Search RHCG Website
Select your language

Delayed Cord Clamping (DCC) WoS MCN, Obstetrics

exp date isn't null, but text field is


This guideline is relevant to all maternity departments in the West of Scotland.

Placental transfusion is the physiological process during which at birth, umbilical blood flow continues to flow from the placenta to the baby1.  Deferred cord clamping (DCC) refers to the practice whereby babies remain attached to the umbilical cord to allow placental transfusion, while they transition to exutero life. 

Various terms and durations are used to describe this process interchangeably, including delayed and optimal cord clamping or management.  For the purposes of this guideline, we will use the term deferred cord clamping, whereby the baby remains attached to the cord for at least 60 seconds after birth. 

National and international guidance is overwhelmingly supportive of the practice of DCC, which is widely recognised as a gold standard of care for both preterm and term infants1-9. The World Health Organisation, National Institute for Clinical Excellence, Cochrane Library, Royal College of Obstetricians and the British Association of Perinatal Medicine, among others, all recommend waiting at least 60 seconds before clamping the umbilical cord, and do not advocate immediate cord clamping. 

This is based on evidence demonstrating both short and long term benefits and crucially, a significant reduction in mortality in preterm infants8,9

DCC is also a key focus and benchmarking measure in both the National Neonatal Audit Programme (NNAP), and as part of national QI workstreams on perinatal optimisation, including that of the SPSP Perinatal Programme’s Preterm Perinatal Wellbeing Package10-14.  

This guideline summarises the physiology, evidence and practical advice to ensure more babies reap the benefits of deferred cord clamping, and we improve outcomes for our most vulnerable patients.


Postnatal transition is a vast and complex physiological process whereby newborns must adapt from an environment of full placental support to complete self-maintenance. Dramatic respiratory and circulatory changes must occur rapidly and are crucial for survival.  While these changes are well described, additional focus has now been brought to the critical timing of these events, with a greater understanding of the integral relationship between lung aeration, pulmonary blood flow and cardiac output. Placental transfusion via DCC is vital in supporting these processes to ensure a successful and stable transition to ex utero life15-19

Full understanding of the physiology is fundamental in appreciating the processes during transition and the importance of placental transfusion. In utero, a large amount of fetal cardiac output lies within the placenta. Up to 50% of a preterm fetus’ circulating volume is within the placenta circulation, compared to up to 30% of a term fetus. As pulmonary blood flow is low, the placental circulation is the source of venous return to the heart. Placental venous return via the umbilical vein is predominantly shunted from the right atrium across the foramen ovale to the left atrium, and therefore provides preload to left ventricle. Placental blood flow is therefore the ultimate source of cardiac output, cerebral and systemic blood flow. 

When babies are born, the umbilical arteries constrict to minimise forward flow to the placenta, while flow via the umbilical vein continues for several minutes. Aeration of the lungs at birth is then the key trigger that sets off the series of events, that combined with clamping of the cord, lead to the dramatic changes in the newborn cardiorespiratory system1,15-21.  Lung aeration results in a rapid fall in pulmonary vascular resistance, and subsequent increase in pulmonary blood flow15-17.  The baby can draw blood from the low resistance placental circulation, allowing redistribution of blood to the lungs, while maintaining venous return.  This process preserves cardiac output which ensures no fall in cerebral or systemic blood flow15-17. The additional blood from the placenta during transition provides cardiovascular stability, by boosting circulating blood volume, maintaining organ perfusion, and facilitating a smoother transition from fetal to newborn circulation15,16.

Physiological based cord clamping (PBCC) is also an emerging practice, which brings additional focus to the timing of cord clamping in relation to lung aeration. PBCC allows generous placental transfusion through DCC, while supporting initiation of respiration and establishment of pulmonary blood flow20-29. In both animal and human studies, PBCC has been shown to allow a smoother transition, by supporting an increase in pulmonary blood flow, maintaining systemic blood flow and providing a more stable cerebral haemodynamic transition with less hypoxia and bradycardia24. Another study found PBCC stabilised core temperature at delivery when compared to those who had immediate cord clamping27.   Further observational studies demonstrated increased mortality, increased risk of chronic lung disease and severe IVH if the cord is clamped prior to onset of breathing23-26.

Through these physiological processes, preterm babies who receive placental transfusion benefit from a significant reduction mortality of one third, as well as less brain haemorrhage, hypotension, anaemia, NEC and sepsis. 

While most term infants can adapt without consequence without full DCC, immediate cord clamping (ICC) however, has now been clearly shown to cause harm in preterm babies18-21. Immediate or early clamping of the cord, particularly when performed prior to lung aeration, forces a baby to transition without the ability to draw from their innate circulation within the placenta. ICC cuts off umbilical venous flow leading to an abrupt drop in venous return by 30-50%15,17. The increase in systemic vascular resistance caused by removing the low resistance placental circulation, also leads to increased systemic arterial pressure. Combining a reduction in preload from reduced venous return, together with an increase in afterload due to increased arterial pressure, a sudden fall in cardiac output leads to hypotension and bradycardia13,22, reduced systemic blood flow and impaired organ perfusion. 

The impact on cerebral blood flow here is also vital. Following the rapid increase in arterial pressure, cerebral blood flow initially increases, but then rapidly falls due to the reduction in cardiac output. These critical mechanisms contribute to the increased the risk of intraventricular haemorrhage and circulatory collapse in the preterm infant, as well as a greater need for inotropic support and need for blood transfusion16,17,20,30,34,38

These negative effects can be mitigated by delaying the time at which the umbilical cord is clamped, allowing a much more physiological and safe transition. By keeping the baby attached to the cord while lung aeration and pulmonary blood flow is established, umbilical venous flow can maintain venous return, ventricular preload and therefore prevent the harm caused by the drop in cardiac output.  

The evidence of benefit from DCC, underpinned by this increased physiological understanding, is now overwhelming and highlights the urgent need to update and improve our clinical practice. PBCC brings further focus to the importance of timing of cord clamping in relation to lung aeration. Perinatal teams should therefore ensure shared goals of clamping the cord after a minimum of 60 seconds and ideally after lung aeration has been achieved. Careful attention should be made to the assessment and understanding of an infant’s rapidly changing physiology at birth, to ensure they benefit from a stable postnatal transition. 

Umbilical cord milking

N.B. Only for babies ≥28 weeks

Umbilical cord milking (UCM) is the practice whereby where the cord is grasped and blood is pushed toward the baby prior to clamping of the cord, achieving placental transfusion in approximately 20 seconds. The exact technique varies between studies, a milking around 20cm every 2 seconds, performed 3-5 times, is the most frequently described process in the literature. Cord milking has been proposed as an alternative to DCC in certain situations, whereby placental transfusion can be achieved quickly in compromised or preterm infants who require resuscitation8.

A meta-analysis comparing UCM to ICC demonstrated that UCM was associated with less IVH of all grades, less chronic lung and higher haemoglobin levels32.

A RCT comprising 197 infants <33 weeks comparing UCM to DCC have demonstrated that UCM is beneficial in infants born by caesarean section. These infants had higher SVC and right ventricular outflow (RVO) blood flow, a higher haemoglobin, better delivery room temperature, higher blood pressure and higher urine output in the first 24 hours31. This is potentially as more blood remains in the placenta at birth due to anaesthetic and surgical interventions interfering with active uterine contractions.

However, a recent study comparing UCM to DCC has demonstrated a significantly increased incidence of severe IVH in the babies under 27 weeks gestation33.  No comparison was made between UCM and ICC however.  This raises sufficient concerns regarding UCM in the very preterm, and we do not currently recommend this option in this group of babies.

The recommendation from the BAPM Optimal Cord Management Toolkit8 is to reserve UCM for the rare situation of maternal collapse requiring resuscitation in babies ≥28 weeks, where cord clamping needs to be expedited due to maternal health issues. 

Benefits & Risks

Benefits in Preterm Infants:

The benefits of DCC are vast, and critical to improving outcomes in the preterm population.  Several high quality studies have clearly demonstrated both short and long term positive impacts of DCC and the stark evidence requiring a change to our practice. This includes: 

  • Reduction in mortality of up to 32%8,9,30,31,38
    • For every 33 babies born ≤32 weeks who receive at least 60 seconds of DCC, there is one additional survivor 
    • In infants ≤28 weeks the NNB reduces to 20
  • Reduction in intraventricular haemorrhage32,40
  • Reduction in late onset sepsis38
  • Reduction in necrotising enterocolitis32
  • Improvement in blood pressure with reduced need for inotropic support30,31
  • Reduction in need for blood transfusion by 10%34
  • Lower risk of death or severe neurodevelopmental impairment at 22-26 months41,42

Benefits in Term Babies:

  • Higher haemoglobin concentration34
  • Higher iron stores with lower incidence of iron deficiency34
  • Improved fine-motor and social domains at 4 years of age41


In both preterm and term infants the only noted negative impact of DCC is a higher incidence of jaundice, with higher peak bilirubin levels and the need for phototherapy8,34. Importantly there is no evidence of an increased need for exchange transfusion or harm.

Access to frequent assessment and treatment for jaundice is recommended.

Contraindications to DCC

All babies will be eligible for delayed cord clamping unless there is an absolute contraindication. In reality, there are very few situations whereby deferred cord clamping is not safe or achievable8. The only true contra-indications whereby DCC is not recommended are in cases of:

  • Massive maternal haemorrhage, with the need for acute resuscitation
  • Cord issues - such as ruptured vasa praevia, a snapped cord or lack of cord integrity, all of which could lead to significant bleeding from the baby
Compromised Infants

When babies are compromised at birth, the team must use their clinical judgement as to when is appropriate to clamp the cord.  It is important to remember that in the absence of major haemorrhage or issues with cord integrity8, compromised babies are likely to benefit from DCC, and their ability to transition may be hampered further by clamping early. In babies where there is a delay in establishing breathing, they are likely to receive substantial benefit from DCC15

Preterm babies are a particularly vulnerable group to highlight. As they may not be vigorous at birth, this often leads to anxiety and early clamping of the cord.  However these infants are expected to have the greatest benefit from placental transfusion, and can potentially be harmed by ICC. We therefore must reframe any misconceptions around DCC, understand the physiology, and do our utmost to achieve a minimum of 60 seconds DCC.  

Where there are signs of life, but concerns regarding the condition of the baby, we can initiate resuscitation by stimulating the baby, drying or placing them in a plastic bag if premature, and opening the airway to help with lung aeration. 

If there are no signs of life, resuscitation should not be delayed. However it is worth considering that in settings where resources are available, e.g. LifeStartTM trolley or similar, resuscitation can be commenced with an intact cord, which can allow the baby to achieve the benefits of placental transfusion and aid in their resuscitation.

Short Cord

A short cord is NOT a contraindication to DCC8. The team should be prepared for this in all scenarios, and adapt to deliver DCC as best as possible. This can still be achieved by placing the baby at the perineum, and in preterm infants, using a plastic bag and heat source where available. 

Complete Placental Separation/En Caul Birth

Where the placenta separates completely and delivers with the baby, it can be held above the baby and gentle pressure applied to facilitate forward flow of blood. The cord can then be clamped at 60 seconds before the placenta is lowered. Umbilical cord milking can be also considered in this situation in the more mature babies8

Preterm Births

Effective perinatal teamwork, including preparation, communication and clarification of shared goals, is vital for preterm births in order to achieve full perinatal optimisation and increase the chance of the best possible outcome for mothers and babies. 

The use of a delivery room prompt or checklist is useful to ensure allocation of roles, checking of equipment and optimisation of the environment. A MDT perinatal “preterm pause” pause should also be performed prior to all preterm births, and formalised into theatre safety briefs.  This provides an opportunity for clear communication of the birth plan including the need for a plastic bag, heat source or LifeStartTM trolley, cord bloods and any plans for delivery room cuddles. The 3 most vital shared perinatal goals should be agreed:

  1. Deferred cord clamping of a minimum of 60 seconds
  2. Lung aeration & gentle transition
  3. Normothermia

Neonatal and obstetric teams should stand side by side to support the process of DCC. During caesarean births, an experienced member of the neonatal team can scrub up and join the theatre team to help stabilise the baby and instil confidence. This will help minimise anxiety and unnecessary early clamping of the cord. Clamping of the cord should be a joint perinatal decision, and should not be performed prior to 60 seconds without discussion between teams. In the absence of maternal concerns, timing of cord clamping should be led by the neonatal team.

Multiple Gestations

Several studies have demonstrated that DCC can be safely achieved in multiple gestation pregnancies. Monochorionic (MCMA/MCDA) multiples present a unique challenge at delivery if there is concern around Twin-To-Twin Transfusion Syndrome. Many studies therefore excluded this group of babies. However, recent small studies have shown DCC is feasible in both monochorionic and dichorionic/trichorionic multiples, with comparable neonatal outcomes in preterm singletons and multiples, first and second order multiples and monochorionic and dichorionic/trichorionic multiples.

DCC can be considered in all multiples, and delivery plans should be made on an individual case bases with by an experienced perinatal team8.  

Maternal considerations

There has been no maternal harm demonstrated by DCC. Evidence confirms DCC does not increase the duration of third stage of labour, post-partum haemorrhage, postpartum transfusion, and importantly has no impact on maternal mortality34. Mothers may receive benefit from DCC and administration of oxytocinin after delivery of the placenta15. Administration of prophylactic uterotonic drugs i.e. syntocinon, should not be delayed as they have no proven impact on the efficacy of DCC.  

If there are maternal health concerns during DCC, this should be communicated between the teams and a joint decision made on cord clamping.

Cord Bloods

DCC may impact the ability to achieve adequate volumes for cord gases and bloods37,38. However this is not a contraindication to performing DCC, and the benefits far outweigh the desire for cord bloods.

  1. Clamping of the Umbilical Cord and Placental Transfusion. Scientific Impact Paper No. 14 February 2015. Royal College of Obstetricians
  2. Guideline: Deferred Umbilical Cord Clamping for improved maternal and infant health and nutrition outcomes. World Health Organisation, 2014.
  3. Intrapartum care Quality standard. National Association for Clinical Excellence; 10 December 2015
  4. Rabe H, Gyte GML, Díaz-Rossello JL, Duley L. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2019, Issue 9. Art. No.:CD003248.
  5. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Volume 142, Issue 16_suppl_1, 20 October 2020; Pages S185-S221
  6. Aziz, K. et al, 2020. Part 5: neonatal resuscitation: 2020 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16_Suppl_2), pp.S524-S550.
  7. Madar J et al. European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth (2021). 
  8. Optimal Cord Management in Preterm Babies – A Quality Improvement Toolkit. British Association of Perinatal Medicine. December 2020 
  9. Antenatal Optimisation for Preterm Infants less than 34 weeks – A Quality Improvement Toolkit. British Association of Perinatal Medicine, October 2020
  10. NNAP Online. National Neonatal Audit Programme: Royal College for Paediatrics and Child Health
  11. Preterm Perinatal Wellbeing Package: Maternity and Children Quality Improvement Collaborative, Scottish Patient Safety Programme. Health Improvement Scotland
  12. Saving Babies’ Lives Care Bundle Version 2: COVID-19 information. Appendix I: Implications of COVID-19 on reducing preterm births: NHS England, 2020.
  13. Maternity and Neonatal Safety Improvement Programme: NHS Improvement
  14. PERIPrem Care Bundle: West of England Academic Health Sciences Network 2020
  15. Hooper, S., te Pas, A., Lang, J. et al. Cardiovascular transition at birth: a physiological sequence. Pediatr Res 77, 608–614 (2015).
  16. Lu J et al. A review on development of placental transfusion in term and preterm infants. Front.Pediatr., 15 September 2022 Sec. Neonatology
  17. Effects of Umbilical Cord Management Strategies on Stem Cell Transfusion, Delivery Room Adaptation, and Cerebral Oxygenation in Term and Late Preterm Infants. Front. Pediatr. Volume 10 - 2022 | 04 April 2022;
  18. Katheria A, Lakshminrusimha S, Rabe H, McAdams R, Mercer J. Placental transfusion: a review. Journal of Perinatology. 2016;37(2):105-111.
  19. Polon R, Abman S, Fox W. Umbilical Cord Blood Flow. Fetal and Neonatal Physiology Textbook, Fifth Edition 2017.
  20. Hooper SB, Siew ML, Kitchen  MJ, te  Pas  Establishing functional residual capacity in the non-breathing infant. Semin Fetal Neonatal Med 2013;18:336–43. Nevill E, Meyer M. Effect of delayed cord clamping (DCC) on breathing and transition at birth in very preterm infants. Early Human Development. 2015;91(7):407-411.
  21. Straňák Z, Feyereislová S, Korček P, Dempsey E. Placental Transfusion and Cardiovascular Instability in the Preterm Infant. Frontiers in Pediatrics. 2018;6
  22. Tarnow-Mordi, M.B . Delayed versus Immediate cord clamping in preterm infants. NEJM 2017;; 377:2445-2455.
  23. Polglase GR, Dawson JA, Kluckow M, Gill AW, Davis PG, Te Pas AB, et al. Ventilation onset prior to umbilical cord clamping (physiological-based cord clamping) improves systemic and cerebral oxygenation in preterm lambs. PLoS One. 2015 Feb;10(2):e0117504.
  24. Bhatt S, Alison B, Wallace E, Crossley K, Gill A, Kluckow M et al. Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. The Journal of Physiology. 2013;591(8):2113-2126.
  25. Ersdal H, Linde J, Mduma E, Auestad B, Perlman J. Neonatal Outcome Following Cord Clamping After Onset of Spontaneous Respiration. PEDIATRICS. 2014;134(2):265-272.
  26. Duley L, Dorling J, Pushpa-Rajah A on behalf of the Cord Pilot Trial Collaborative Group, et al. Randomised trial of cord clamping and initial stabilisation at very preterm birth. Archives of Disease in Childhood - Fetal and Neonatal Edition 2018;103:F6-F14.
  27. Blank DA, Crossley KJ, Kashyap AJ, Hodges RJ, DeKoninck PLJ, McGillick EV, Rodgers KA, te Pas AB, Hooper SB and Polglase GR (2020) Physiologic-Based Cord Clamping Maintains Core Temperature vs. Immediate Cord Clamping in Near-Term Lambs. Frontiers in Paediatrics. 8:584983. doi: 10.3389/fped.2020.584983
  28. Vain, N; Satragno, D; Gorenstein, A; Gordillo, J; Berazategui, J; Guagalupe Alda, M; Prudent, L. (2014) Effect of gravity on volume of placental transfusion: a multicentre, randomised, noninferiority trial. The Lancet. 384, pp. 235-40.
  29. Katheria A, Poeltler D, Durham J, Steen J, Rich W, Arnell K et al. Neonatal Resuscitation with an Intact Cord: A Randomized Clinical Trial. The Journal of Pediatrics. 2016;178:75-80.e3.
  30. Fogarty M, Osborn D, Askie L, Seidler A, Hunter K, Lui K et al. Delayed vs early umbilical cord clamping for preterm infants: a systematic review and meta-analysis. American Journal of Obstetrics and Gynecology. 2018;218(1):1-18.
  31. Rabe H, Gyte GM, Díaz-Rossello JL, et al. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev 2019;9(9):Cd003248
  32. Lodha A, Shah PS, Soraisham AS, et al. Association of Deferred vs Immediate Cord Clamping With Severe Neurological Injury and Survival in Extremely Low-Gestational-Age Neonates. JAMA Netw Open. 2019;2(3):e191286. doi:10.1001/jamanetworkopen.2019.1286
  33. Katheria, A., Truong, G., Cousins, L., Oshiro, B. and Finer, N. (2015). Umbilical Cord Milking Versus Delayed Cord Clamping in Preterm Infants. PEDIATRICS, 136(1), pp.61-69.
  34. Al-Wassia H, Shah PS. Efficacy and safety of umbilical cord milking at birth: a systematic review and meta-analysis. JAMA Pediatr (2015) 169:18–25. doi:10.1001/jamapediatrics.2014.1906
  35. Anup C. Et al. Premature Infants Receiving Cord Milking or Delayed Cord Clamping: A Randomized Controlled Non-inferiority Trial. American Journal of Obstetrics & Gynecology Supplement to January 2019: S682.
  36. Katariya D, Swain D, Singh S, Satapathy A. The Effect of Different Timings of Delayed Cord Clamping of Term Infants on Maternal and Newborn Outcomes in Normal Vaginal Deliveries. Cureus. 2021 Aug 14;13(8):e17169. doi: 10.7759/cureus.17169.
  37. Wiberg N, Källén K, Olofsson P. Delayed umbilical cord clamping at birth has effects on arterial and venous blood gases and lactate concentrations. BJOG 2008;115:697–703.
  38. Wong C et al. Delayed cord clamping: Impact on fetal cord blood gas analysis. Australian and New Zealand Journal of Obstetrics and Gynaecology Volume 62, Issue 2Apr 2022 Pages177338, E3-E5
  39. Robledo, K. P., Tarnow-Mordi, W. O., Rieger, I., Suresh, P., Martin, A., Yeung, C., & Bowen, J. (2022). Effects of delayed versus immediate umbilical cord clamping in reducing death or major disability at 2 years corrected age among very preterm infants (APTS): a multicentre, randomised clinical trial. The Lancet Child & Adolescent Health, 6(3), 150-157.
  40. Mercer, J; Vohr, B; McGrath, M; Padbury, J; Wallach, M & Oh, W. (2006) Delayed cord clamping in very premature infants reduces the incidence of IVH and late onset sepsis: A randomised control trial. Paediatrics. 117(4), pp. 1235-1242.
  41. Handley SC, et al. Exposure to umbilical cord management approaches and death or neurodevelopmental impairment at 22-26 months' corrected age after extremely preterm birth Archives of Disease in Childhood. Fetal and Neonatal Edition 2022 October 17
  42. Andersson O, Lindquist B, Lindgren M, Stjernqvist K, Domellöf M, Hellström-Westas L. Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age: A Randomized Clinical Trial. JAMA Pediatr. Published online May 26, 2015. doi:10.1001/jamapediatrics.2015.0358
Editorial Information

Last reviewed: 09 October 2023

Next review: 09 October 2026

Author(s): Dr Lynsey Still, Consultant Neonatologist, Princess Royal Maternity & Royal Hospital for Children, Glasgow, National Neonatal Clinical Lead, SPSP Perinatal; Tom McEwan – Principal Educator, NHS Education for Scotland.

Version: 2

Co-Author(s): Other Professionals consulted: Dr Felicity Watson, Consultant Obstetrician, Queen Elizabeth University Hospital

Approved By: West of Scotland Managed Clinical Network for Neonatology

Document Id: 345