterearlycord clampingthere was a marked bradycardia inthe term
infants.Dawsonetal.describedamedianheartrateof100bpmatoneminuteoflifeinterm
andpretermneonates.Bhattetaldemonstrateda50%dropinpulmonarybloodflowandan
abrupt40%dropinheartrate(duetocessationofumbilicalvenousflowfromtheplacenta)in
anesthetizedfetallambsreceivingimmediatecordclamping(ICC).2
ThebenefitsofUCMonHRandSpO2appeartobemostsignificantinthefirstfew
minutesoflife.Inananimalmodelusingpretermlambs,Bhattetal.demonstratedthatICC
leads to bradycardia until ventilation was established, but lambs that had delayed cord
clamping(DCC)didnothavebradycardia.Inaddition,lambswithICChadarapidrisein
carotidarterypressure,carotidarterialbloodflow,andpulmonarybloodpressurestartingat4
beatsafterclampingandcontinuingfor30seconds,whichwasfollowedbyadecreaseinto
belowbaselineby90secondsafterclampingthecord.ThelambswithDCCuntilventilation
wasestablisheddidnothavesignificantchangesincarotidarterypressure,carotidartery
bloodflow,orpulmonaryarterypressureafterclampingtheumbilicalcord.UCMoffersan
alternativetoDCCbecauseUCMdoesnotdelayresuscitation.2

Plasentaltransfusionandoxygendelivery
Placental transfusion has shown to be beneficial to the preterm infant. A recent
CochraneReviewdemonstratedthatdelayingumbilicalcordclampingforatleast30to120
seconds in preterm infants decreased the need for red blood cell transfusion, and
intraventricularhemorrhage.2ReductioninanytypeofIVHisinagreementwiththatofRabe
et al, who reported that DCC was associated with improvement in blood pressure and
reductionsintheneedforbloodtransfusionandrisksforIVH(allgrades)andnecrotizing
enterocolitis.1
HoweverplacentaltransfusionhadnoeffectontheAPGARscoresat1,5,and10
minutes.Kaempfetal.reportthatDCCinprematureinfants,1500ghadhigher1minute
APGARscores,lessneedforsupplementaloxygenandlessbagandmaskventilationand
concludedthatdelayedcordclampingissafeinsingletonprematureinfants.2

Hemoglobinvalue
AlthoughhematocritlevelsweresignificantlyhigherintheUCMgroup,nostudyreportedan
increasedriskforpolycythemiaorhyperbilirubinemiarequiringtreatment.Ininfantswitha
GAofatleast33weeks,UCMwasassociatedwithahigherhemoglobinvalueinthefirst48
hoursoflifeandat6weeksofagewithoutanincreaseintheriskforhyperbilirubinemia1,5
A study that held by Dr. Katheria et al, comparing UCM with DCC in infants
deliveredbyCDandthefirsttodemonstrateimprovementsinplacentaltransfusion,asseen
byhigherHbatbirth,improvedhemodynamics(highermeasuresofbloodflowandimproved
bloodpressure),andimprovedurineoutputwithUCMcomparedwithDCCinpremature
infantsdeliveredbyCD.3NeonateswhounderwentUCMhadhigheradmissionHb,higher
urineoutput(Table1),andhighermeasuresofSBF(SVCflowandRVO,Table2).There
were no differences in cerebral saturation, pulse oxygen saturation, cardiac output by
impedance,orheartrateover24hours(Fig1).Bloodpressurewashigherinthefirst15
hoursoflifeintheUCMgroup(Fig1).3

Table1.NeonatalOutcomesforInfantsDeliveredbyCD3

(Kathariaetal.UmbilicalCordMilkingVersusDelayedCordClampinginPretermInfants.Pediatrics
2015;136;61)

Table2.HemodynamicOutcomesforInfantsDeliveredbyCD
(Katharia et al. Umbilical Cord Milking Versus Delayed Cord Clamping in Preterm Infants. Pediatrics
2015;136;61)

Figure1.Continuoushemodynamicmeasurementsover24hoursoflife3
Dottedline,UCM;solidline,DCC;CO,cardiacoutputbyelectricalcardiometry;HR,heartrate;MAP,mean
arterialpressure;SpO2,pulseoxygensaturation;SV,strokevolumebyelectricalcardiometry;StO2,cerebral
saturations by nearinfrared spectroscopy. (Katharia et al. Umbilical Cord Milking Versus Delayed Cord
ClampinginPretermInfants.Pediatrics2015;136;61)

Figure2.OutcomesinUmbilicalCordMilking(UCM)vsControl(ImmediateorDelayed
CordClamping)GroupsinPretermInfants

(AlWassiaet al.EfficacyandSafetyofUmbilical CordMilkingat BirthASystematicReviewandMeta


analysis.JAMAPediatr.2015;169(1):1825)

UmbilicalCordMilkinginExtremelyPreterm
Onlyonepublishedrandomizedcontrolledtrialhascomparedumbilicalcordmilking
withimmediatecordclampinginextremelypretermdeliveries(lessthan28weeks).Astudy
thatwasperformedinJapanandreportedthatumbilicalcordmilkingreducedtheneedfor
redbloodcelltransfusionsintheneonatalperiod.Thesamestudyalsoreportedthatmilking
thecordinextremelypreterminfantsincreasedinfantbloodpressureinthefirst12hoflife
andurineoutputinthefirst72hoflife.Arecentretrospectivestudyconfirmedtheseresults
anddemonstratedthatumbilicalcordmilkingascomparedwithimmediatecordclamping
also improvedneonatal left ventricular diastolicfunction andstabilized neonatalcerebral
oxygenation.4
In the cord milking group, 83.3%of neonates required transfusion of packed red
bloodcellsinthefirst28daysoflifecomparedwith97.4%inthecontrolgroup(P=0.05),
yieldingaRRof0.86(95%confidenceinterval:0.73to1.0).Althoughnotan apriori
specifiedanalysis,weevaluatedtheneedfortransfusioninthemoreimmediatepostnatal
period(thefirst14daysoflife).Inthecordmilkinggroup,19(52.8%)neonates hada
transfusionbefore14daysoflifeversus30neonates(76.9%)inthecontrolgroup(riskratio:
0.67;95%confidenceinterval:0.48to0.98;P=0.04).4
Inaddition,theincidenceofintraventricularhemorrhagewassignificantlylowerin
thecordmilkinggroup(25.0%)comparedwiththecontrolgroup(51.3%;P=0.0195),such
thatneonatesinthecordmilkinggroupwere51%lesslikelytodevelopanintraventricular
hemorrhage(riskratio:0.49;95%confidenceinterval:0.26to0.93).4
Theneonatesinthecordmilkinggrouphadsignificantlyhigherinitialhemoglobin(P
=0.005)andhematocrit(P=0.004)levelsthantheneonatesinthecontrolgroup.Therewas
notasignificantincreaseintheneedforphototherapytotreathyperbilirubinemiainthecord
milkinggroup(91.7%)comparedwiththecontrolgroup(97.4%;P=0.35).Therealsowere
nosignificantdifferencesbetweenthegroupswithrespecttomedianApgarscoresat1,5and
10minandmediancordpH(allP>0.44).4

Table3.NeonatalOutcome
March et al. The effects of umbilical cord milking in extremely preterm infants: a randomized controlled trial. J
Perinatol. 2013 October ; 33(10): 763767

UmbilicalCordMilkinginTermandNearTermInfants
Recent studies have demonstrated that UCM and DCC result in comparable in
creasesinhemoglobininprematurebabies.However,dataabouttheeffectofUCMinfull
termneonatesareinsufficient.6
Asinglecenter,randomized,controlledtrialwasconductedfromApril2010through
September2011atateachinghospitalinNorthIndia.Thistrialincludedallinfantsmorethan
34weeks6daysofcompletedgestationdeliveredeitherbylowuterinesegmenttransverse
cesarean or vaginal delivery (Two hundred fulfilled the inclusion criteria and were
randomizedtoaninterventionandcontrolgroup).6
The primaryoutcomeofthe studywashemoglobinandserumferritinat6
weeks of postnatal age in term and nearterm infants. Secondary outcomes were
hemodynamicparameters(heartrate,respiratoryrate,bloodpressure,temperature,urine
output in the first 48 hours), clinical parameters (respiratory distress, jaundice requiring
phototherapy, polycythemia, jitteriness in 48 hours), and hematologic parameters
(hemoglobin,packedcellvolumeat12and48hours,andbilirubinat48hours).7,8,9
Thisstudydemonstratedthatthemilkingofextrabloodintothebaby3timesfrom
about25cmofumbilicalcordleadstohigherhemoglobinandserumferritinlevels6weeks
afterbirth.Wealsodemonstratedrelativelyhigherbloodpressure,althoughwithinthenor
malrange,afterthefirst48hoursinthemilkedgroup.UCMleadstotransfusionofabout20
mLextrablood.Theresultingvolumeexpansionprobablyleadstoincreasedbloodpressure
andcardiacoutput.6
Thegreatestbarriertotheclinicalapplicationofplacentaltransfusionisthelongheld
beliefthatovertransfusioncanleadtosymptomaticpolycythemiaandhyperbilirubinemia.In
ametaanalysisinvolving1912infants,HuttonandHassanreportedaslightlyhigherrateof
asymptomaticpolycythemiaat24to48hofagewithdelayedclamping,buttreatmentwas
unnecessary and not associated with higher levels of jaundice and hyperbilirubinemia.
Another recent metaanalysis found no differences in the amount of asymptomatic
polycythemia or clinical jaundice, but did report a small increase in jaundice requiring
treatmentalthoughbilirubinlevelswerenotreported.EricksonOwensetalreportedthere
wasnoreportofsymptomaticpolycythemiaandnosignificantdifferencesbetweentheICC
andUCMgroupsintheincidenceofclinicaljaundice,peakTSBlevels,hyperbilirubinemia
requiringhospitalizationorreadmissionforphototherapy.7,8,9

Table4.HematologicalParameters
(Upadhyay et al. Effect of UCM in term infants. Am J Obstet Gynecol 2013)

CONCLUSSION
Umbilical cord milking was associated with some benefits and no adverse effects in
the immediate postnatal period in preterm infants. Premature infants who receive UCM have
higher heart rates and SpO2 and require lower amounts of oxygen after delivery when
compared to infants whose umbilical cords are clamped immediately after birth. Premature
infants benefit from a placental transfusion as seen in the delivery room and UCM offers an
approach that can be used in the most compromised infants. UCMimprovedSBFandurine
outputforinfantsdeliveredbyCD.UCMmaybepreferableinpreterminfantsdeliveredby
CD. Milking of the cord of the extremely preterm infants increases the neonates
initialhematocritandmaylessentheneedfortransfusionintheneonatalperiod.The
observed reduction in the incidence of intraventricular hemorrhage may have
importantlongtermimplications.UCM is a safe procedure and it improved Hgb and iron
status at 6 weeks of life among term and near term neonates.