Intended for healthcare professionals


A practical approach to timing cord clamping in resource poor settings

BMJ 2006; 333 doi: (Published 02 November 2006) Cite this as: BMJ 2006;333:954
  1. Patrick F van Rheenen, consultant paediatrician (,
  2. Bernard J Brabin, professor of tropical child health2
  1. 1 Paediatric Gastroenterology, Department of Paediatrics, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, Netherlands
  2. 2 Emma Children's Hospital-Academic Medical Centre, Amsterdam, Netherlands
  1. Correspondence to: P F van Rheenen
  • Accepted 9 October 2006

There is little agreement among doctors and midwives about the optimal time to clamp the umbilical cord after birth. The most important points of difference relate to maternal and infant safety. Many healthcare workers worldwide tend to clamp the cord and pass the baby off as quickly as possible. Infants in resource poor settings are the main victims of immediate clamping, as this prevents a cost-free means of boosting their small iron stores.

Infant anaemia is common in poor communities, especially where malaria is endemic. In sub-Saharan Africa more than 75% of infants are anaemic before 6 months of age.w1-w3 Infant anaemia is associated with increased mortalityw4 w5 and with impaired mental and motor development.w6 Its prevention is of critical importance, and delaying clamping of the umbilical cord could be an effective strategy to reduce anaemia and improve child survival.

We propose a practice guideline on cord clamping for resource poor countries for singleton vaginal deliveries, based on published systematic reviews, randomised controlled trials, and biological evidence. Taking account of the safety of mothers and infants, we provide evidence about inclusion and exclusion criteria for delayed cord clamping, optimal timing of clamping, infant position during placental-fetal transfusion, and potential side effects. We present the evidence as a series of structured clinical questions, which identify the population concerned (mothers and infants from resource poor countries), the options being compared (mostly delayed versus immediate cord clamping), and the outcome measures used to measure effectiveness and safety of delayed cord clamping. We also present a practical and simple flow chart for quick reference.

Clinical questions

Is delayed cord clamping associated with improved haematological status in infancy?

Four randomised controlled trials, all from developing countries, evaluated haemoglobin concentrations in term infants 2-4 months after birth.25 Meta-analysis showed that haemoglobin concentrations were significantly higher after delayed cord clamping (317 infants, weighted mean …

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