NeoReviews -- E-Letters for Philip and Saigal, 5 (4) 142-154

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E-Letters published:

We Should Not;. Physiology Clamps the Cord Perfectly: George M. Morley (30 December 2004)

Wait at least for the first breath: Eileen Nicole Simon, PhD, RN (30 December 2004)

Cochrane review: Alistair G.S. Philip (4 January 2005)

We Should Not;. Physiology Clamps the Cord Perfectly 30 December 2004

George M. Morley,
Retired Obstetrician
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Re: We Should Not;. Physiology Clamps the Cord Perfectly

obgmmorley{at}aol.com George M. Morley

The authors conclude that the answer to, “When Should We Clamp the Umbilical Cord” remains “enigmatic.” It was no puzzle for Erasmus Darwin (1801) who wrote: “The navel string should be left untied until the child has breathed repeatedly and till all pulsation in the cord ceases.” He described tying the cord before these events occur as “injurious,” causing blood to be left in the placenta – blood that ought to have been in the child. He recognized childbirth, umbilical cord closure, and placental transfusion to be physiological, normal, natural, healthy (and fragile) events.
The authors omit the one reference that clearly illustrates physiological cord closure (PCC) and placental transfusion – Mavis Gunther’s 1957 article in the Lancet. PCC involves reflexive initiation of crying, reflexive dilatation of pulmonary arterioles, erection and aeration of alveoli by pulmonary blood flow, establishment of the adult circulation by the placental transfusion that initiates function in all the neonate’s life support organs – lungs, brain, heart, liver, gut, respiratory muscles, kidneys and skin, and reflexive control and termination of the placental transfusion – after the child’s life support organs are functioning with a blood volume that is optimal for survival. PCC has produced healthy neonates for millions of years.
After the details of PCC are defined, the authors’ question becomes, “When should we disrupt this delicate anatomy and intricate physiology?” and the results of timed clamping (disruption) can be evaluated in relation to the physiological norm. There is no enigma.
The usual cord-clamping pathology is hypovolemia – blood volume clamped in the placenta; very occasionally, too much blood may be clamped in the neonate – hypervolemia. Common neonatal hypovolemic / ischemic disorders are anemia, hypotension, oliguria / anuria, pallor, hypothermia, IRDS (shock lung), hypovolemic shock and heart failure (retraction respiration), NEC (ischemic bowel infarction), IVH (ischemic hemorrhagic infarction of the germinal matrix), hypoxic-ischemic encephalopathy HIE / CP and mental deficiency / autism. All these injuries correlate with IMMEDIATE cord clamping, (ICC) done to obtain a cord arterial blood pH sample as promoted by ACOG, RCOG, and SOGC; they do not occur with PCC.
Similarly, ICC is a crucial error in neonatal resuscitation, done to rush the child to a resuscitation table. In the depressed child, if the cord is pulsating at birth, the placenta is its only functioning life support organ; it also contains the blood volume needed to establish lung function and function of all other life support organs of the neonate. After ICC, it is futile to ventilate lungs if the child does not have enough blood volume to perfuse them. Rational resuscitation necessitates keeping placental life support functioning until the neonate reflexively closes the cord vessels after its own life support organs are functioning.
In conclusion, despite enigma, the authors seem to recognize that something is seriously amiss with current neonatal practice, and suggest a neonatology campaign to “WAIT A MINUTE”. The rational neonatology campaign should be: “DO NOT CLAMP THE CORD; I WILL RESUSCITATE THE CHILD WITH THE CORD AND PLACENTA INTACT!” Physiology should clamp the cord. A full, referenced answer to this NeoReview is available at www.cordclamping.com
G. M. Morley, MB ChB FACOG

Wait at least for the first breath 30 December 2004

Eileen Nicole Simon, PhD, RN,
Nurse
conradsimon.org/ 11 Hayes Avenue, Lexington, MA 02420-3521
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Re: Wait at least for the first breath

eileen4brainresearch{at}yahoo.com Eileen Nicole Simon, PhD, RN

I am glad to see the shift in opinion from immediate clamping of the umbilical cord to "wait a minute" [1]. Better still would be to wait until pulsations in the cord cease; this would ensure that transition from the placenta as respiratory organ to the lungs has completely taken place.
Philip and Saigal cite the important paper by Redmond et al. that demonstrated that the first breath redirects blood from the placenta to the lungs [2]. Most but not all infants breathe within seconds of birth, and continuing placental respiration is crucial for infants who are slow to begin breathing [3].
Over the past year I have made a systematic search of textbooks on obstetrics and midwifery to determine what the traditional teaching has been. Until about 20 years ago the teaching was explicit that the cord should not be cut until the infant was breathing; most taught waiting for the pulsations to cease. Clamping of the cord immediately at birth is a fairly recent addition to obstetric protocols [4].
If the immediate cord-clamping protocol is followed too literally, nature's intended shift of placental blood to the lungs with the first breath will be prevented in those infants who do not breathe immediately. Even a brief lapse in delivery of oxygen to the brain is detrimental.
A pattern of symmetric bilateral brainstem lesions was found in newborn monkeys subjected to asphyxia for six to eight minutes [5, 6, 7]; asphyxia was inflicted by delivering the infant head into a saline-filled rubber sac and clamping the umbilical cord [6, p247]. Damage was restricted to the brainstem, which led to the idea that a brief lapse in respiration was at most minimally harmful to the newborn infant [5]. However, growth of later maturing areas of the cortex was disrupted in the monkeys subjected to asphyxia at birth [7].
The thoroughbred foals delivered by human assistance (which included umbilical cord clamping) were later found to have brainstem lesions similar to those in monkeys asphyxiated at birth [8]. This suggests that a similar sudden cutoff of circulation and respiration had been inflicted on the foals. Seizure disorder as well as respiratory distress was part of the "Barker Foal Syndrome."
Return to the tradition of waiting for an infant to breathe before clamping the cord might well reduce the rising numbers of mentally handicapped children.
Eileen Nicole Simon References
1. Philip AGS, Saigal S. When should we clamp the umbilical cord? NeoReviews 5(4):e142-e153.
2. Redmond A, Isana S, Ingall D. Relation of onset of respiration to placental transfusion. Lancet. 1965 Feb 6;17:283-5.
3. Dunn PM. Postnatal placental respiration. Dev Med Child Neurol. 1966 Oct;8(5):607-8.
4. Turrentine JE. Clinical Protocols in Obstetrics and Gynecology, Second Edition. The Parthenon Publishing Group, Boca Raton, London, New York, Washington DC, 2003.
5. Windle WF. Brain damage by asphyxia at birth. Sci Am. 1969 Oct;221(4):76-84.
6. Myers RE. Two patterns of perinatal brain damage and their conditions of occurrence. Am J Obstet Gynecol. 1972 Jan 15;112(2):246-76.
7. Faro MD, Windle WF. Transneuronal degeneration in brains of monkeys asphyxiated at birth. Exp Neurol. 1969 May;24(1):38-53.
8. Palmer AC, Rossdale PD. Neuropathological changes associated with the neonatal maladjustment syndrome in the thoroughbred foal. Res Vet Sci. 1976 May;20(3):267-75.

Cochrane review 4 January 2005

Alistair G.S. Philip,
Neonatologist
Stanford University
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Re: Cochrane review

aphilip{at}stanford.edu Alistair G.S. Philip

Readers may like to consult a recent Cochrane Review on this subject. They can find it from the following citation :
Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. The Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003248.pub2. DOI: 10.1002/14651858.CD003248.pub2.