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Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39405.539282.BE (Published 10 January 2008) Cite this as: BMJ 2008;336:85

Rapid Response:

Old News Ignored at Great Cost, and Used with Great Benefit

In 2001, Levine et al published an extensive review [1] on the
incidence of persistent pulmonary hypertension (PPH,) and respiratory
diseases in elective cesarean sections (ECS). In response to that
article, [2] I, like Mr. D. Hutchon above, referenced Landau’s 1950 full
placental transfusion [3] that completely prevented respiratory disorders
in C-sections. Immediate cord clamping (ICC) is routine treatment of the
ECS child, and deprives it of physiological placental transfusion (PPT.)

PPH is also termed “persistent fetal circulation” (PFC.) In the
fetus, virtually no blood flows through the pulmonary vessels. At a
normal birth, using no cord clamp, PPT provides the blood volume needed to
establish the pulmonary circulation and convert fetal circulation to adult
circulation. ICC impedes this conversion, botches PPT, and leads to blood
volume being diverted from all other organs to fill the pulmonary circuit.
In some cases, especially ECS, this blood volume may not be sufficient,
and the fetal circulation persists – often fatally. Peltonen [4]
described clamping before the first breath as potentially fatal – and to
be avoided.

In 1982, in an exhaustive review on placental transfusion [5],
Linderkamp wrote:

“Immediate cord clamping can result in hypotension, hypovolemia and
anemia. … Why does Nature intend maximal placental transfusion to the
neonate? Obviously it is not to prevent the respiratory distress syndrome
in immature neonates. It may be speculated that the prevention of severe
iron deficiency in infants living under primitive conditions is more
important than the risk of circulatory overload shortly after birth. In
civilized countries, a medium placental transfusion appears to be more
appropriate in order to escape the risk of hyper-viscosity, whereas Iron
Deficiency in later infancy is probably less dangerous.”

Conclusions: PPT prevents infant iron deficiency and respiratory
distress syndrome; infant iron deficiency is DANGEROUS.

Nature apparently intends maximal placental transfusion, PPT, to
convert the fetal circulation to the adult circulation, and also to
prevent DANGEROUS infant anemia.

What, then, is so DANGEROUS about infant iron deficiency anemia?

In 2007, Lozoff published a review of 99 articles [6] (from 1974 to
2006) that linked Infant Iron Deficiency Anemia to Long Lasting Neural and
Behavioral Effects – mental retardation (MR) – in civilized and
uncivilized countries. Ultee published a study [7] linking ICC with
infant anemia and cognitive defects (MR) in a civilized country.

Last week (February 8, 2008) I had the good fortune of putting
Landau’s [3] experience into practice. My daughter was scheduled for an
elective term C-section for a breech presentation. I gave the operating
obstetrician a summary of the risks of elective cesarean section (PPH,
IRDS, autism [8]) and the risks of ICC (Infant anemia,[5] mental
retardation, autism, neural and behavioural disorders. [6, 7])

The obstetrician readily agreed to my suggestions that:

• IV oxytocin would be started one hour ahead of the operation to develop
the lower uterine segment and ensure uterine contractility after delivery
for effecting placental transfusion. [9]

• The newborn would be lowered below the level of the placenta immediately
after delivery.

• The cord would not be clamped until the child was crying and until all
pulsation in the cord ceased.

All these requests were complied with, the child was crying within a
minute; the placenta separated and was spontaneously delivered prior to
the cord being clamped. My granddaughter received a full PPT and
reflexively clamped her own cord. [9] The child was red, vigorous and
plethoric, and at no risk for anemia, or respiratory, neural, mental or
developmental disorders.

Other responses have mentioned the “value” of ante-natal steroids.
Steroids produce vaso-constriction of the placental vessels – a de-facto
prenatal placental transfusion that ameliorates the effect of ICC, and
improves neonatal blood volume by shifting some blood from placenta to
child. Long term steroids produce growth retardation. Physiology – not
clamping the cord – works much better than steroids in preventing
respiratory disorders.

Any procedure that tends to produce neonatal hypovolemia and infant
iron deficiency anemia is VERY DANGEROUS and should be avoided. [4, 7]
Clamping the umbilical cord before the child has closed the cord vessels
physiologically is contraindicated. Every neonate requires a
physiological, maximal placental transfusion to ensure the integrity of
its brain and optimal function of all vital organs.

The danger of ICC is readily demonstrable to any doubting midwife or
physician: Deliver several babies with a scalp FHR lead attached to record
the heart rate while the cord is immediately clamped between finger and
thumb. If the child does not breathe, the heart rate will plummet to 60
bpm due to hypoxia and loss of venous return to the heart; there may be
brief cardiac arrest. [4] Severe bradycardia and neonatal distress
releases the finger and thumb within 10-20 seconds and PPT rapidly
restores normality to the monitor, the newborn and apprehensive observers.

A dozen or so documented, (videotaped) instances of this ICC-induced
near calamity, and its recovery with PPT, should convince enlightened
authorities (RCOG, ACOG, NICE) that, after birth, “There is good reason …
to keep the umbilical circulation intact … in civilized countries.” [4, 5]

References:

1. Levine E. Vivek G. Barton J. Strom C. Mode of Delivery and Risk of
Respiratory Diseases in Newborns. Obstetrics & Gynecology Vol. 97, No.
3, Mar 2001 439-441

2. Morley G. Letters. Obstetrics & Gynecology Vol. 97, No. 6, June
2001 1025-1026.

3. Landau D. Death of Cesarean Infants. A Theory as to Its Cause and a
Method of Prevention. The Journal of Pediatrics (1950) 36. 421-426

4. Peltonen T. Placental Transfusion, Advantage - Disadvantage. Eur J
Pediatr. 1981;137:141-146

5. Linderkamp O. Placental transfusion: determinants and effects. Clinics
in Perinatology 1982;9:559-592

6. Lozoff B et al. Long-Lasting Neural and Behavioral effects of Iron
Deficiency in Infancy. Nutrition Reviews Vol. 64 No. 5 s34–s43

7. Ultee c. et al. Delayed cord clamping in Preterm Infants Delivered at
34-36 weeks. Heart 2008. Arch Dis. Childh. Feb 2007 Online.

8. Glasson EJ. Et al. Perinatal factors and the development of autism: a
population study. Ach. Gen. Psychiatry 2004 Jun;61 (6):618-27

9. Gunther M. The transfer of blood between the baby and the placenta in
the minutes after birth. Lancet 1957;I:1277-1280.

Competing interests:
None declared

Competing interests: No competing interests

26 February 2008
George M Morley MD
Retired Obstetrician Gynecologist
none
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