250 - Implementation of an Umbilical Cord Milking (UCM) Initiative in Non-Vigorous Late-Preterm and Term Infants

Publication Number: 4246.250

Nava Katz, Cooper Medical School of Rowan University, Philadelphia, PA, United States; Meredith L. DeForest, Cooper Medical School of Rowan University, Camden, NJ, United States; Alla Kushnir, Cooper Medical School of Rowan University, Camden, NJ, United States

Background: Recent literature has demonstrated that Umbilical Cord Milking (UCM), milking intact umbilical cord from the placenta toward the infant, yields comparable outcomes to delayed cord clamping (DCC) in terms of hemoglobin levels and blood pressure. Additionally, UCM offers the advantage of expediting neonatal resuscitation efforts, making it a potentially beneficial alternative in non-vigorous infants ≥35 weeks gestation. The 2023 AHA and AAP guidelines now suggest that UCM in late-preterm and term infants is a reasonable approach.

Objective: To implement and achieve > 80% adherence to a standardized Umbilical Cord Milking protocol for non-vigorous infants born at ≥35 weeks gestation at an academic medical center.

Design/Methods: IRB-exempt quality improvement project
• Conducted at a tertiary-care academic medical center.
•All non-vigorous infants born at ≥35 weeks gestation were eligible for inclusion.
•Exclusion criteria: if neonate qualified for DCC or became vigorous within 15 seconds of stimulation, < 35 weeks gestation or if a true nuchal was noted at delivery
•UCM procedure - milking a 20 cm segment of the cord four times, allowing brief pauses between each pass to facilitate vessel refill, ensuring no more than a two-second interval between passes.
•PDSA cycle #1: developing a standardized protocol and creating documentation of UCM in the delivery note to track compliance (September 2024).
•PDSA cycle #2: education of pediatric residents and attendings, labor and delivery (L&D) nurses, residents and attendings, as well as all NICU staff through formal and informal presentations.
•PDSA cycle #3: re-education of L&D and NICU staff (November 2024)

Results: •There was no UCM prior to implementation of the protocol.
•In October, 2 of 19 infants who met eligibility criteria (10.53%) received UCM.
•In November, adherence to UCM guideline decreased to 7.69%.
•In December, after the 3rd PDSA, 6 out of 13 eligible infants (46%) received UCM.
•Adherence decreased in January (0% receiving UCM) and February (18.18% received UCM).
•In March utilization decreased to 7% but increased to 40% in April.
•In May utilization decreased to 0% but increased to 25% in both June and July.
•Adherence again decreased to 0% in August

Conclusion(s): Initial provider concerns included maternal consent, infant positioning during UCM, and potential delays in resuscitation. Despite protocol modifications to minimize resuscitation delays, and MFM support, provider hesitancy persisted. With compliance falling again in the most recent month, further PDSA cycles will focus on enhanced interdisciplinary communication and provider engagement.

Adherence to Umbilical Cord Milking Guideline:
IMG_6869.jpegFigure 1. Percentage of eligible infants who received umbilical cord milking (UCM) from October 2024 to August 2025.
The data illustrates monthly variations in UCM utilization, with a peak in December 2024 and a notable decline in August 2025.

Driver Diagram:
IMG_6871.jpegThis driver diagram outlines the key factors involved in implementing and assessing the use of Umbilical Cord Milking (UCM) in our included patient population.