P2.275: Implementation and Evaluation of an Umbilical Cord Milking Protocol in Non-Vigorous Late-Preterm and Term Infants

Purpose/Objectives: Recent literature has demonstrated that Umbilical Cord Milking (UCM), milking the intact umbilical cord from the placenta toward the infant, yields outcomes comparable 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. UCM has been associated with reduced need for cardiorespiratory support at birth and a lower incidence of moderate-to-severe hypoxic-ischemic encephalopathy when compared to early cord clamping. The 2023 AHA and AAP guidelines now suggest that UCM in late-preterm and term infants is a reasonable approach. This study aimed to implement and evaluate a standardized UCM protocol for non-vigorous infants born at ≥35 weeks gestation at an academic medical center.

Design/Methods: This IRB-exempt quality improvement study was conducted at a tertiary-care academic medical center. All non-vigorous infants born at ≥35 weeks gestation were eligible for inclusion. Infants were excluded if they qualified for DCC or became vigorous within 15 seconds of stimulation. Providers were instructed to perform UCM by milking a 20 cm segment of the cord four times, pausing briefly between passes to allow for vessel refill, with no more than two seconds between each pass.
The initial PDSA cycle, implemented in September 2024, focused on developing a standardized protocol and establishing a documentation process to monitor compliance. The second PDSA cycle emphasized education, targeting residents, attending physicians, L&D nurses, and NICU staff through formal presentations and informal discussions. In December 2024, the third PDSA cycle focused on re-education of L&D and NICU personnel. Future PDSA cycles will aim to reinforce awareness, improve adherence, and evaluate short-term outcomes of UCM and DCC to guide further implementation.

Results: Prior to protocol implementation, no eligible infants received UCM. In October, following the initial rollout, 2 of 19 eligible infants (10.5%) received UCM. This decreased to 1 of 13 infants (7.7%) in November. Following the third PDSA cycle in December, 6 of 15 eligible infants (40%) received UCM. However, utilization declined again in January, with none of the 9 eligible infants (0%) receiving UCM, and only 2 of 11 infants (18.2%) receiving UCM in February.

Conclusion/Discussion: Challenges in coordinating with the obstetrics team delayed the project start by two months. 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 below 20% in the most recent month, further PDSA cycles will focus on enhanced interdisciplinary communication and provider engagement to improve consistent adherence to the protocol. Future steps include workshops to reinforce UCM techniques and regular monthly meetings with the obstetrics team to improve compliance.