Delayed cord clamping (DCC), cord milking (CM), and intact cord resuscitation (ICR) are all strategies that pursue the benefits of maximizing placental transfusion.1 Although unevenly, these practices are increasingly featured in recent international guidelines.2 However, there is no evidence regarding the extent and characteristics of their implementation in Spain.

We designed a cross-sectional observational study conducted via an online survey, distributing a questionnaire (Google Forms) to all members of the Sociedad Española de Neonatología (SENeo, Spanish Society of Neonatology) for participation on a voluntary and anonymous basis. Responses were collected between October 2024 and January 2025. The questionnaire included items concerning the use and duration of DCC, the use and indications of CM, and the practice of ICR and how it was implemented.

We received 110 responses corresponding to 69 hospitals, with representation from the 17 autonomous communities in Spain. The sample included respondents from 32.5% of the 212 hospitals offering childbirth and maternity care in Spain.3 Of the total responses, 97.1% corresponded to level 2 and level 3 hospitals (Fig. 1A and B).

Figure 1.

Distribution of hospitals by autonomous community (A) and by level of care (B). Implementation of the main umbilical cord management strategies in the delivery room (C). CM, cord milking; DCC, delayed cord clamping; ICR, intact cord resuscitation.

Of all hospitals, 97.1% reported practicing DCC (≥1 min) in neonates who do not require resuscitation (Fig. 1C). In those that practiced DCC, there were two approaches to determining the timing of cord clamping: when the cord stopped pulsating (61.2%) and after a preestablished interval of 60 to 120 seconds (38.8%).

Only 5.8% of participating hospitals (4/69 centers) had established ICR as an ongoing practice (Fig. 1C), and ICR was implemented exclusively in level 3 hospitals. Three of these hospitals had special resuscitation beds specific for ICR, and two had standard operating procedures to implement ICR in emergency deliveries. The main candidates for ICR are preterm neonates (with gestational age < 34 weeks in two hospitals and < 32 weeks in one). Cord clamping was performed at 2 minutes post birth (two hospitals), 1 minute post birth (one hospital), or based on physiological criteria (one hospital). The barriers to the implementation of ICR reported most frequently by hospitals that did not practice it (94.2% of participating hospitals) were the lack of an adapted protocol (6%), lack of specialized equipment (15%), or the combination of both (79%).

Most hospitals (92.8%) did not practice CM (Fig. 1C). A few (7.2%) practiced it in select cases, mainly in neonates born at or after 28 weeks who needed resuscitation when DCC or ICR were not possible.

The first minutes of life comprehend umbilical cord management and can be a critical window for neonatal outcomes. Our study contributes an updated overview of umbilical cord management and confirms that DCC is a widely adopted practice in Spanish hospitals in neonates who do not need resuscitation.

In nonvigorous neonates, the predominant practice is early cord clamping (ECC), despite the fact that this recommendation was established solely on the basis of expert opinion. Intact cord resuscitation combines the benefits of DCC and early neonatal care delivery and is emerging as an alternative that has already shown benefits in relation to the transition to extrauterine life compared to ECC.4 Despite its feasibility, its implementation is still very limited in Spain due to lack of equipment and protocols.

With regard to CM, the most recent neonatal resuscitation guidelines of the SENeo did not recommend its use due to a lack of scientific evidence.5 However, the American Heart Association, in an update on its neonatal resuscitation guidelines, concluded that CM would be preferable to ECC in nonvigorous neonates born at or after 34 weeks of gestation and a reasonable option for those born at or after 28 weeks who do not require resuscitation.6 In spite of the evidence supporting its use in certain scenarios, our study found that 92.8% of participating hospitals did not practice CM. This low implementation is probably due to the lack of a recommendation in support of it at the national level5 as well as a study by Katheria et al that found an association with an increased incidence of intraventricular hemorrhage in preterm infants less than 27 weeks of gestational age, which may have affected its acceptability.7

Among the limitations of the study, we ought to highlight the potential for selection bias inherent in the voluntary nature of the survey, which may hinder the generalization of the results. Furthermore, the lack of representation of level 1 hospitals limits the extrapolation of the results to this subset of centers. Future studies should specify the gestational age of neonates managed with ICR in order to characterize its applicability according to the degree of prematurity.

To advance toward the optimal umbilical cord management approach, clinical trials are needed that directly compare ICR with current practices, in addition to investment on specialized equipment (particularly specialized resuscitation beds) and staff training. Protocols should also be developed to safely integrate ICR and consider CM in select cases in which ICR or DCC are not feasible.