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Rapid Responses: Rapid Responses published:
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cord clamping in uk
- pa price (4 November 2006)
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Re: cord clamping in uk
- David JR Hutchon (5 November 2006)
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Is there a role for delayed cord clamping in newborns with cyanotic congenital heart disease?
- Thomas Krasemann (6 November 2006)
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Lotus birth: an alternative to cord clamping?
- Martino Dall'Antonia (10 November 2006)
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Delayed Cord Clamping and HIV
- Douwe A A Verkuyl (10 November 2006)
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Delayed Cord Clamping Should be Adopted Immediately
- Eileen Nicole Simon, PhD, RN, Bridgewater MA 02324, USA (14 November 2006)
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Is there a necessity to clamp on the maternal side of the umbilical cord?
- GIRISH K LAKSHMANA (20 November 2006)
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A Rational Approach to Timing Cord Clamping in Any Setting
- George M. Morley (20 November 2006)
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Risk of HIV with delayed cord clamping
- Rory H Wilson (25 November 2006)
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Examine the effects of immediate Cord Blood Clamping
- Norman Ende (20 June 2007)
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pa price, np primary care uk reading
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Dear Sirs, What recommendations if any would you make regarding cord clamping in uk? Competing interests: None declared |
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David JR Hutchon, Consultant Obstetrician and Gynaecologist Memorial Hospital, Darlington DL3 8QZ
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Sir, Immediate cord clamping is clearly not physiological. Immediate clamping probably does even more harm in developing countries than in the developed countries because immediate clamping leads to anaemia. There are however other implications and neonatal anaemia is still important in the developed countries. In Darlington, we have a guideline to delay cord clamping for at least 40 seconds, the details can be seen at http://www.hutchon.net/NFMMSIG/cordclamp.htm and this guideline has been in place at the Darlington Memorial Hospital for the past two months. It was a pragmatic decision to make 40 seconds the interval and the rather longer time as suggested by Patrick F van Rheenen and Bernard J Brabin is likely to be closer to the physiological interval. We have also developed a method of resuscitation of the neonate at caesarean section with the cord intact. (Annual meeting of the RANZCOG Nelson 2005). Although we have not included this method in the guideline there are plans to do so. Fetal distress is a common reason for instrumental delivery or caesarean section. The fetal compromise is often due to cord compression associated with a nuchal cord. A nuchal cord results in compression of the low pressure venous return of oxygenated blood from the placenta. Blood continues to be pumped out by the fetal heart and the obstructed return from the placenta results in a congested placenta and a depleted fetal blood volume. If the cord is clamped immediately at delivery, although the return from the placenta is now relieved, the excess blood, which is oxygenated blood, never has any opportunity to return to the newborn. In these circumstances it is particularly important to be able to resuscitate the baby with the cord return still intact. Preparation for neonatal resuscitation needs to be made at the same as preparation for the caesarean section. Every maternity unit in the UK needs to adopt these guidelines. David Hutchon Competing interests: None declared |
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Thomas Krasemann, Consultant Paediatric Cardiologist Evelina Children's Hospital, Guy's & St Thomas Hospital, Lambeth Palace Road, London SE1 7EH
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With interest I read the article by van Rhenen and Brabin. Their recommendations are very practical and detailed. While their focus on the children was mainly on weight and gestational age, other conditions like congenital heart disease might be taken into account. It is known that anaemia in newborn babies might lead to haemodynamic changes including cardiac failure (1, 2). Prenatal anaemia might present as severe cardiac failure as hydrops fetalis. After birth the symptoms are usually tachycardia and tachydyspnea. Babies with congenital heart disease might react even more severely, especially in the presence of a single ventricle morphology. A Hb-level in the upper range of normal is usually wanted in these cyanotic congenital heart diseases. Now that the diagnosis is often known prenatally (3), the delayed cord clamping might be very useful especially in this subgroup of newborns. 1. Moller JC, Schwarz U, Schaible TF, Artlich A, Tegtmeyer FK, Gortner L: Do cardiac output and serum lactate levels indicate blood transfusion requirements in anemia of prematurity? ntensive Care Med. 1996 May;22(5):472-6. 2. Alkalay AL, Galvis S, Ferry DA, Simmons CF, Krueger RC Jr: Hemodynamic changes in anemic premature infants: are we allowing the hematocrits to fall too low? Pediatrics. 2003 Oct;112(4):838-45. 3. Sharland G: Routine fetal cardiac screening: what are we doing and what should we do? Prenat Diagn. 2004 Dec 30;24(13):1123-9. Review. Competing interests: None declared |
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Martino Dall'Antonia, Microbiology consultant Queen Elizabeth Hospital Woolwich London SE18 4QH
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Dear Sir, The article adds to the body of evidence of the beneficial effects of delayed umbilical cord clamping. Umbilical cord infections contribute to neonatal mortality and morbidity in resource poor settings. We should question if cord clamping is necessary. The experience of mothers and midwifes that practice the so-called lotus birth would suggest the contrary. Unfortunately, there is at present an almost complete lack of scientific evidence to support it. Competing interests: None declared |
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Douwe A A Verkuyl, Gynaecologist Driebergen, The Netherlands
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Sir, The contribution about delayed cord clamping is timely and helps to sharpen the approach in the third stage of labour. Nothing is said however about Rhesus incompatibility which is a minor problem in most developing countries (1). However, early clamping of the cord is nevertheless everywhere advocated if the mother is known to be Rhesus negative, the delivery is not certain to be her last and the father of the child is not certain to be also Rhesus negative. We are worried in Rhesus incompatibility that erythrocytes, at the time that the placental connections become disrupted, will pass from the baby to the mother: from a low blood pressure system to a higher pressure system. Around 30% of the Human Immunodeficiency Virus (HIV) mother-to- child transmissions seems to occur during delivery. It is likely that the infection is caused by exposure to secretions and blood of the mother of the baby’s skin and mucous membranes during delivery, but also via blood of the mother entering the baby’s circulation directly. This seems easier then the other way round because of the pressure gradient. In the Far East cords are clamped early I understand because of the fear of Hepatitis B transmission, while Hepatitis B can be largely prevented by active and passive immunisation. Of course,possible larger transfusions from child to mother in case of Rhesus incompatibility can be controlled by giving more Anti D. Similar management options do not exist for HIV transmission. Is in areas where HIV infections are a large problem delayed cord clamping really wise? (2) 1.Verkuyl DAA. Is antenatal antibody screening worthwhile in a Zimbabwean population. Central African Journal of Medicine 2001; 47(1): 26 -28. 2.Verkuyl DAA. Practising obstetrics and gynaecology in areas with a high prevalence of HIV infection. Lancet 1995; 346:293-6. Competing interests: None declared |
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Eileen Nicole Simon, PhD, RN, Nurse Bridgewater State Hospital, Bridgewater MA 02324, USA
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The advice of van Rheenen and Brabrin [1] should be immediately adopted in all obstetric practice. It is heartening to see in Rapid Responses from Shrestha and Lemay [2, 3] that some memory remains of the long tradition of waiting for pulsations in the cord to cease before severing it. Pulsations are from the infant's heart circulating blood back to the placenta, for maintaining respiration until the lungs are fully functional. Transfer of blood from the placenta to the lungs is essential for neonatal transition without a lapse in respiration [5]. Respiration at the cellular level, in all organs, depends upon gas exchange mediated by hemoglobin. Adequate blood must fill capillaries surrounding the alveoli before carbon dioxide can begin to be exchanged for oxygen in the lungs. Current practice, to "deliver - clamp - ventilate," prevents transfer of blood to the lungs with the clamp. What good then is ventilation? Respiratory depression at birth has become a frightening dilemma [6, 7]. As for concerns about Rhesus incompatibility and jaundice: (1) Clamping of the cord creates pressure and bursting of capillaries in the placenta. This could be the mechanism by which fetal blood gets into the mother's circulation. (2) Bilirubin levels are normally high in the newborn, but bilirubin only gets into the brain if the blood-brain barrier is compromised. The blood brain barrier is disrupted by even a brief lapse in respiration at birth [8]. [1] van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. BMJ. 2006 Nov 4;333(7575):954-8. [2] Shrestha BM. Rapid response to: This week in the BMJ/Delayed cord clamping reduces infant anaemia. BMJ 2006 Nov 4;333(7575) http://www.bmj.com/cgi/eletters/333/7575/0-b#147269 [3] Lemay C. Rapid response to: This week in the BMJ/Delayed cord clamping reduces infant anaemia. BMJ 2006 Nov 4;333(7575) http://www.bmj.com/cgi/eletters/333/7575/0-b#148041 [5] Mercer JS, Skovgaard RL, Peareara-Eaves J, Bowman TA. Nuchal cord management and nurse-midwifery practice.J Midwifery Womens Health. 2005 Sep-Oct;50(5):373-9. [6] Baskett TF, Allen VM, O'Connell CM, Allen AC. Predictors of respiratory depression at birth in the term infant. BJOG. 2006 Jul;113(7):769-74. [7] Milsom I, Ladfors L, Thiringer K, Niklasson A, Odeback A, Thornberg E. Influence of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a Swedish urban population. Acta Obstet Gynecol Scand. 2002 Oct;81(10):909-17. [8] Lucey JF, Hibbard E, Behrman RE, Esquival FO, Windle WF. Kernicterus in asphyxiated newborn monkeys. Experimental Neurology 1964; 9:43-58. Competing interests: None declared |
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GIRISH K LAKSHMANA, Senior House Officer in Paediatrics Bassetlaw Hospital, Worksop S81 0BD
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I am not going to the argument of clamping the cord delayed or early is beneficial to baby. My point is that, is there any basis for the clamping the cord on the maternal side because logically not clamping the cord on maternal side makes the placenta less congested and helps in the easy expulsion of placenta there by reducing the time of third stage of Labour. I am making this point from my personal experience. I was born in a village in south India . My mom told me that experienced(not medically trained) old lady was incharge of the delivery . As soon as I was born she tied the cord on my side and cut the cord and did not put the clamp(as there was no facility to have a clamp) on my mothers side. The placenta was expelled and there were no issues of maternal bleeding. When I enquired this with my mom who is living in India now, she says that this was the way delivereies use to happen at that time, and she says she cannot recall any incident of prolonged maternal bleeding Competing interests: None declared |
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George M. Morley, Retired Obstetrician Gynecologist Northport, MI 49670
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The concept of an optimal time to clamp an umbilical cord is illogical; it falsely presumes that the cord should be clamped. The child’s anatomy and physiology close the cord vessels perfectly. Placental transfusion (PT) and umbilical cord vessel closure are physiological parts of physiological childbirth, regulated by reflexes and responses to stimuli. The cord vessels close when the child has attained a physiological (optimal, maximum) blood volume. [1] The umbilical arteries usually close first as does the ductus arteriosis [2] in response to oxygenated blood. [2] Placental respiration is maintained until the lungs function; asphyxia is avoided. High central venous pressure closes the umbilical vein and the ductus venosis reflexively; the hepatic portal venous system is formed. Increased pulmonary blood flow closes the foramen ovale, changing fetal to adult circulation. PT is instrumental in effecting these massive circulation changes; in essence, blood volume, transferred by gravity or uterine contraction, shifts the respiratory, alimentary and excretory functions of the placenta to the corresponding life support organs of the newborn. PT also ensures adequate brain blood flow for neural regulation and coordination of all newly functioning life support systems. Physiological cord closure ensures physiological placental transfusion and results in a physiological neonate – a red, bawling, squirming, active, hungry child that soaks diapers within hours of birth. All of this complex, exquisite physiology requires ABSENCE OF THE CORD CLAMP. The iatrogenic cord clamp is not a part of human, primate or mammalian anatomy or physiology. Application of a cord clamp prior to physiological cord closure botches this intricate anatomy and physiology, resulting in injury. In general terms, the sooner the clamp is applied, the greater is the injury. Brabin and van Rheenen’s “victims of immediate cord clamping,” (ICC) have lost a lot of blood. In extreme cases they are very hypovolemic, and after birth are prone to hypovolemic / ischemic pathology – ischemic encephalopathy with infarction of basal nuclei and brain cortex, hyaline membrane disease – “shock lung,” necrotizing entero-colitis – bowel infarction, and cortical necrosis (infarction) of the kidneys. The ICC child gradually restores blood volume with plasma, diluting its remaining red cells; the degree of resulting anemia accurately reflects the amount of blood clamped in the placenta. Transfusion of red cells readily corrects this anemia and the infant’s iron stores; it does not correct the ischemic brain damage. The association of infant anemia “with impaired mental and motor development” is NOT confined to “resource poor countries.” [3] A large study on grade school children in Dade County, Florida compared a standard IQ test to infant hemoglobin levels. “FOR EACH DECREMENT IN HEMOGLOBIN, THE RISK OF MENTAL RETARDATION INCREASED BY 1.28.” [4] In other words, for each portion of blood volume clamped in the placenta at birth, the grade school IQ of the child decreases accordingly. Thus the true origin of impaired mental and motor development is birth hypovolemia / brain ischemia due to early cord clamping. Macroscopic brain infarcts are visible in the NICU on MRI scans. Mental retardation may not be apparent until grade school. Infant anemia results from birth blood loss. The degree of anemia documents the amount of blood loss, and forecasts the degree of mental retardation in grade school. A child with a physiological blood volume at birth is immune to ischemic injury and mental retardation. Hutchon’s response to this paper deserves comment: Hutchon’s description of physiological reversal of hypovolemic pathology in cases of fetal distress doubly emphasizes the extensive damage that can result from compounding existing pathology with a cord clamp. Hutchon’s delayed clamping at C-section should prevent the frequent hypovolemia / anemia that occurs in these neonates. Autism (mental retardation) is several times more likely to occur in C-section children than in vaginal births. [5] The autism epidemic has paralleled the C- section epidemic; normal blood volumes should reverse it. Brabin and van Rheenen’s paper is a milestone in the direction of preventing birth trauma caused by the cord clamp. All their recommendations are pointing towards physiological perfection. Prudent obstetricians and midwives should read this paper carefully and use cord clamps with great discretion, if at all. Physiology works! Every time. References: 1. Gunther M. The transfer of blood between the baby and the placenta in the minutes after birth. Lancet 1957;I:1277-1280. 2. 1986 Beischer, Norman A & MacKay Eric V (1986) WQ 100.3 B 4230 1986 Obstetrics and the Newborn: An illustrated textbook, Second Edition. WB Saunders Company, Sydney, Philadelphia, London, Toronto, Tokyo, Hong Kong, 1986. Q. What is the significance of continued pulsation of the arteries in the umbilical cord at birth? A. It means that respiration has not commenced. The physiological stimulus causing closure of umbilical arteries (and ductus arteriosus) is an increase in oxygen saturation of the blood which occurs when the lungs expand with air." 3. Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T. Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev 2006 May;64(5 Pt 2):S34-S43. 4. Hurtado E, Claussen AH, Scott KG. Early Childhood Anemia and Mild to Moderate Mental Retardation. Am.J. Clin Nut. 1999:69:115-119 5. Hultman CM, Sparen P, Cnattingius S (2002) Perinatal risk factors for infantile autism. Epidemiology. 2002 Jul;13(4):417-23. G. M. Morley, MB ChB FACOG Northport, Michigan USA obgmmorley@aol.com www.cordclamp.com Competing interests: None declared |
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Rory H Wilson, Medical Superintendent Kiwoko Hospital. Luwero. Uganda
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Sir, the paper by Patrick van Rheenen and Bernard Brabin was most practical and pragmatic. However it's lack of referring to HIV is a huge ommission. They rightly comment on the prevelance of neonatal anaemia in sub-Saharan Africa. This distribution corresponds closely with the epidemic of HIV. Since the advent of HIV, early cord clamping has been advocated and practiced in Uganda in an effort to minimise the risk of transfer of virus from mother to infant as the placenta separates. In a well organised unit with regular antenatal HIV testing it should be possible to screen out those mothers with negative HIV serology tests to have delayed cord clamping practiced, however this could easily lead to confusion in less organised units with the risk of delayed clamping being practiced more widely. It would be most helpful if the authors had addressed this issue in an attempt to quantify risks and suggest a clear approach in the very setting where with such prevalent anaemia there is potenitally much to be gained for some, and with such prevalent HIV there is potentially so much to be lost for others. rory@doctors.org.uk Competing interests: None declared |
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Norman Ende, Professor of Pathology and Laboratory Medicine UMDNJ New Jersey Medical School 070101
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Sir, I recently read van Rheenen and Brabin’s November 2006 BMJ article, “A practical approach to timing cord clamping in resource poor settings”1. This article served to underscore the recent developing world interest in the ethical, legal and clinical significance of the timing of clamping the umbilical cord at birth2,3. Cord blood contains cells, called various names including Berashis (“in the beginning”) cells, which are undesignated pleuripotent (possibly totipotent) stem cells. Cord blood’s potential benefit has been seen in its greater than human bone marrow ability to produce hematopoeitic colonies in culture, as well as in its effective transplantation for treating hematopoeitic disease in infants and, more recently, in adults 4 When the medical community became aware of cord blood’s potential to treat hematological diseases, there was a movement to collect larger samples by means of immediate cord clamping after delivery. Some of these collection techniques produced samples even over 200 mLs 5. Although there was immediate concern as to the clinical effects of removing such a large volume (i.e., anemia, interventrical hemorrhage, additional long- term effects) 6,7, this practice of immediate clamping was executed in major medical centers, making the evaluation of the long term significance of early clamping possible. The practice began and continued through the early nineties, those newborns would now be late teens. It was not until 1994 that Medical Ethic Committees of the American Medical Association made a ruling on this matter in cord blood. Concomitantly, technological advances have allowed very low birth weight infants to survive. There is now evidence that these infants develop diseases sooner than normal birth weight infants. Therefore, there may be considerable clinical significance in the number of stem cells available to the infant at birth. Publications as far back as 1989 have confirmed a direct correlation between high birth weight and successful hematopoeitic colony formation. For adult cord blood transplantation, recent publications indicate that more than one unit, only partially matched for HLA 4 can be utilized. This increases availability of cord blood and negates the necessity of collecting larger units. Human cord blood has been shown to ameliorate diseases associated with aging in animal models. There have been recent publications of the successful use of cord blood for type 2 diabetes 8 and ongoing studies on type 1 diabetes treatment using autologous transplant. This research may add to understanding the significance of the number of stem cells the new born receives at birth 9,10. As long as the cord is pulsating it can be assumed that the cord blood is returning to the new born, which may be approximately 3 minutes 5,11,12. A retrospective study of these immediately clamped infants could not only shed light on the appropriate time to clamp cord, but might also expedite clinical trials on human disease that have been successfully treated with human cord blood mononuclear cells in animal models without immunosuppressant 13. Sincerely,
1. van Rheenen PF, Brabin BJ A practical approach to timing cord clamping in resource poor settings. BMJ. 2006 Nov 4;333(7575):954-8. 2. Diaz-Rossello JL. International Perspectives: Cord Clamping for Stem Cell Donation: Medical Facts and Ethics. Neoreviews 2006;7(11):e557-63. 3. Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 2007 Mar 21;297(11):1241-52. 4. Schoemans H, Theunissen K, Maertens J, Boogaerts M, Verfaillie C, Wagner J. Adult umbilical cord blood transplantation: a comprehensive review. Bone Marrow Transplant 2006;38(2):83-93. 5. Wagner JE, Broxmeyer HE, Byrd RL, et al. Transplantation of umbilical cord blood after myeloablative therapy: analysis of engraftment. Blood 1992;79(7):1874-81. 6. Grizzard WS, Sr., Payne FR, Jr. Collection of umbilical cord blood for transplantation. Blood 1992;80(6):1623; author reply 4. 7. Ende N. Cord blood collection: effects on newborns (medical-legal). Blood 1995;86(12):4699-700. 8. Bhattacharya N. Placental umbilical cord blood transfusion: a new method of treatment of patients with diabetes and microalbuminuria in the background of anemia. Clin Exp Obstet Gynecol 2006;33(3):164-8. 9. MJ Haller, HL Viener, T Brusko, C Wasserfall, K McGrail, C Cogle, S Staba, M Atkinson, DA Schatz Insulin Requirements, HbA1c, and Stimulated C-peptide following Autologous Umbilical Cord Blood Transfusion in Children with T1D. Abstract 10. Ende, N, Reddi, A. Administration of human umbilical cord blood to low birth weight infants may prevent the subsequent development of type 2 diabetes. Medical Hypotheses 66:1157-1160, 2006. 11. Moinian M, Meyer WW, Lind J. Diameters of umbilical cord vessels and the weight of the cord in relation to clamping time. Am J Obstet Gynecol 1969;105(4):604-11. 12. Yao AC, Moinian M, Lind J. Distribution of blood between infant and placenta after birth. Lancet 1969;2(7626):871-3. 13. Riordan NH, Chan K, Marleau AM, Ichim TE. Cord blood in regenerative medicine: do we need immune suppression? J Transl Med 2007;5:8. Competing interests: None declared |
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