BOTTOM LINE: You are probably doing fine in your ED already, just delay cord clamping 60 seconds when possible.
The latest guidelines for neonatal resuscitation recommend a 60 second delay minimum in clamping the cord for neonates of all gestational ages who are stable.
In those OVER 28 weeks for whom clamping cannot be delayed (due to maternal or neonatal factors), cord milking can be performed. DO NOT milk the cord in neonates under 28 weeks as this can increase the risk of intraventricular hemorrhage.
Cord milking is performed by gently massaging the cord blood starting about 20cm away from the infant and moving toward the infant's body 3-4 times before clamping. This essentially allows for a transfusion before clamping occurs, increasing LV preload and allowing for improved oxygenation.
Fortunately, in most EDs, the time to obtain the equipment for cord clamping likely takes more than 1 minute, so chances are in your practice you don't have to worry too much about this. But if you happen to have everything prepared, wait 60 seconds before clamping.
References
Lee HC, Strand ML, Finan E, Illuzzi J, Kamath-Rayne BD, Kapadia V, Mahgoub M, Niermeyer S, Schexnayder SM, Schmölzer GM, Weglarz J, Williams AL, Weiner GM, Wyckoff M, Yamada NK, Szyld E. Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2026 Jan 1;157(1):e2025074352. doi: 10.1542/peds.2025-074352. PMID: 41122855.
