ACOG updates clinical guidance on delayed umbilical cord clamping in preterm neonates

ACOG updates clinical guidance on delayed umbilical cord clamping in preterm neonates | Image Credit: © Kirill Gorlov – stock.adobe.com.

The American College of Obstetricians and Gynecologists (ACOG) has issued updated clinical guidance on the management of umbilical cord clamping in preterm neonates. This Clinical Practice Update, developed in collaboration with expert clinicians and endorsed by leading professional organizations, is based on recent data from 2 systematic reviews and individual participant data meta-analyses published in November 2023.¹

The update revises Committee Opinion No. 814 from 2020 and includes recommendations regarding short, medium, and long deferral of cord clamping, umbilical cord milking, and immediate cord clamping in neonates born before 37 weeks of gestation.

The newly reviewed data include 2 meta-analyses of randomized controlled trials comparing deferred cord clamping or cord milking with immediate clamping in preterm births. The analyses incorporated data from 48 and 47 trials, involving 6,367 and 6,094 neonates, respectively. The median gestational age in both analyses was 29 weeks.^2,3

Deferred umbilical cord clamping, defined in the studies as a delay ranging from 30 to 180 seconds, was associated with a statistically significant reduction in neonatal death before hospital discharge compared to immediate clamping (within 15 seconds). The odds ratio (OR) was 0.68 (95% CI, 0.51–0.91). In contrast, umbilical cord milking did not show a statistically significant difference in mortality (OR 0.73, 95% CI, 0.44–1.20).

When stratified by timing, long deferral (120 seconds or more) was associated with a more pronounced reduction in neonatal death (OR 0.31, 95% CI, 0.11–0.80). However, short (15–<45 seconds) and medium (45–<120 seconds) deferrals, as well as cord milking, did not demonstrate a statistically significant mortality benefit compared with immediate clamping.

There were no differences across groups in the incidence of any grade of neonatal intraventricular hemorrhage. For neonates born before 32 weeks’ gestation, both deferred clamping (OR 0.59, 95% CI, 0.47–0.73) and cord milking (OR 0.69, 95% CI, 0.51–0.93) were associated with lower rates of red blood cell transfusion.

The findings prompted a re-evaluation by the International Liaison Committee on Resuscitation (ILCOR). The committee noted limitations in the evidence supporting long deferral of 120 seconds or more, including small sample sizes, adherence issues (as low as 67%), and the controlled nature of clinical trial settings. A post hoc ILCOR analysis comparing deferred clamping of 60 seconds or more with immediate clamping found a reduced odds of neonatal death (OR 0.63, 95% CI, 0.44–0.88), based on broader trial data with better adherence.

Given these findings, ACOG now recommends the following for obstetric care professionals:

• Defer umbilical cord clamping for at least 60 seconds in preterm neonates born before 37 weeks of gestation who do not require immediate resuscitation.
• In neonates born between 28 0/7 and 36 6/7 weeks of gestation, when deferred clamping is not performed, umbilical cord milking is a reasonable alternative to immediate clamping to improve hematologic outcomes.

The document emphasized that deferred clamping should be individualized in certain clinical situations, including the need for immediate resuscitation, multiple gestations, congenital anomalies, placenta previa, antepartum hemorrhage, and others. These considerations align with the exclusion criteria in the systematic reviews.

ACOG highlighted the need for careful, multidisciplinary collaboration before adopting long deferral protocols of 120 seconds or more. The authors note, “More evidence is needed before recommending the routine practice of long deferral of cord clamping for 120 seconds or more in preterm newborns.”

This guidance reflects ACOG’s ongoing effort to incorporate the most current evidence into clinical practice and to support improved outcomes in neonatal care.

References:

1. An Update to Clinical Guidance for Delayed Umbilical Cord Clamping After Birth in Preterm Neonates. Obstetrics & Gynecology. Published online July 24, 2025. doi:https://doi.org/10.1097/aog.0000000000006020
2. Seidler AL, Aberoumand M, Hunter KE, Barba A, Libesman S, Williams JG, et al. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis. Lancet 2023;402:2209–22. doi: 10.1016/S0140-6736(23)02468-6
3. Seidler AL, Libesman S, Hunter KE, Barba A, Aberoumand M, Williams JG, et al. Short, medium, and long deferral of umbilical cord clamping compared with umbilical cord milking and immediate clamping at preterm birth: a systematic review and network meta-analysis with individual participant data. Lancet 2023;402:2223–34. doi: 10.1016/S0140-6736(23)02469-8