Paradigm Shift In Neonatal Resuscitation

Initiating a cord management plan is currently positioned as the absolute first step immediately following birth in the Neonatal Resuscitation Program (NRP) 9th Edition.
These placental transfusion strategies augment neonatal blood volume, reducing anemia and long-term neurodevelopmental risks.

Definitions And Methodologies

Involves deliberately deferring the clamping of the umbilical cord for at least 60 seconds post-delivery.
The infant is held at or below the level of the placenta during the delay.
Transfusion relies on physiological factors, including gravity, uterine contractions, and neonatal respiration.

Involves the manual stripping or squeezing of blood through the untied umbilical cord toward the newborn prior to clamping.
The clinician grasps the cord and pushes blood 2 to 4 times from the placental side toward the umbilicus.
Acts as a rapid, active, and forced mechanical displacement of placental blood.

Parameter	Delayed Cord Clamping	Umbilical Cord Milking
Primary Driver	Physiological (uterine contractions, breathing)	Manual or mechanical (active stripping)
Time Required	At least 60 seconds	Rapidly completed within 10 to 15 seconds
Hemodynamic Effect	Smooth, gradual transition with stable blood flow	Rapid, bolus-like expansion of blood volume
Resuscitation Impact	Delays immediate access to resuscitation trolleys	Allows rapid separation for immediate resuscitation
Target Population	Term and preterm newborns not requiring resuscitation	Non-vigorous infants where DCC is unfeasible

Both modalities significantly increase neonatal blood volume, optimizing initial hemoglobin and hematocrit levels.
Preterm infants show reduced requirements for blood transfusions, stabilized systemic blood pressure, and lower incidence of necrotizing enterocolitis (NEC).
Term infants gain enhanced iron stores lasting up to 6 months of age, which prevents early childhood anemia and improves neurodevelopmental milestones.

The AHA/NRP 2025 guidelines recommend DCC for at least 60 seconds in vigorous term and preterm infants.
UCM is considered a reasonable alternative for non-vigorous term and late preterm infants (≥35 weeks), or preterm infants between 28 and 34 weeks, only when DCC is impossible.
The Indian Academy of Pediatrics (IAP) aligns with these international standards, prioritizing DCC while restricting UCM based on gestational age.

UCM is strictly contraindicated in extremely preterm infants under 28 weeks gestation.
Rapid bolus effects from UCM cause large fluctuations in cerebral blood flow, significantly increasing the risk of severe intraventricular hemorrhage (IVH) in extreme preemies.
Both techniques increase the volume of red blood cell breakdown, elevating the risk of neonatal hyperbilirubinemia and necessitating vigilant monitoring for phototherapy.

Neither modality should be attempted during maternal or fetal emergencies requiring immediate cord severing.
Contraindications include placental abruption, placenta previa with heavy bleeding, cord avulsion, hemodynamically unstable hydrops fetalis, and twin-to-twin transfusion syndrome (TTTS).