Umbilical cord management strategies and risk of intraventricular haemorrhage in preterm neonates: a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract

• Effect Size: DCC vs ICC for any grade IVH: RR 0.90; DCC vs I-UCM for any grade IVH: RR 1.03

• Primary Outcome: No umbilical cord management strategy showed clear benefit for preventing IVH

• Nnt Or Sensitivity: Cannot be calculated due to non-significant results and lack of absolute risk data

• Confidence Interval: DCC vs ICC: 95% CI 0.65-1.26; DCC vs I-UCM: 95% CI 0.80-1.32

Clinical Application

All interventions are feasible in delivery room settings with appropriate training Relevant to Australian NICUs; current RANZCOG guidelines recommend delayed cord clamping but this review suggests uncertainty about optimal strategy for IVH prevention specifically Preterm neonates <37 weeks gestation in tertiary neonatal intensive care units

Abstract

OBJECTIVES: To assess the comparative effectiveness of different umbilical cord management strategies for preventing intraventricular haemorrhage (IVH) in preterm neonates. DESIGN: A systematic review and meta-analysis. STUDY SOURCES: PubMed, Scopus and Web of Science were searched from inception to March 2025 for relevant randomised controlled trials. PARTICIPANTS: All preterm neonates born <37+0 weeks of gestation. INTERVENTIONS: All umbilical cord management strategies, including immediate cord clamping (ICC), delayed cord clamping (DCC), intact umbilical cord milking (I-UCM), cut umbilical cord milking (C-UCM), intact cord stabilisation (ICS), physiology-based cord clamping and extrauterine placental perfusion. MAIN OUTCOME MEASURES: Any grade IVH (grades I-IV) and severe IVH (grades III-IV). DATA SYNTHESIS: Random-effects meta-analyses were conducted to calculate risk ratios (RRs) with 95% CIs. Analyses were stratified for very preterm (<32 weeks) and extremely preterm neonates (<28 weeks). RESULTS: Forty-nine studies with 8706 neonates were included. Thirty-five direct comparisons between strategies were made, but no clear evidence of benefit or harm emerged. Certainty of evidence ranged from moderate to very low, often downgraded due to imprecision, risk of bias and inconsistency. The most frequent comparison was DCC versus ICC, with 14 studies (RR 0.90, CI 0.65 to 1.26) for any grade IVH and 11 studies (RR 1.14, CI 0.69 to 1.87) for severe IVH. The second most common comparison, DCC versus I-UCM, showed no benefit: RR 1.03 (CI 0.80 to 1.32; eight studies, 2200 participants) and RR 0.77 (CI 0.35 to 1.66; seven studies, 2032 participants). ICS versus DCC was the only comparison which was rated as moderate certainty of evidence for both, any grade IVH (RR 0.96, CI 0.82 to 1.13) and severe IVH (RR 0.91, CI 0.62 to 1.35). CONCLUSIONS: No umbilical cord management strategy was clearly associated with increased or decreased IVH risk. Evidence certainty was generally low to very low, primarily due to bias and imprecision.

References

1. 1.Kuitunen, I., Haapanen, M., Kekki, M., & Kiviranta, P. (2026). Umbilical cord management strategies and risk of intraventricular haemorrhage in preterm neonates: a systematic review and meta-analysis. Archives of Disease in Childhood. Fetal and Neonatal Edition. https://doi.org/10.1136/archdischild-2025-329006