Re:Is it time to end early cord clamping?
I am grateful for this response from Professor Whittle. His response clearly demonstrates how easy it is to see what we want or expect to see.
The definition of early cord clamping is stated by the RCOG SAC opinion paper 14 (1) as within 20 seconds. Late cord clamping is defined as around three minutes by the World Health Organisation. These two institutions are good enough for me. If the definition of early and late clamping is so unclear why do NICE use "early cord clamping" without a specific definition in their intrapartum guideline? The guideline includes early cord clamping as an essential element in the triad of active management of the third stage to reduce PPH.. There is no evidence that early cord clamping is essential, whatever the definition.(1)
Professor Whittle fails to understand that early cord clamping is an intervention affecting the baby's circulation, and he agrees that there is no evidence to show that early clamping provides any benefit to term babies born here in the UK. Interventions which provide no benefit should not be continued simply because of traditional practice. Professor Whittle clearly does not know the studies of Yao et al (2) and the recent studies of Farrar et al (3), nor does he appear familiar with the opinion of the RCOG SAC Opinion paper 14 (1) which concluded "Hence, neither intramuscular oxytocin nor intramuscular Syntometrine, given with delivery of the anterior shoulder, as in the UK, is likely to have a substantive effect on placental transfusion ". Professor Whittle's statement "blood transfer is probably short circuited by the use of oxytocin" is obscure and he needs to fully explain his concept with references.
While I am not a gambling man, I too am concerned at our failure to reduce our stillbirths of which 7.8% occur intrapartum.(4) The hypovolaemia, sometimes representing over 40% of the baby's circulation, caused by immediate cord clamping may be sufficient to render a weak hearted neonate into one with no detectable heart activity and no response to resuscitation. These babies are likely to represent the tip of the iceberg concealing a large amount of morbidity associated with immediate cord clamping and hypovolaemia. As a recently retired obstetrician I would want to see more debate and research to prevent antenatal stillbirths and research into the reduction of intrapartum morbidity and mortality by incorporating resuscitation of the neonate with the cord circulation intact. The work of Wiberg et al (5) shows how promising this is likely to be from the amount of oxygen returning from the placenta in the first few minutes after birth.
I can understand that Professor Whittle does not wish the NICE guideline to be found wanting. Perhaps his presumptions prevented him from seeing much of the arguments and evidence I presented in my personal view in the same way that he expected to see an "e" in my surname, repeatedly referring to me as Mr Hutcheon.
David J R Hutchon FRCOG
1. Royal College of Obstetricians and Gynaecologists. Clamping Of The Umbilical Cord And Placental Transfusion, Scientific Advisory Committee Opinion Paper 14 May 2009
2. Yao AC, Hirvensalo M, Lind J. Placental transfusion rate and uterine contraction. Lancet 1968;1:380-3.
3. Farrar D, Airey R, Tuffnell D, Law G, Cattle B, Duley L. MEASURING PLACENTAL TRANSFUSION FOR TERM BIRTHS:WEIGHING BABIES AT BIRTH WITH CORD INTACT. Poster Presentation at BMFMS Liverpool 2009 Arch Dis Child Fetal Neonatal Ed 2009 94: Fa4-Fa10
4. Heazell A E. Towards an end to stillbirths BMJ 2010;341:c5070
5. Wiberg N, Kallen K, Olofsson P. Delayed umbilical cord clamping at birth has effects on arterial and venous blood gases and lactate concentrations. BJOG 2008;115:697-703.
Competing interests: No competing interests