Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Ask the right questions and delayed clamping becomes a "no-brainer"
- Cory Mermer (28 November 2004)
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Immediate cord clamping does increase intraventricular haemorrhage
- David J R Hutchon (29 November 2004)
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Common sense...the least common of all senses
- Graciela Scagliotti (29 November 2004)
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Ending the Epidemic
- George M. Morley (29 November 2004)
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Neurodevelopmental Outcomes of Immediate Cord Clamping
- George M. Morley (11 December 2004)
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Cory Mermer, Independent Researcher New Jersey, USA
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EDITOR, Tucker and McGuire (1) claim that there is "little evidence" of benefit to delayed cord clamping other than reduced need for blood transfusions. Even if this were true, which I have serious doubts about, is this really such a minor benefit as to dismiss it as inconsequential, which they appear to do? I could cite many studies showing far-reaching benefits to allowing physiological placental transfusion to take place (e.g., reduced RDS, reduced anemia, higher blood pressure, improved renal function, higher rate of successful breastfeeding, among others). However, I do not dispute Tucker and McGuire’s assessment that some of these have yet to be proven conclusively in large trials. However, they have framed the question entirely wrong. They are trying to say that a normal physiological process has yet to be proven beyond all doubt as beneficial in some areas. Fine....but so what? Since when do we accept medical interventions as the safe and acceptable norm, while demanding clinical proof of the safety of a natural process? This is a very dangerous assumption to make in ANY aspect of health or medicine. It is an arrogant and misguided concept. But worst of all, in the case of cord clamping, it is a concept that continues to harm the most helpless and innocent in society. Thank goodness for Hutchon’s letter (2) or I would have lost all hope that there was any common sense left in the world. References 1. Epidemiology of preterm birth: Author’s reply. Tucker J, McGuire W. BMJ 2004;329:1287. 2. Epidemiology of preterm birth: Delayed cord clamping used to be taught and practiced. Hutchon DJR. BMJ 2004;329:1287. Competing interests: None declared |
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David J R Hutchon, Consultant Obstetrician and Gynaecologist Darlington Memorial Hospital. DL3 6HX
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Tucker and McGuire need to read the recently published Cochrane review once more. I quote the reviewers conclusions – “Delayed cord clamping by 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion and less intraventricular haemorrhage.” I agree that further large trials are needed to clarify whether the intervention of immediate cord clamping for very preterm infants should be continued. Competing interests: None declared |
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Graciela Scagliotti, Tocogynecologist MD Pirovano Hospital, Buenos Aires, Argentina
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Editors: I am so happy to read about common sense between our colleagues. I agree with the brave answer of Mermer that precedes mine. The lack of common sense is particulary the last cause of harm to our pacients. Why do we forget to think about how many invasive procedures are still done because of our own hurry? Here, at the bottom of the world, we admire your large investigations, indeed, but I'm very glad to read that someone is caring to rescue the simple things to do or not to do, in case we are affecting the natural course of blood passing from placenta to the baby. In our country, 50% of all pregnant women have some kind of anemia. The reason is clear: poverty has risen to 50% of our people. In the land of meat, we don´t eat meat. So, in this case, we agree in this simple and logic procedure: to clamp the umbilical cord when it stops pumping blood. We have recently started to do it this way, after MBE has demonstrated that baby's anemia decreases. We have no results so far, to publish this experience with a brillant statistic program. Beside, it wouldn´t be ethical, but common sense must be applied when there is no money to buy ferrum salt drops. Competing interests: None declared |
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George M. Morley, Retired Obstetrician Northport, Michigan 49670
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Editor: In Tucker and McGuire’s reply to Hutchon’s letter, they completely miss the point he makes, and the point that the Cochrane review emphasizes. That critical point is: THAT IMMEDIATE CLAMPING OF THE UMBILICAL CORD AT BIRTH IS VERY INJURIOUS TO THE CHILD, MUCH MORE INJURIOUS THAN DELAYED CLAMPING. [1] The type and degree of that injury become evident with comprehension of the physiological functions of the cord and placenta during birth. After birth, placental life support functions continue (respiration, alimentation and excretion) until the child’s lungs are functioning and the heart has changed from fetal circulation to the adult circulation. Oxygenated blood is then circulating through the umbilical arteries, and they close in response to increased oxygen tension (cord pulsation ceases). During this time, a massive amount of blood volume is transfused from the placenta; [2] this blood establishes the pulmonary circulation and provides blood volume for initiation of function in all the child’s life support organs – brain, lungs, kidneys, gut, liver, skin and respiratory muscles. When the child’s central venous pressure reaches an adequate level, the intra-abdominal umbilical vessels (arteries and vein) close reflexively and permanently – physiological cord closure. This physiology has been developed over millions of years to produce optimal survival of the neonate with optimal function of its life support organs. The more premature the child, the larger is the relative size of the placenta, and the needed placental transfusion is correspondingly larger. The premature child has all the necessary reflexes to control and terminate that transfusion and reach optimal hemodynamic stability with its placenta. Immediate cord clamping amputates the placental transfusion. The resultant hypovolemia readily accounts for the usual “disorders” of the preemie – IRDS (hypovolemic shock lung); ischemic, hemorrhagic infarction of the germinal matrix (IVH); oliguria; hypothermia (shock); hypotension; ischemic infarction of the bowel (necrotizing entrocolitis); anemia; persistent fetal circulation. The authors extol the value of antenatal steroids without explaining their mode of action. Given long term, they cause growth retardation; given after delivery, they are worthless. But given within hours of delivery, they are powerful constrictors of the placental and umbilical vessels, expressing blood volume from the placenta into the child that is then born with a fairly adequate blood volume – enough to establish lung function despite immediate cord clamping. Hutchon has a better idea that avoids drug side effects and permits placental transfusion after birth. All the above will be met with disbelief from many members of the perinatal professions who have been indoctrinated with the concept that placental transfusion is very pathogenic, causing polycythemia, hyperviscosity, plethora, and generally too much blood. If this concept were true, primates would have become extinct long before the discovery of the cord clamp; even if it were occasionally true, the harmful trait would be bred out at birth. Placental transfusion is a very necessary physiological event in healthy childbirth. Those practitioners who think they can improve physiology with a cord clamp pursue a biological impossibility. Epidemiology is a branch of medical science that deals with the incidence, distribution and control of a disease in a population; the authors assume that preterm birth is a disease, that preterm birth is, in essence, a pathological condition. Hutchon infers, from his experience, that it is quite possible to produce normal healthy preterm babies using delayed clamping, thus asserting that preterm birth is not essentially or invariably pathogenic. The authors have indeed documented an epidemic but the pathogen is not preterm birth; it is a devastating epidemic of immediate cord clamping. Scientifically, the study is fatally flawed by the absence of a physiological control cohort. This cohort should consist of preemies delivered drug free, and with the cord and placenta left intact and attached to the umbilicus for a considerable time after the placenta has been delivered. With the pathogenic cord clamp removed from the scene, and with physiology being uninterrupted, it is quite possible that the epidemic will disappear. This method of delivery (not clamping the cord until the placenta is delivered) is practiced routinely by many midwives in the U.S.A. with excellent results – routine, robust, healthy neonates – and is increasingly popular. Were Hutchon to initiate such a physiological cohort of preterm babies, it is very possible that the results would start another epidemic – of physiology. References: 1. “Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child.” Erasmus Darwin, Zoonomia, 1801 2. Gunther M. The transfer of blood between the baby and the placenta in the minutes after birth. Lancet 1957;I:1277-1280. George Malcolm Morley, MB ChB FACOG Northport, Michigan USA obgmmorley@aol.com Competing interests: None declared |
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George M. Morley, Retired Obstetrician 10252 E. Johnson Road, Northport, Michigan 49670 USA
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Editor: In the worldwide responses to Hutchon’s letter, Tucker and Mcguire admit to evidence that delayed cord clamping (DCC) prevents blood transfusions that correct severe anemia, thus immediate cord clamping (ICC) increases the risk of severe anemia. Mermer cites many studies of DCC reducing anemia and Scagliotti reports that practicing DCC does indeed prevent infant anemia – that is readily treated with oral iron. A full placental transfusion supplies the term infant with enough iron to prevent anemia for one year. However, THE SEEMINGLY INNOCUOUS DIAGNOSIS OF INFANT ANEMIA PORTENDS A VERY OMINOUS DEVELOPMENTAL PROGNOSIS for the ICC child. The multiple publications (1982 – 1991+) of Lozoff [1] show very strong correlation between infant anemia and learning disabilities, behavioural dysfunction, hyperactivity, aggression and attention deficit disorders in grade school children. Lack of mental achievement persists through high school, and treatment of the anemia does not appear to influence outcome. In 1999, Hurtardo [2] reported on a large population of grade school children whose infant blood counts were documented; they were subjected to a standard intelligence test: “The effect of [infant] hemoglobin was significant after all covariates were entered into the equation [odds ratio (OR): 1.28; 95% CI: 1.05, 1.60]. Therefore, for each decrement in hemoglobin, risk of mild or moderate mental retardation increased by 1.28, even after we controlled for all other variables in the equation.” [2] In Hutchon’s second letter, he points out that immediate cord clamping (ICC) results in increased risk of IVH (Cochrane); IVH indicates high risk of permanent brain damage. Contrary to the authors’ claim that there is insufficient evidence on the effect of DCC on neurodevelopmental outcomes in the longer term, there is ample evidence that ICC increases the risk of neurological and mental dysfunction, and that a normal placental transfusion (DCC) indicates high probability of the neonate having normal blood counts and a normal brain. Given an epidemic of preterm birth [3] that includes immediate cord clamping (ICC is also widespread in term births), one would expect to find, in that same population, an epidemic of mental dysfunction, such as autism. It is, therefore, not surprising to find that cesarean birth (where ICC is quite routine) has a higher incidence of autism than vaginal birth. [4,5] The epidemics of autism and ICC are remarkably parallel, and the pathogenicity of ICC is not confined to the domain and standard of care of CESDI [6] mentioned by Hutchon. RCOG, SOGC and ACOG have promoted ICC for over a decade for cord arterial pH determination on compromised neonates, term and preterm, without mention of possible side effects. [7] A thorough discussion of the role of ICC in cerebral palsy and hypoxic ischemic encephalopathy (HIE) follows Shah’s [8] publication at the following BMJ web address: http://fn.bmjjournals.com/cgi/eletters/89/2/F152#539 The current available data on ICC not only make suggested further large trials of DCC unnecessary; they make them impossible. Scagliotti sensibly mentions the ethics of performing ICC. The authors’ suggested further studies require the legal informed consent of the parents to perform this ICC / DCC experiment. The extensive injuries caused by ICC must be disclosed to parents, who would opt otherwise. There are no known hazards of physiological cord closure. Scagliotti’s derision of thoughtless medical intrusion, large investigations and brilliant statistic programs puts the whole situation in proper perspective. If the cord clamp is used routinely to amputate the normally functioning placenta, how many cases need to be recorded to provide adequate odds ratios, mean deviations and met-analysis to assess the statistical probability of injury to the child? The cord clamp can be used without iatrogenic injury after the cord vessels have closed physiologically. George Malcolm Morley MB ChB FACOG obgmmorley@aol.com References: Lozoff B. Jimenez E. Wolf AW. Long Term Development Outcome in Infants with Iron Deficiency. N Eng J Med 1991; 325: 687-94. Hurtado EK et al. Early childhood anemia and mild to moderate mental retardation. Am J Clin Nut. 1999; 69(1): 115-9. Janet Tucker and William McGuire. Epidemiology of preterm birth. BMJ 2004;329: 675 – 8. Hultman CM, Sparen P, Cnattingius S (2002) Perinatal risk factors for infantile autism. Epidemiology. 2002 Jul;13(4):417-23. Glasson, EJ et al., Autism. Arch. Gen. Psychiatry 2004, 61, 618-627 Project 27/28. An enquiry into quality of care and its effect on the survival of babies born at 27-28 weeks. CESDI, 2003. www.cemach.org.uk/publications/p2728/execsum.pdf ACOG Committee Opinion Number 138 - April 1994, published in the International Journal of Gynaecology and Obstetrics 45:303-304 [54], reaffirmed 2000, and listed as current in OBSTETRICS & GYNECOLOGY, February 2002. “Immediately after delivery of the neonate, a segment of the umbilical cord should be doubly clamped …” P Shah, S Riphagen, J Beyene, and M Perlman. Multiorgan dysfunction in infants with post-asphyxial hypoxic-ischaemic encephalopathy Arch. Dis. Child. Fetal Neonatal Ed., Mar 2004; 89: 152 - 155. Competing interests: None declared |
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