UMBILICAL CORD MILKING

INTRODUCTION
1949, McCausland et al surveyed members of the American Board of Obstetrics and
Gynecology and reported no uniformity of practice in their management of umbilical cord and
placental blood. The benefits of delayed cord clamping (DCC) and other strategies to influence
placental transfusion at birth have been under investi- gation for decades. Recently, interest in
the evidently old procedures of transferring residual blood from the placenta to the infant by
means of DCC or umbilical cord milking (UCM) has shown a resurgence. However, practice
among obstetricians varies 7 decades later.1
Recently the 2012 ACOG guidelines recommended delayed cord clamping (DCC) for
at least 30 seconds and up to one minute in preterm infants. Despite the evidence and
recommendations for DCC, there is still reluctance by the neonatal/obstetrical community to
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 allowing
resuscitation of the premature infant to proceed without delay.2 This 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
The stripping of blood from the umbilical cord, or UCM, was pondered for years and
suspected to be beneficial. Nevertheless, methodologic limitations of older studies hindered
the adoption of UCM as a standard of care. A more recent series of studies assessed the safety
and efficacy of UCM. The key difference between DCC and UCM is the mechanism of cord
blood transfer to the infant. In DCC, a passive transfer of additional blood volume occurs at a
slow rate, mostly by uterine contractions, whereas in UCM an active transfer of additional
blood volume occurs at a rapid rate and within a short time, which may or may not be beneficial
to neonates, especially preterm neonates.1

UMBILICAL CORD MILKING

After birth, the timing of cord clamping may have a substantial impact on the amount of blood
transfused to the newborn from the placenta. During the first 5 to 15 s after delivery, blood
volume increases by 5 to 15 ml kg−1 as a result of uterine contractions. This early placental
transfusion does not occur if the cord is clamped immediately after birth or if uterine
contractions do not occur. In preterm neonates, randomized trials and meta-analyses have
shown that delaying cord clamping for at least 30 s compared with immediate cord clamping
results in increased circulating blood volume in the first 24 h of life, and a lower incidence of
red blood cell transfusion, necrotizing enterocolitis and intraventricular hemorrhage.4
Despite these advantages, a delay in cord clamping of 30 s or more may theoretically
interfere with neonatal resuscitation and potentially increase the risk of neonatal
hyperbilirubinemia. An alternative method, active placental transfusion (milking the umbilical
cord toward the baby before clamping), should take less than 5 s and therefore should not
interfere with neonatal resuscitation. One published randomized controlled trial has compared
delaying cord clamping for 30 s to cord milking in preterm infants and found that the two
interventions resulted in a similar amount of placento-fetal blood transfusion. A recent study
of cord milking compared with immediate clamping in term infants delivered by cesarean
section showed an increase in hematocrit at 36 to 48 h of age. Although some practitioners
have adopted this practice of active milking of the umbilical cord in preterm deliveries, there
is a paucity of data to support this practice.4

Umbilical Cord Milking in Preterm Infants

A recently published study compared UCM with DCC (n = 58) in infants delivered at
33 weeks’ gestational age. Although no major clinical differences were found between UCM
and DCC, this trial did not analyze any outcomes by mode of delivery. To date there have been
no trials comparing UCM and DCC at cesarean delivery (CD). Given that up to 90% of preterm
infants are delivered by CD, there is a critical need to determine which therapy should be given
to preterm infants.3
A systematic review and meta-analysis of the efficacy and safety of UCM in full-term
and preterm neonates that held by Heidi Al-Wassia and Prakesh S. Shah found heterogeneity
in the method of actual implementation of UCM between studies. In infants with a GA of less
than 33 weeks, UCM was not associated with a difference in the primary outcome of the risk
for mortality before discharge; however, UCM was associated with higher initial hemoglobin
values, a lower risk for oxygen requirement at a postmenstrual age of 36 weeks, and a lower
risk for IVH of all grades. These improvements did not translate into a reduction in the need
for blood transfusion or in the risk for severe IVH or periventricular leukomalacia.1

Heart Rate
 According to the Neonatal Resuscitation Program guidelines, heart rate is the most
important indicator of infant well-being during neonatal resuscitation. In 1962, Brady et al
demonstrated that after early cord clamping there was a marked bradycardia in the term infants.
Dawson et al. described a median heart rate of 100 bpm at one minute of life in term and
preterm neonates. Bhatt et al demonstrated a 50% drop in pulmonary blood flow and an abrupt
40% drop in heart rate (due to cessation of umbilical venous flow from the placenta) in
anesthetized fetal lambs receiving immediate cord clamping (ICC).2
The benefits of UCM on HR and SpO2 appear to be most significant in the first few
minutes of life. In an animal model using preterm lambs, Bhatt et al. demonstrated that ICC
leads to bradycardia until ventilation was established, but lambs that had delayed cord clamping
(DCC) did not have bradycardia. In addition, lambs with ICC had a rapid rise in carotid artery
pressure, carotid arterial blood flow, and pulmonary blood pressure starting at 4 beats after
clamping and continuing for 30 seconds, which was followed by a decrease in to below baseline
by 90 seconds after clamping the cord. The lambs with DCC until ventilation was established
did not have significant changes in carotid artery pressure, carotid artery blood flow, or
pulmonary artery pressure after clamping the umbilical cord. UCM offers an alternative to
DCC because UCM does not delay resuscitation.2

Plasental transfusion and oxygen delivery

Placental transfusion has shown to be beneficial to the preterm infant. A recent
Cochrane Review demonstrated that delaying umbilical cord clamping for at least 30 to 120
seconds in preterm infants decreased the need for red blood cell transfusion, and
intraventricular hemorrhage.2 Reduction in any type of IVH is in agreement with that of Rabe
et al, who reported that DCC was associated with improvement in blood pressure and
reductions in the need for blood transfusion and risks for IVH (all grades) and necrotizing
enterocolitis.1
However placental transfusion had no effect on the APGAR scores at 1, 5, and 10
minutes. Kaempf et al. report that DCC in premature infants ,1500 g had higher 1 minute
APGAR scores, less need for supplemental oxygen and less bag and mask ventilation and
concluded that delayed cord clamping is safe in singleton premature infants.2

Hemoglobin value
Although hematocrit levels were significantly higher in the UCM group, no study reported an
increased risk for polycythemia or hyper- bilirubinemia requiring treatment. In infants with a
GA of at least 33 weeks, UCM was associated with a higher hemoglobin value in the first 48
hours of life and at 6 weeks of age with- out an increase in the risk for hyperbilirubinemia1,5
A study that held by Dr. Katheria et al, comparing UCM with DCC in infants delivered
by CD and the first to demonstrate improvements in placental transfusion, as seen by higher
Hb at birth, improved hemodynamics (higher measures of blood flow and improved blood
pressure), and improved urine output with UCM compared with DCC in premature infants
delivered by CD.3 Neonates who underwent UCM had higher admission Hb, higher urine
output (Table 1), and higher measures of SBF (SVC flow and RVO, Table 2). There were no
differences in cerebral saturation, pulse oxygen saturation, cardiac output by impedance, or
heart rate over 24 hours (Fig 1). Blood pressure was higher in the first 15 hours of life in the
UCM group (Fig 1).3

Table 1. Neonatal Outcomes for Infants Delivered by CD3


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


Table 2. Hemodynamic Outcomes for Infants Delivered by CD

(Katharia et al. Umbilical Cord Milking Versus Delayed Cord Clamping in Preterm Infants. Pediatrics
2015;136;61)
Figure 1. Continuous hemodynamic measurements over 24 hours of life3

Dotted line, UCM; solid line, DCC; CO, cardiac output by electrical cardiometry; HR, heart rate; MAP, mean
arterial pressure; SpO2, pulse oxygen saturation; SV, stroke volume by electrical cardiometry; StO2, cerebral
saturations by near-infrared spectroscopy. (Katharia et al. Umbilical Cord Milking Versus Delayed Cord
Clamping in Preterm Infants. Pediatrics 2015;136;61)
Figure 2. Outcomes in Umbilical Cord Milking (UCM) vs Control (Immediate or Delayed Cord
Clamping) Groups in Preterm Infants

(Al-Wassia et al.Efficacy and Safety of Umbilical Cord Milking at Birth A Systematic Review and Meta-analysis.
JAMA Pediatr. 2015;169(1):18-25)

Umbilical Cord Milking in Extremely Preterm

Only one published randomized controlled trial has compared umbilical cord milking
with immediate cord clamping in extremely preterm deliveries (less than 28 weeks). A study
that was performed in Japan and reported that umbilical cord milking reduced the need for red
blood cell transfusions in the neonatal period. The same study also reported that milking the
cord in extremely preterm infants increased infant blood pressure in the first 12 h of life and
urine output in the first 72 h of life. A recent retrospective study confirmed these results and
demonstrated that umbilical cord milking as compared with immediate cord clamping also
improved neonatal left ventricular diastolic function and stabilized neonatal cerebral
oxygenation.4
In the cord milking group, 83.3% of neonates required transfusion of packed red blood
cells in the first 28 days of life compared with 97.4% in the control group (P = 0.05), yielding
a RR of 0.86 (95% confidence interval: 0.73 to 1.0). Although not an a priori-specified
analysis, we evaluated the need for transfusion in the more immediate postnatal period (the
first 14 days of life). In the cord milking group, 19 (52.8%) neonates had a transfusion before
14 days of life versus 30 neonates (76.9%) in the control group (risk ratio: 0.67; 95%
confidence interval: 0.48 to 0.98; P = 0.04).4
In addition, the incidence of intraventricular hemorrhage was significantly lower in the
cord milking group (25.0%) compared with the control group (51.3%; P = 0.0195), such that
neonates in the cord milking group were 51% less likely to develop an intraventricular
hemorrhage (risk ratio: 0.49; 95% confidence interval: 0.26 to 0.93).4
The neonates in the cord milking group had significantly higher initial hemoglobin (P
= 0.005) and hematocrit (P = 0.004) levels than the neonates in the control group. There was
not a significant increase in the need for phototherapy to treat hyperbilirubinemia in the cord
milking group (91.7%) compared with the control group (97.4%; P = 0.35). There also were
no significant differences between the groups with respect to median Apgar scores at 1, 5 and
10 min and median cord pH (all P>0.44).4

Table 3. Neonatal Outcome

March et al. The effects of umbilical cord milking in extremely preterm infants: a randomized controlled trial. J
Perinatol. 2013 October ; 33(10): 763–767

Umbilical Cord Milking in Term and Near Term Infants

 Recent studies have demonstrated that UCM and DCC result in comparable in- creases
in hemoglobin in premature babies. However, data about the effect of UCM in full-term
neonates are insufficient.6
A single-center, randomized, controlled trial was conducted from April 2010 through
September 2011 at a teaching hospital in North India. This trial included all infants more than
34 weeks 6 days of completed gestation delivered either by low uterine segment transverse
cesarean or vaginal delivery (Two hundred fulfilled the inclusion criteria and were randomized
to an intervention and control group).6
The primary outcome of the study was hemoglobin and serum ferritin at 6 weeks
of postnatal age in term and near-term infants. Secondary outcomes were hemodynamic
parameters (heart rate, respiratory rate, blood pressure, temper- ature, urine output in the first
48 hours), clinical parameters (respiratory distress, jaundice requiring phototherapy,
polycythemia, jitteriness in 48 hours), and hematologic parameters (hemoglobin, packed cell
volume at 12 and 48 hours, and bilirubin at 48 hours). 7,8,9
This study demonstrated that the milking of extra blood into the baby 3 times from
about 25 cm of umbilical cord leads to higher hemoglobin and se- rum ferritin levels 6 weeks
after birth. We also demonstrated relatively higher blood pressure, although within the nor-
mal range, after the first 48 hours in the milked group. UCM leads to transfusion of about 20
mL extra blood. The resulting volume expansion probably leads to increased blood pressure
and cardiac output. 6
The greatest barrier to the clinical application of placental transfusion is the long held
belief that overtransfusion can lead to symptomatic polycythemia and hyperbilirubinemia. In a
meta- analysis involving 1912 infants, Hutton and Hassan reported a slightly higher rate of
asymptomatic polycythemia at 24 to 48 h of age with delayed clamping, but treatment was
unnecessary and not associated with higher levels of jaundice and hyperbilirubinemia. Another
recent meta-analysis found no differences in the amount of asymptomatic polycythemia or
clinical jaundice, but did report a small increase in jaundice requiring treatment although
bilirubin levels were not reported. Erickson-Owens et al reported there was no report of
symptomatic polycythemia and no significant differences between the ICC and UCM groups
in the incidence of clinical jaundice, peak TSB levels, hyperbilirubinemia requiring
hospitalization or readmission for phototherapy.7,8,9

Table 4. Hematological Parameters

(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. UCM improved SBF and urine
output for infants delivered by CD. UCM may be preferable in preterm infants delivered by
CD. Milking of the cord of the extremely preterm infants increases the neonate’s initial
hematocrit and may lessen the need for transfusion in the neonatal period. The observed
reduction in the incidence of intraventricular hemorrhage may have important long-
term implications. UCM is a safe procedure and it improved Hgb and iron status at 6 weeks
of life among term and near term neonates.