From clamp to care: evidence-based insights to cord management in non-vigorous neonates

BACKGROUND: Placental transfusion through delayed cord clamping is the standard of care for vigorous neonates due to its well-established benefits. However, in non-vigorous infants, the immediate need for resuscitation presents significant challenges, making optimal cord management strategies less clear. Optimizing placental transfusion strategies in this population can enhance hemodynamic stability and facilitate smoother postnatal transition. CONTENT: This narrative review examines current practices, emerging trends, and available evidence on cord management in non-vigorous neonates. It explores various placental transfusion strategies, including intact umbilical cord milking (I-UCM), cut-cord umbilical cord milking (C-UCM), resuscitation with an intact cord (RIC), and short delayed cord clamping (S-DCC). Evidence suggests that I-UCM enables rapid placental transfusion and improves early hemodynamic parameters in term and near-term neonates. However, its use in extremely premature infants is limited due to safety concerns, particularly the risk of intraventricular haemorrhage. RIC represents a physiologically sound approach by allowing resuscitation while maintaining placental circulation, though its implementation is constrained by logistical and infrastructural challenges. C-UCM offers a practical alternative when intact cord strategies are not feasible. S-DCC provides an intermediate transitional strategy, permitting brief stabilization before cord clamping. SUMMARY: Cord management in non-vigorous neonates remains an area of ongoing debate. Alternative strategies such as I-UCM and RIC offer potential advantages, but their use should be individualized based on gestational age, clinical condition, and available resources. OUTLOOK: Further high-quality research is required to determine the safest and most effective cord management strategies for non-vigorous neonates across different gestational age groups.