Cord Management Strategies in Multifetal Gestational Births

Over the past four decades, the global rate of multiple gestations has risen dramatically; about 3.2 million twins are born each year.1 In the US, twin and higher-order multiple birth rates were 31.2 and 0.8 per 1,000 births.2 Twins and triplets are nine and thirty times more likely to be born before 34 weeks of gestation, respectively.2 There is approximately a seven-fold increase in neonatal death in twins.3,4 Prematurity is the main contributor to neonatal mortality and complications (e.g., interventricular hemorrhage) and long-term disabilities. (e.g., cerebral palsy).3,5 Improving outcomes of multiple gestations has a significant impact on infant survival and children's health.

During the first few minutes of life, newborns undergo rapid changes in the cardiopulmonary system to adapt to the extrauterine environment. Delivery room (DR) management is crucial for the successful fetal-neonatal transition. Delayed cord clamping (DCC) and umbilical cord milking (UCM) have been shown to facilitate postnatal transition, reduce neonatal morbidities and mortality, and improve neurodevelopmental outcomes.6, 7, 8, 9, 10, 11, 12, 13, 14, 15 The benefits of DCC are even greater in preterm infants compared to term infants. A recent Cochrane review and meta-analyses have shown that DCC reduces neonatal mortality by 30% in preterm infants.9,12,14 Given the high rate of prematurity and associated mortality and morbidity in multiples, this high-risk population may benefit more from DCC and UCM. However, multiple deliveries pose many unique challenges in DR management, including performing DCC and UCM safely for newborns and their mothers. Multiples often require DR resuscitation due to premature births, compromised newborns with twin-twin transfusion syndrome (TTTS), twin anemia polycythemia sequence (TAPS), growth restriction or discordance, fetal anemia, hydrops, cord accident, and/or asphyxia. From an obstetric perspective, multifetal deliveries are associated with an increased risk of postpartum hemorrhage (PPH) due to uterine overdistension, uterine atony, and a high Cesarean delivery (CD) rate. The risk may be further heightened in cases of unplanned or emergent CD, chorioamnionitis, or the use of magnesium sulfate or other uterine relaxants. Logistical considerations include whether delivery of the second/third-born multiple should be undertaken during or following completion of DCC for the first twin, the timing of oxytocin administration for active management of the third stage of labor, and the role of UCM.

Our literature search identified one DCC randomized clinical trial (RCT) and seven observational studies (six on DCC and one UCM) that investigated cord management in the DR in multiple births (Table 1). This review summarized the available evidence on the feasibility, safety, and short-term outcomes of DCC and UCM (Table 2), current recommendations from professional organizations (Table 3), and future perspectives on cord management in multiple births.

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