Placental transfusion has become the accepted standard in newborn care with benefits to the neonate including decreased mortality in preterm infants¹ and improved developmental outcomes in term infants.² Umbilical cord milking has been endorsed as an alternative to delayed umbilical cord clamping, which is the current standard of care. Umbilical cord milking provides a placental transfusion by pushing blood toward the newborn before the umbilical cord is clamped with a duration similar to immediate umbilical cord clamping, allowing the neonatal team to begin resuscitation promptly.

BACKGROUND AND OBJECTIVE: Delayed cord clamping (DCC) is recommended for premature infants to improve blood volume. Most preterm infants are born by cesarean delivery (CD), and placental transfusion may be less effective than in vaginal delivery (VD). We sought to determine whether infants <32 weeks born by CD who undergo umbilical cord milking (UCM) have higher measures of systemic blood flow than infants who undergo DCC. METHODS: This was a 2-center trial. Infants delivered by CD were randomly assigned to undergo UCM or DCC. Infants delivered by VD were also randomly assigned separately. UCM (4 strippings) or DCC (45–60 seconds) were performed. Continuous hemodynamic measurements and echocardiography were done at site 1. RESULTS: A total of 197 infants were enrolled (mean gestational age 28 ± 2 weeks). Of the 154 infants delivered by CD, 75 were assigned to UCM and 79 to DCC. Of the infants delivered by CD, neonates randomly assigned to UCM had higher superior vena cava flow and right ventricular output in the first 12 hours of life. Neonates undergoing UCM also had higher hemoglobin, delivery room temperature, blood pressure over the first 15 hours, and urine output in the first 24 hours of life. There were no differences for the 43 infants delivered by VD. CONCLUSIONS: This is the first randomized controlled trial demonstrating higher systemic blood flow with UCM in preterm neonates compared with DCC. UCM may be a more efficient technique to improve blood volume in premature infants delivered by CD.

Recently there have been a number of studies and presentations on the importance of providing a placental transfusion to the newborn. Early cord clamping is an avoidable, unphysiologic intervention that prevents the natural process of placental transfusion. However, placental transfusion, although simple in concept, is affected by multiple factors, is not always straightforward to implement, and can be performed using different methods, making this basic procedure important to discuss. Here, we review three placental transfusion techniques: delayed cord clamping, intact umbilical cord milking and cut-umbilical cord milking, and the evidence in term and preterm newborns supporting this practice. We will also review several factors that influence placental transfusion, and discuss perceived risks versus benefits of this procedure. Finally, we will provide key straightforward concepts and implementation strategies to ensure that placental-to-newborn transfusion can become routine practice at any institution.

OBJECTIVE: To compare the time required to obtain a continuous audible heart rate signal from an electrocardiogram (ECG) monitor and pulse oximeter (PO) in infants requiring resuscitation. METHODS: Infants who had both ECG and PO placed during resuscitation were analyzed using video and analog recordings. The median times from arrival until the ECG electrodes and PO sensor were placed, and the time to achieve audible tones from the devices, were compared. RESULTS: Forty-six infants had ECG and PO data. Thirty infants were very low birth weight (23–30 weeks). There was a difference in the median total time to place either device (26 vs 38 seconds; P = .04), and a difference (P < .001) in the time to achieve an audible heart rate signal after ECG lead (2 seconds) versus PO probe (24 seconds) placement. In infants weighing >1500 g (n = 16), the median time (interquartile range) to place the ECG was 20 seconds (14–43) whereas the time to place the PO was 36 seconds (28–56) (P = .74). The median times (interquartile range) to acquire a signal from the ECG and PO were 4 seconds (1–6) and 32 seconds (15–40, P = .001), respectively. During the first minutes of resuscitation, 93% of infants had an ECG heart rate compared with only 56% for PO. CONCLUSIONS: Early application of ECG electrodes during infant resuscitation can provide the resuscitation team with a continuous audible heart rate, and its use may improve the timeliness of appropriate critical interventions.