Umbilical cord management strategies and risk of intraventricular haemorrhage in preterm neonates: a systematic review and meta-analysis

Objectives To assess the comparative effectiveness of different umbilical cord management strategies for preventing intraventricular haemorrhage (IVH) in preterm neonates. Design A systematic review and meta-analysis. Study sources PubMed, Scopus and Web of Science were searched from inception to March 2025 for relevant randomised controlled trials. Participants All preterm neonates born <37+0 weeks of gestation. Interventions All umbilical cord management strategies, including immediate cord clamping (ICC), delayed cord clamping (DCC), intact umbilical cord milking (I-UCM), cut umbilical cord milking (C-UCM), intact cord stabilisation (ICS), physiology-based cord clamping and extrauterine placental perfusion. Main outcome measures Any grade IVH (grades I–IV) and severe IVH (grades III–IV). Data synthesis Random-effects meta-analyses were conducted to calculate risk ratios (RRs) with 95% CIs. Analyses were stratified for very preterm (<32 weeks) and extremely preterm neonates (<28 weeks). Results Forty-nine studies with 8706 neonates were included. Thirty-five direct comparisons between strategies were made, but no clear evidence of benefit or harm emerged. Certainty of evidence ranged from moderate to very low, often downgraded due to imprecision, risk of bias and inconsistency. The most frequent comparison was DCC versus ICC, with 14 studies (RR 0.90, CI 0.65 to 1.26) for any grade IVH and 11 studies (RR 1.14, CI 0.69 to 1.87) for severe IVH. The second most common comparison, DCC versus I-UCM, showed no benefit: RR 1.03 (CI 0.80 to 1.32; eight studies, 2200 participants) and RR 0.77 (CI 0.35 to 1.66; seven studies, 2032 participants). ICS versus DCC was the only comparison which was rated as moderate certainty of evidence for both, any grade IVH (RR 0.96, CI 0.82 to 1.13) and severe IVH (RR 0.91, CI 0.62 to 1.35). Conclusions No umbilical cord management strategy was clearly associated with increased or decreased IVH risk. Evidence certainty was generally low to very low, primarily due to bias and imprecision.