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Rapid Responses: Rapid Responses published:
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Cord management for nuchal cord
- Soo Downe, Cathie Melvin, Hilary Jackson (17 August 2007)
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Early clamping and cutting of the umbilical cord
- louise sandler (18 August 2007)
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Cord clamping can cause a lapse in respiration, and brain damage
- Eileen Nicole Simon, PhD, RN (18 August 2007)
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How immediate cord clamping causes intraventicular haemorrhage
- David JR Hutchon, Ben O Ononeze (21 August 2007)
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Resuscitation with the cord intact
- David JR Hutchon, Dr Indra Thakur, Consultant Paediatrician. (21 August 2007)
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Umbilical cord claming ending in intestinal obstruction
- Wajdi M Q Amayreh, Waleed Tareef, Ahmed Al Rimoni. (21 August 2007)
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What if there is a high HIV or Hepatitis B prevalence
- Douwe A.A. Verkuyl, Netherlands (23 August 2007)
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Evidence not conclusive
- Diane Farrar, Lelia Duley (23 August 2007)
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Caution with delayed clamping of the umbilical cord
- Nisar A Mir (25 August 2007)
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Evidence-based and quality third stage practices
- Jose Luis Diaz-Rossello, Dr Susan Bewley MA MD FRCOG Consultant Obstetrician/ Maternal Fetal Medicine Guy's & St Thomas' NHS Foundation Trust Women's Services, 10th Floor North Wing St Thomas' Hospital Lambeth Palace Rd London SE1 7NH Susan.bewley@gstt.nhs.uk (25 August 2007)
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Evidence conclusive enough
- David JR Hutchon (27 August 2007)
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Document timing of cord clamping
- David JR Hutchon (30 August 2007)
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Umbilical Cord Clamping: Try Physiology - Let the baby do it!
- George M. Morley, MB ChB FACOG (1 September 2007)
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Ancient routines despite modern medical science
- Linda Morge (3 September 2007)
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Birth Without Violence
- Linda Morge, Stockholm, Sweden (4 September 2007)
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Paediatricians and Obstetricians views
- David J R Hutchon (7 January 2008)
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References for paediatricans and obstetricians view
- David JR Hutchon (8 January 2008)
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Soo Downe, Professor Women, Infant and Sexual Health (WISH) group, University of Central Lancashiire Preston, PR1 2HE, Cathie Melvin, Hilary Jackson
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Dear Editor We were very interested to read the editorial by Andrew Weeks on umbilical cord clamping after birth. We are in the process of designing an observational study of the impact of the widely varying approaches among midwives to managing the nuchal cord, as identified by our recent regional survey in this area1. In designing this study, we have been influenced by work of Judy Mercer and colleagues on the Blood Volume Model of neonatal transition 2, 3, and we feel this work could inform the growing debates both in the area of timing of umbilical cord severance for the normal term neonate, and in the circumstance of a nuchal cord. We feel that this is particularly relevant in centres and studies where early labour ultrasonographic imaging of the fetus is being considered to identify the presence of nuchal cord, since there seems to be little agreement on the best approach to take once such a cord is identified. In our view, consideration of both the risks and the benefits of early versus late severing of the nuchal cord should be taken into account in such settings, and in studies of this area of practice. Yours sincerely Soo Downe, Cathie Melvin, Hilary Jackson 1 Jackson H, Melvin C, Downe S 2007 Midwives and the fetal nuchal cord: a survey of practices and perceptions. Journal of Midwifery and Womens Health 52 49-55 2. Mercer, J. and R. Skovgaard R 2002 Neonatal transitional physiology: a new paradigm. J Perinat Neonatal Nurs, 2002. 15(4): p. 56-75. 3. Mercer J, Skovgaard R 2004 Fetal to neonatal transition: first do no harm. In: Downe, S (ed). Normal Childbirth: evidence and debate. Elsevier, Edinburgh. Competing interests: The authors are designing a study in this area |
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louise sandler, special ed aide Radnor Middle School
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This is a thought on early cutting and clamping of the umbilical cord. My son was born with the umbilical cord around his neck and so it had to be cut very early. He was diagnosed with jaundice and I am wondering if that may have been avoided if the cord had not be cut so soon. 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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It is appalling that immediate clamping of the umbilical cord has become such a common practice. The traditional teaching, before the 1980s, was that the newborn infant should be clearly breathing on his own before clamping the cord, and that it was safer to wait for cessation of pulsations in the cord. Pulsations of the cord are evidence of persistent fetal circulation. Pulsations are from the infant's heart continuing to pump blood back to the placenta. Transition from placental to pulmonary respiration depends upon closure of shunts in the heart, the foramen ovale and ductus arteriosus, and placental blood must be transferred to the capillaries that supply the alveoli [1, 2]. Jaykka demonstrated that the alveoli are not opened by simple ventilation. The alveoli expand, first from fluid filling the capillaries [1]. Then hemoglobin releases carbon dioxide, and exhalation initiates the first breath. Hooper et al. (2007) have just published some dramatic pictures of this process in rabbits [3]. Most infants breathe immediately at birth, indicating that a rapid shift of placental blood to the lungs takes place in the majority of infants [4]. Clamping the umbilical cord thus may appear to be harmless, but "respiratory depression" has recently become a matter of some concern [5, 6]. The statistics for respiratory depression are similar to statistics for the increased prevalence of autism [7]. The inferior colliculi in the midbrain auditory pathway are more susceptible to damage than any other part of the brain following a catastrophic lapse of respiration, as can happen with clamping of the umbilical cord before a baby has begun breathing [8-10]. That the brain can be impaired in a way that might disrupt language development is the greatest danger of a sudden disruption of respiration at birth. Umbilical cord clamping (and cord blood banking) are dangerous. These practices should be stopped immediately. Eileen Nicole Simon, PhD, RN conradsimon.org References 1. Jaykka S. Capillary erection and lung expansion; an experimental study of the effect of liquid pressure applied to the capillary network of excised fetal lungs. Acta Paediatr Suppl. 1957 Jan;46(suppl 112):1-91. 2. Mercer JS, Skovgaard RL. Neonatal transitional physiology: a new paradigm. J Perinat Neonatal Nurs. 2002 Mar;15(4):56-75. 3. Hooper SB, Kitchen MJ, Wallace MJ, Yagi N, Uesugi K, Morgan MJ, Hall C, Siu KK, Williams IM, Siew M, Irvine SC, Pavlov K, Lewis RA. Imaging lung aeration and lung liquid clearance at birth. FASEB J. 2007 May 29; [Epub ahead of print] 4. Redmond A, Isana S, Ingall D. Relation of Onset of Respiration To Placental Transfusion. Lancet. 1965 Feb 6;1:283-5. 5. 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. 6. 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. 7. Hitchen L. Rise in prevalence of autism in children continues to baffle researchers. BMJ. 2007 May 19;334(7602):1027. 8. Windle WF. Brain damage by asphyxia at birth. Sci Am. 1969 Oct;221(4):76-84. 9. Leech RW, Alvord EC Jr. Anoxic-ischemic encephalopathy in the human neonatal period. The significance of brain stem involvement. Arch Neurol. 1977 Feb;34(2):109-13. 10. Natsume J, Watanabe K, Kuno K, Hayakawa F, Hashizume Y. Clinical, neurophysiologic, and neuropathological features of an infant with brain damage of total asphyxia type (Myers). Pediatr Neurol. 1995 Jul;13(1):61- 4. Competing interests: My second son, born in a face presentation, was resuscitated with difficulty. His early motor development was normal, but sadly his language development was not. The articles by Windle and others, demonstrating damage in the auditory pathway by asphyxia at birth, provided me with a plausible explanation for my son's difficulties learning to speak. |
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David JR Hutchon, Consultant Obstetrician and Gynaecologist Darlington Memorial Hospital, DL3 6HX, Ben O Ononeze
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Intraventricular haemorrhage is a well recognised complication of preterm birth. Immediate cord clamping increases the risk of this haemorrhage (1,2) and has been implicated in other forms of brain damage.(3)
How can immediate cord clamping cause brain damage?
The model clarifies what must happen when the cord is clamped before the pulmonary circulation is fully functional. When the cord is clamped 40% of the CCO must be proportionately redirected to the residual circulation. The systemic pressure almost doubles as does the cerebral circulation. The model shows that blood flow in the aortic isthmus must reverse as most of the flow through the ductus arteriosus is directed back up the aorta to the carotid arteries. Once the pulmonary circulation increases the abnormal cerebral and aortal flow returns to normal. However early cord clamping results in a loss of 40% of the cardiac return from the placenta and so shortly after the return to normal, the systemic blood pressure falls further as the cardiac output falls. If ventilation has started by this stage the pulmonary circulation greatly increases and flow through the ductus arteriosus virtually ceases, further reducing the systemic blood pressure. The filled capacity of the fully functional pulmonary circulation also reduces the circulating volume for the rest of the body. Could the sudden sharp increase in the cerebral pressure and flow be responsible for the vascular damage which later shows as intra-ventricular haemorrhage? It is commonly observed that quickly after clamping the cord of the apnoeic neonate, respiratory efforts commence. Could this be due to the sudden cerebral insult described above? Could the subsequent hypotension lead to hypoxic ischaemic encephalopathy. Could the sudden increase in blood pressure cause myocardial strain which leaves the heart weakened? The model confirms that the precise time of clamping is less important than the state of the circulation when the clamp is applied. Clamping a functional placental circulation will always result in a sudden redirection of blood flow. Physiological transformation consists of a slow closure of the cord arteries flowed by a controlled closure of the ductus venosus. This will normally have been completed by three minutes. References 1. 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. 2. Mercer J S, Vohr B R, McGrath M M, Padbury J F, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular haemorrhage and late onset sepsis: A randomised controlled trial. Pediatrics 2006 117 1235 - 1242 3. Hutchon DJR Immediate cord clamping must stop - no excuses! http://bmj.com/cgi/eletters/334/7602/1027-f#166259, 20 May 2007 4. Hutchon D, Ononeze B. A model to explain intra-ventricular haemorrhage following immediate cord clamping at birth. The British International Congress of Obstetrics and Gynaecology. London July 2007 P02.37 Competing interests: None declared |
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David JR Hutchon, Consultant Obstetrician and Gynaecologist Darlington Memorial Hospital. DL3 8 6HX, Dr Indra Thakur, Consultant Paediatrician.
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References 1. Hutchon DJR, Thakur I. Delayed cord clamping with full neonatal resuscitation at caesarean section. British International Congress of Obstetrics and Gynaecology. London 2007:FC4.15 2. Hutchon DJR. How to resuscitate the neonate with the cord intact at Caesarean Section. British International Congress of Obstetrics and Gynaecology. London 2007:P02.28 Competing interests: None declared |
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Wajdi M Q Amayreh, Specialist paediatrician King Hussein Medical Centre, Amman, Jordan, Waleed Tareef, Ahmed Al Rimoni.
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During my experience in paediatrics, I did not face any particular problems related to the timing of umbilical cord clamping until recently we were faced by an interesting case of acute intestinal obstruction in a newborn baby. Although this seems to be a very rare complication, but in view of the medical as well as the medicolegal consequences, I do think that apart from other reasons supporting delayed clamping, this sort of complication should warrant extra care in clamping the umbilical cord and if at all possible not to rush for early cord clamping. Competing interests: None declared |
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Douwe A.A. Verkuyl, gynaecologist Hoogeveen,, Netherlands
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The evidence for late clamping seems overwhelming and logical. Working in the Netherlands this is how I do it. I also worked for 25 years in Southern Africa. The last few years there, 30% of the deliveries were by HIV positive women. Most of who did not know their HIV status. I thought/think that delayed cord clamping will increase the chance of mother to child transmission especially because it is at a time that the mother to child circulatory barriers are destroyed. Similarly early clamping is adviced, is it not, with potential future Rhesus problems. Am I wrong? Can somebody please give an educated answer. Competing interests: None declared |
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Diane Farrar, Senior Research Midwife Bradford Institute of Health Research, Lelia Duley
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Weeks believes there is ‘considerable evidence that early cord clamping does not benefit mothers or babies and may even be harmful’. Whilst we agree that delay in clamping is closer to what nature intended at birth, and may well have other advantages, we do not agree that current evidence is conclusive enough to justify recommendations for universal change in practice without further evaluation. For the mother, most trials evaluating timing of cord clamping have not reported maternal outcome. In the systematic review for preterm infants, none of the trials reported maternal outcome.(3) The review of trials for term infants comments there are insufficient data for conclusions about maternal outcome.(1) It is plausible that drainage of the placental circulation may influence the speed of uterine contraction and placental separation.(4) Evidence about the comparative effects for the baby is promising, but inconclusive. The study quoted by Weeks to support the statement that average haemoglobin concentration increases at four months following delayed cord clamping included 91 infants, and the difference was not sustained to six months.(5) The only other trial to have followed children until six months also failed to show a clear impact on anaemia (356 infants’ relative risk (RR) 0.85, 95% confidence interval (CI) 0.51 to 1.43).(5) This does not seem adequate support for the view that the increased placental transfusion associated with delayed clamping is ‘life saving’. If delayed cord clamping does reduce either iron deficiency or anaemia in early childhood, this may in turn improve neurodevelopment. (2) As iron deficiency in early childhood may lead to irreversible delay in neurodevelopment this would seem a particularly important outcome to assess. Similarly, the evidence about potential harmful effects for delayed clamping is not as reassuring as Weeks suggests. For term babies, delay in clamping the cord appears to be associated with an increase in the risk of polycythaemia (haematocrit above (55%) at 24-48 hours (7 trials, 403 infants; RR 3.82, 95% CI 1.11 to 13.21).(1) No infants in either group required treatment. In the three trials (699 infants) reporting treatment for jaundice, the confidence intervals for the relative risk are 0.71 to 4.46; too wide for reliable conclusions about the impact of timing of clamping. (1) We would therefore argue that in countries such as the UK, where early clamping is the recommended policy in three quarters of maternity units (6), there is an opportunity to conduct large randomised trials, which measure outcome for both women and children, including follow up until children are one or two years old. References 1. Hutton E, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates - Systematic review and meta-analysis of controlled trials. JAMA, 2007. 297(11): p. 1241-1252. 2. Martins S, Logan S, Gilbert R. Iron therapy for improving psychomotor development and cognitive function in children under the age of three with iron deficiency anaemia. Cochrane Database of Systematic Reviews, 2001(2): p. Art. No.: CD001444. DOI:10.1002/14651858.CD001444. 3. Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews, 2004. 4: p. Art. No.: CD003248. DOI: 10.1002/14651858.CD003248.pub2. 4. Soltani H, Dickenson F, Symonds I. Placental cord drainage after spontaneous vaginal delivery as part of management of the third stage of labour. Cochrane Database of Systematic Reviews 2005(4): p. CD004665. DOI: 10.1002/14651858.CD004665.pub2. 5. Van Rheenen MP, Brabin B. Late umbilical cord clamping as an intervention for reducing iron deficiency anaemia in term infants in developing and industrialised countries: a systematic review. Annals of tropical paediatrics, 2004. 24: p. 3-16. 6. Winter CM, Macfarlane A, Deneux-Tharaux C, Zhang W-H, Alexander S, Brocklehurst P, Bouvier-Colle M-H, Prendiville W, Cararach V, van Roosmalen J, Berbik I, Klein M, Ayres-de-Campos D, Erkkola R, Chiechi LM, Langhoff-Roos J, Stray-Pedersen B, Troegerp C. Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe. British Journal of Obstetrics and Gynaecology, 2007: p. 845-854. Competing interests: The authors are developing a protocol for a trial of early verses delayed cord clamping |
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Nisar A Mir, Consultant Paediatrician North Cheshire Hospitals NHS Trust WA5 1QG
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Dr Weeks has brought to our attention the long awaited need to review our practice of cord clamping after birth.1 The midwifery practice till early 20th century was to clamp the cord when the pulsations had ceased and or the placenta was expelled. A significant proportion of these babies showed delay in the onset of respiration, respiratory depression or frank asphyxia with the need for immediate respiratory intervention and hence early cord clamping (within 30 seconds) after birth was advocated. There is paucity of data regarding the need for neonatal resuscitation in term infants in the UK. In our study of 2750 babies born at North Cheshire Hospital (2002-3), a total of 108 infants (3.9%) showed signs of delay in onset of respiration at birth (Apgar score of 6 or less at 1 minute).2 Of these 108 infants, 98 were born at term and 10 were preterm (< 37 weeks); 8 infants required endotracheal intubation, thus constituting 0.3 % of all births. The identifiable cause for the delay in the onset of respiration in the term infants was: maternal sedation with opiates (48) and the operative delivery (23). However, only 20 infants required continued resuscitation beyond 5 minutes after birth. Hence, it should not be difficult to offer the basic life support in term infants by the mother’s side and reserve early clamping only for those infants who require major intervention like CPR or endotracheal intubation (around 3/1000 births).2 In the developing countries. there is poor antenatal care and majority of the deliveries take place in the rural areas. Fetal IUGR is seen in over 40% of the cases, the perinatal mortality continues to be high with asphyxia as one of the leading causes.3,4 There is need for further studies to evaluate the beneficial effect of delayed cord clamping in these infants. Fetal polycythemia is an important complication of maternal diabetes in the developing countries.5 In a cohort of 145 diabetic pregnancies (with over 14% overtly poor control), neonatal polycythemia (Hct >60) was seen in 51 of the cases and the perinatal mortality was three-fold higher in infants of diabetic mothers compared with infants of non- diabetic mothers. The beneficial effects of delayed clamping (2-3 minutes) needs to be weighed against early clamping of the umbilical cord in infants born of at-risk pregnancies. References: 1.Weeks A. Umbilical cord clamping after birth. Brit. Med J 2007;335:312-3 2.Mir NA, Robinson C, Theison S. Neonatal Resuscitation at birth; An audit of current practices (unpublished data) 3.Malik S, Mir NA. Perinatal mortality in high risk pregnancy: A prospective study of preventable factors. Asia-Oceania J Obstet Gynecol 1992; 18 (1): 45-48 4.Mir NA, Faquih AM, Legnain M. Perinatal risk factors in birth asphyxia: Relationship of obstetric and neonatal complications to neonatal mortality in 16, 365 consecutive live births. Asia-Oceania J Obstet Gynecol 1989;15(4)351-357) 5.Faquih AM, Mir NA, Leganain M. Pattern of morbidity and mortality in infants of diabetic mothers. Asia-Oceania J Obstet Gynecol 1988; 14(2): 171-176 Competing interests: None declared |
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Jose Luis Diaz-Rossello, Perinatal Pediatrics, Latin American Centre for Perinatology Women Maternal and Reproductive Health Pan American Health Organization (PAHO/WHO) Casilla de Correo 627 Montevideo Uruguay, Dr Susan Bewley MA MD FRCOG Consultant Obstetrician/ Maternal Fetal Medicine Guy's & St Thomas' NHS Foundation Trust Women's Services, 10th Floor North Wing St Thomas' Hospital Lambeth Palace Rd London SE1 7NH Susan.bewley@gstt.nhs.uk
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Dear Madam Week's editorial (1) on the timing of cord clamping raises several further issues: a) It is imperative that the timing of cord clamping be registered as it is the only means for monitoring and auditing practice. This has already been proposed, within the context of cord clamping for neonatal blood banking (2). The RCOG has recently recommended that during blood collection there should be not interfere with normal third stage practices (3). How can the public be reassured if the practice is not monitored? It would be timely for the RCOG and RCM to issue guidance and recommend that the timing is noted in seconds. b) Cord blood gases have been a traditional way to document facts in legal disputes regarding wellbeing or asphyxia during labour and in Canada, for example it has been considered necessary for every delivery. Mandatory immediate cord clamping is thought to be the only way to document the fetal status for the purposes of later retrospective analysis. Delayed cord clamping allows acute changes that in all cases will modify the values. Fortunately, lactate plasma levels have been found to be a much better indicator of fetal asphyxia and they may be measured at anytime after initial resuscitation (4). Neurological outcome is best related to those values and to the speed of clearance of lactate in the first hours of life. Clinical and legal standards may benefit both from abstaining from early clamping and from substituting the measurement of cord blood gases and pH in every baby to lactate. Monitoring lactate in those babies that need ventilatory support at birth, present with early seizures or systemic symptoms of perinatal asphyxia may be a more reliable way to diagnose fetal asphyxia. c) "Wait a minute" as a slogan may not even be enough (5). Minutes and seconds in the delivery room are difficult to sense, unless, while watching the baby and the cord you watch a watch. We suggest a new phrase to help obstetricians, midwives, babies and mothers: WATCH before clamping. This comprises both components of "watch until the cord is flat and pulseless in the placental side before clamping" and "Time clamping in seconds by your watch". d) Lastly, other third stage practices have been incorporated recently and have stayed as "default" rather than evidence-based, e.g. putting the baby on the mother's abdomen. There is not sufficient evidence that this is best practice. Indeed, there are some concerns related to safe neonatal adaptation, the hypervagotonic condition of the neonate and the risk of severe apnea in the prone position during the first minutes of life. Sudden deaths have been reported in the delivery room (6,7). References 1. Weeks A. Umbilical cord clamping after birth. BMJ 2007;335:312- 3. 2. Diaz-Rossello JL. Early umbilical cord clamping and cord-blood banking. Lancet 2006;368:840. 3. Templeton A,.Braude P. Umbilical cord blood banking and the RCOG. Lancet 2007;369:1077. 4. Murray DM, Boylan GB, Fitzgerald AP, Ryan CA, Murphy BP, Connolly S. Persistent lactic acidosis in neonatal hypoxic-ischaemic encephalopathy correlates with EEG grade and electrographic seizure burden. Arch.Dis.Child Fetal Neonatal Ed 2006. 5. Philip AG. Delayed cord clamping in preterm infants. Pediatrics 2006;117:1434-5 6. Hays S, Feit P, Barre P, Cottin X, Huin N, Fichtner C et al. [Respiratory arrest in the delivery room while lying in the prone position on the mothers' chest in 11 full term healthy neonates]. Arch.Pediatr. 2006;13:1067-8. 7. Toker-Maimon O, Joseph LJ, Bromiker R, Schimmel MS. Neonatal cardiopulmonary arrest in the delivery room. Pediatrics 2006;118:847-8. Yours sincerely Dr Jose Luis Díaz-Rossello Dr Susan Bewley Competing interests: None declared |
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David JR Hutchon, Consultant Obstetrician Dept of Obstetrics and Gynaecology, Memorial Hospital, Darlington. DL3 6HX
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The current pattern of practice throughout Europe certainly gives us an opportunity to carry out a large multicentre observational study. The opportunity for conducting a large multicentre randomised controlled trial of early vs delayed cord clamping is rapidly diminishing, in view of the current evidence which is more conclusive than is generally admitted. Indeed it is equally or more conclusive than the evidence of benefit and safety of antenatal steroids were when, in the early 1990’s, they were universally adopted. Dalziel et al (1) recently published figures to show that in the Auckland steroid trial there was actually "much the same morbidity" (by their assessment) and "similar survival" (long term survival) in the control and treatment groups. This differed from the figures used in the original Cochrane review and now, other trials in the original Cochrane review have since been withdrawn or modified because of unsatisfactory data.(2) We fully support rigorous assessment of the evidence but it is naive to believe that everything in Cochrane has been appraised completely objectively. We note that a protocol for a trial is under development and welcome this but feel that with the current evidence, informed consent could be difficult to obtain, especially where delayed cord clamping is already the usual practice. What mother is going to consent to risking hypovolaemia and anaemia [and intraventricular haemorrhage in the preterm](3) in her baby in order to establish that there is no detectable effect on her own health. At worst there could be an increased risk of haemorrhage. We already know that active management increases the risk of retained placenta and the need for manual removal of placenta in low risk women.(6)
Farrer and Duley (4) accept that immediate cord clamping is not physiological and therefore is an intervention which should have been fully justified by an evidence base before it was so widely introduced. This occurred in the latter half of the last century when cord blood collection, neonatal resuscitation, active management of the third stage, intrapartum CTG monitoring and greatly increased operative delivery all played a part. While it is true that the studies of delayed cord clamping did not assess any effect on maternal health, it is also true that the studies on active management of the third stage did not assess effects on the neonate such as anaemia or long-term health. It appears that there was an assumption on both sides that cord clamping would have no effect on the mother or the neonate! It is often stated that immediate cord clamping is an integral part of the active management of the third stage. This is not the case. In the Bristol study protocol (5) it was stated in the active management group that the cord should be clamped “at about one minute”. The requirement for inclusion in the Cochrane review (6) was cord clamping before delivery of the placenta in the active management group. This interval is well within the range considered to be appropriate for delayed clamping. From this we can reasonably conclude that delayed clamping at one minute has no adverse effect on maternal health. There are further logical arguments to suggest that a longer interval would have no harmful effects on maternal health and could have a benefit. (7) The Cochrane review (6) shows a significantly increased need for manual removal of placenta [RR 2.05 (1.20 – 3.51)] in the low risk women who had active management. While manual removal of placenta may not present much increased risk and does not appear to result in an overall increase in postpartum haemorrhage, these conditions may not apply in a developing country. Indeed the lack of readily available blood for transfusion, the lack of safe anaesthesia, and the shortage of antibiotics will seriously reduce any advantage of active management in these situations. The evidence base applies to active management of the third stage of labour after vaginal delivery. Therefore the 20 – 25% of babies now delivered by caesarean section can be spared any guilt about any uncertain risk to their mother as a result of delayed cord clamping! Indeed these are the babies who will probably benefit the most from delayed clamping as the placental transfusion is less and slower with this method of delivery. The indication is often fetal distress associated when resuscitation and functional pulmonary respiration before the cord is clamped may be vital. (8) Endpoints in practical research are always difficult and very often surrogate endpoints are used. For example it is often argued that the grade 1 intraventricular haemorrhage is not considered significant since it is not associated with symptoms, but asymptomatic polycythemia is considered to be a concern. This is not a consistent approach. While we can nearly always have better evidence, harmful effects of immediate clamping on the baby are consistently shown in the trials used in the Cochrane review and in those trials which have been published since. Anaemia and hypotension needing transfusion can certainly never be taken lightly. Neither can grade 1 intraventricular haemorrhage be disregard. Grade 1 intraventricular haemorrhage detected on ultrasound may not usually be associated with detectable harm but is clearly within the spectrum of worrying pathology. The definition for polycythemia depends on what is considered the normal range for the haematocrit and what group of individuals have been used to generate the normal range. Did they have early or did they have physiological cord clamping? Asymptomatic polycythemia is in a different category from asymptomatic grade 1 intraventricular haemorrhage. Intraventricular haemorrhage must surely be regarded as pathological in all circumstances.
References. Competing interests: I have been studying all the evidence over the past three years. |
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David JR Hutchon, Consultant Obstetrician Memorial Hospital, Darlington. DL3 6HX
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We fully agree with Jose Luis Diaz-Rossello and Dr Susan Bewley. We have a protocol in place here in Darlington which includes the following section: " The protocol should be applied at the discretion of the obstetrician and paediatrician but in all deliveries the interval of the cord clamping after delivery should be recorded in seconds. (The time of the first breath by the baby should also be recorded ie before or after the cord was clamped.)" Competing interests: None declared |
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George M. Morley, MB ChB FACOG, Retired Obstetrician Gynecologist 10242 E. Johnson Road, Northport, MI 49670 USA
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The Editorial “Umbilical Cord Clamping after Birth” and its ‘Rapid Responses’ confirm that the cord clamp is injurious; physiology is not. Knowledge of fetal, placental, umbilical and neonatal physiology is essential if cord clamp injury is to be avoided. Placental blood transfusion is an essential component of physiological birth; it is controlled by the child’s reflexes and terminated by physiological cord vessel closure. The neonate thus attains an optimal, physiological blood volume. This additional blood establishes the pulmonary circulation and activates all other life support organs in the healthy neonate. Transition from placental to neonatal life support may be complete within a minute or two, but it may take more than 20 minutes. [1] The cord clamp is not a part of human anatomy or human physiology. If it is applied before physiological cord closure, it disrupts normal anatomy and physiology, injuring the child by blocking placental respiration, and by clamping neonatal blood volume in the placenta. The earlier the cord clamping, the greater is the blood loss and injury. The extent of injury becomes evident in the degree of hypovolemia, ischemia and anemia that develop in the neonate. There is some debate in the Rapid Responses about “conclusive evidence” on the safety of early clamping, and on documenting the time of cord clamping. A major portion of peer reviewed literature clarifies these points. I refer to every article on ischemic encephalopathy and cerebral palsy (CP) that has been published in the last 20 years. There are dozens (if not hundreds) of such articles that document hundreds (possibly thousands) of the birth records of CP neonates. Nearly every one of these brain-injured children has been subjected to early or immediate cord clamping. Proof of this is found in the arterial cord blood pH (ACBpH) report in the child’s record. An arterial cord blood sample is obtained by clamping the cord while it is pulsating and while blood is flowing INTO the placenta. [2] ACBpH proves that the placental transfusion has been aborted, leaving the child hypovolemic, ischemic and anemic. The clinical signs of hypovolemia (low BP, oliguria) and of ischemia (MRI brain scan) and anemia (blood transfusion) are also usually documented on individual CP records. It is very evident that amputating a functioning placenta is injurious, and that early cord clamping is a major causative factor in cerebral palsy. In contrast, thousands of home births across N. America attended by Certified Professional Midwives (CPM) routinely have cords clamped after the placenta is delivered; all these babies receive a full physiological placental transfusion, all have normal blood volumes, and none are at risk for hypovolemic, ischemic or anemic complications. Physiology is not injurious. This CPM timing of cord clamping is much less injurious than the one minute wait suggested by Dr. Weeks. If, at one minute after delivery by c -section, the child is not breathing, is above the placenta and the cord is still pulsating, the child could be exsanguinated by gravity drainage of blood into the placenta. A one minute cord clamp would finalize its fate into ischemic encephalopathy. Man is the only mammal to routinely injure its newborns with a cord clamp. All other newborn mammals survive and prosper using the physiological clamp. The human newborn can also do this. Cord vessel closure and placental transfusion can be accelerated by lowering the child below the placental level or by use of oxytocin to contract the uterus around the placenta; the child should not be elevated onto the mother’s abdomen. Bewley’s “WATCH before clamping” is sound advice. The cord arteries should be visibly empty and pulse-less. The vein clamp can be tested by stripping the cord away from the umbilicus – the vein should remain empty. If it fills from the abdomen, the intra- abdominal clamp has not been applied and the child may need more blood volume; in this case WATCH until the uterus expels the placenta. If the vein does not fill from the abdomen, the vein clamp can be tested by gently trying to strip some blood into the child. A tense vein indicates intra-abdominal closure. At this point, physiological cord closure and placental transfusion are complete, and the cord clamp is a completely safe and superfluous instrument, but it can be used to stop blood from dribbling out of the placental end of the cord. However, it will usually continue to be applied to the bloodless cord stump on the abdomen as an act of lack of faith in Mother Nature, and of pompous obstetrics. [1] Gunther M. The transfer of blood between the baby and the placenta in the minutes after birth. Lancet 1957;I:1277-1280. [2] ACOG Committee Opinion #348, November 2006. OBSTETRICS & GYNECOLOGY, VOL. 108, NO. 5, 1319. www.autism-end-it-now.org Competing interests: None declared |
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Linda Morge, Retired neonatal nurse St Görans Children´s Hospital, Stockholm, Sweden
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Dear Editor Obstetricians have during centuries acted as if they had a subconscious belief that the first urgent life-saving measure to make when a child is born is throttling the umbilical flow as soon as possible. It is very hard to understand why the ancient routine Early Cord Clamping is still used in our days, despite modern medical science, and to find any explicable reason to why well educated modern doctors and scientists persist to intervene in Mother Nature´s wise plan by depriving the newborn up to 50% of its total blood volume and the life supporting oxygen from the cord - as if it never caught their minds that all other mammals survive, and even escape jaundice, when the cord is left intact until the placenta has been delivered. Competing interests: None declared |
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Linda Morge, Retired neonatal nurse St Görans Children´s Hospital, Stockholm, Sweden
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Among all the positive things with delayed cord clamping is that the newborn will not be whisked away and separated from the mother at this critical first minutes of life, when what is needed is a reunion with the mother whose body has sheltered and nourished the infant for nine months. Abrupt, unannounced, and often painful separation from the mother is bound to be a shock. Birth is the first time we relate to people in the way we relate to people now. And for most of us, our first experience in relating to people was with the obstetrician or midwife who cut our life supporting umbilical cord and who separated us from our mother. The French obstetrician Frederick Leboyer states in his book Birth Without Violence that we have “unlimited sadness” about the way we were mistreated at birth. Competing interests: None declared |
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David J R Hutchon, Consultant Obstetrician Darlington Memorial Hospital. DL3 6HX
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Since Weeks Editorial was published I have frequently discussed his recommendation with colleagues. Objections from both paediatricians and obstetricians are common. From the paediatricians I hear about fear of hypothermia, polycythemia, hyperbilirubinaemia and of course the need for resuscitation of the baby. From obstetricians I hear that immediate cord clamping is an integral part of the active management of the third stage of labour (which helps to prevent post-partum haemorrhage) and the requirement for cord blood gas measurements.
Competing interests: None declared |
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David JR Hutchon, Consultant Obstetrician Darlington Memorial Hospital. DL3 6HX
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To save readers further effort in establishing the facts I quote directly form the relevant pages.
"How to do controlled cord traction
Competing interests: None declared |
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