6 - When or should the umbilical cord be clamped?

The Cochrane Review, "Early versus delayed umbilical cord clamping in preterm infants" only looked back only as far as 1966, and turned up only 7 studies considered to be randomized and controlled trials, and in these investigations the maximum delay was only 120 seconds.  The first statement in the abstract of the review is, "Optimal timing for clamping of the umbilical cord at birth is unclear."  The authors then stated, "Early clamping allows for immediate resuscitation of the newborn. Delaying clamping may facilitate transfusion of blood  between the placenta and the baby."  The conclusion they arrived at was, "Delaying cord clamping by 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion and less intraventricular haemorrhage." The reviewers did not look at Gunther's (1957) paper or any of the earlier studies done when many if not most obstetricians waited for pulsations of the cord to cease before cutting it - this was still what was recommended in most of the textbooks, and that the cord can be cut without loss of blood after the newborn has fully completed the natural transition from placental to pulmonary respiration.  A decade later, the trend toward earlier and earlier clamping of the cord was on the rise.

Access to historical documents

I am fortunate to have access to the Countway Library of Medicine at Harvard in Boston, where sitting for hours among the old textbooks of midwifery and obstetrics, I was able to compile the list of quotes on umbilical cord clamping.   Likewise, I am able to sit in the stacks and peruse old medical journals, which I do whenever I get a chance.  I don't know if I could get a grant to do this, but at this point, I still need the income from my regular job, which for learning and trying to understand the roots of mental illness, is also more instructive than reading books in a library; and, I see plenty of documentation in patient records of developmental problems, often attributed by mothers to oxygen insufficiency at birth (and mostly scoffed at as anecdotal). In any case, this essay is incomplete - a work in progress.  I am posting it as I go along, because traditional thinking appears to be completely unknown to the present-day mainstream authorities in the field.  Safe delivery of our children into this world is too important to not try to speak up against current childbirth practices.

Invention of the clamp

Ziegler (1922) described the need for clamping the cord as follows:

"The primary object of ligating or clamping the cord is, of course, to prevent hemorrhage; and while it is true that hemorrhage would rarely occur even were the cord not compressed, especially after the establishment of respiration, the fact is that hemorrhages have occurred and even with fatal termination.  In fifteen years I have had two cases of secondary hemorrhage from the cord which were all but fatal.  It is likely, therefore, that some form of compression will always be regarded as necessary."

Note Ziegler's remark that hemorrhage would rarely occur even were the cord not compressed, especially after the establishment of respiration.  This corroborates Gunther's observation that cessation of placental transfusion was often apparent after a main reservoir had been filled - and this reservoir would appear to be the capillary system surrounding the alveoli of the lungs (Jäykkä 1958, Mercer & Skovgaard 2002).

Ziegler's paper described several new devices tor use in obstetrics, of which the clamp was one, a replacement for the earlier technique of tying the cord.   That not all obstetricians clamped or tied the cord at that time can be inferred from his next statement:

"To those members of the profession whose custom it is to clamp the cord, this clamp will make its strongest appeal."

Descriptions of observations no longer made

With the now nearly universal practice of immediate cord clamping, how many doctors trained in the last two decades have ever been in attendance at what Apgar referred to as a "slow birth," waiting for pulsations of the cord to cease.   We therefore need to go back to historical accounts, as in the case of vanishing diseases like smallpox, neurosyphilis, tuberculosis, leprosy, or polio.  Frischkorn and Rucker's (1939) paper would be as useful to include in a Cochrane Review as any of the randomized-controlled trials so highly thought of today. Frischkorn and Rucker provide a description of postnatal umbilical cord function, that perhaps even in the 1930s was not waited for or witnessed by many obstetricians:

"If a cord be wached immediately after delivery the umbilical vessels can be seen to pulsate strongly throughout their entire length.  In a varying length of time the pulsations cease in the more distal part and as this occurs the umbilical vessels collapse.  This process of cessation of pulsation and collapse of the vessels proceeds toward the umbilicus until finally there is no pulsation even at the navel.  The vessels are then entirely collapsed.  If now the cord be tied and cut very little  blood will escape from the placental end." Frishkorn & Rucker (1939), p 593.

Summaries of research from the nineteenth century

Frischkorn and Rucker also described the experiments of Buden (1875), Schucking (1877), and Haselhorst (1929).  Budin measured the blood that drained out of the umbilical vessels when the cord was cut at varying intervals of time.  In 32 cases, the cord was not tied until pulsations had ceased, with an average yield of 11.2 cc of residual blood.  In 30 cases, after immediate ligation of the cord, the average was 98.4 cc.

Buden wrote in French, Schucking and Haselhorst in German, and I am as grateful as anyone for the summaries Frischkorn and Rucker provided in their article.

Schucking (1877) described the blood recovered in Budin's experiments as "reserve blood," which he said was intended to fill the pulmonary vessels.  This certainly makes intuitive sense because the most important transition from fetal to postnatal life is the transfer of respiratory function from the placenta to the lungs.  Schucking weighed each infant at the time of delivery, then again after tying of the cord.  Infants gained from 30 to 110 grams when the cord was not tied.  Babies whose cords were tied immediately had a more rapid pulse and gained weight more slowly, whereas those whose cords were tied late had a slower pulse and regained their birth weight in four to six days.  Schucking observed no jaundice in the latter group.

Frischkorn and Rucker reported having found only one "recent" article (Franklin 1931) in which jaundice was observed more frequently in babies whose cords were tied late.

Haselhorst's (1929) non-invasive weight measurements

Haselhorst (1929) recorded infant weight changes during the period of placental transfusion, showing fluctuations between loss and gain during the period of strong pulsations of the umbilical arteries.  Strong pulsations are from the infant heart, pumping blood back to the placenta for oxygen, and following the exertion involved in being born, strong pulsations may be the equivalent of increased heart and respiratory rates following exercise.

Haselhorst's method was completely non-invasive, as he recorded the weights of all infants until pulsations ceased - until transition was complete from placental to pulmonary respiration.  In 20 babies, the average overall gain was 114 grams, with the greatest weight gain taking place in the first few minutes.

Frischkorn and Rucker (1939)

Frischkorn and Rucker (1939) measured red blood cell counts in addition to weight in 400 infants.  The cord was not tied until pulsations ceased in 59 cases,  Frischkorn and Rucker described use of sodium amytal scopolamine analgesia analgesia and ether anesthesia in all cases.  They noted with interest that the cord continued to pulsate longer than in Budin's cases, which pre-dated use of anesthesia.  In one of Frischkorn and Rucker's cases, pulsations continued for 50 minutes.  Blood counts were make within 24 to 36 hours of birth, with a range of 3.28 to 7.12 million red blood cells.  The average red cell count in the 59 infants whose cords were not tied until after pulsations ceased was 5,783,400, as opposed to the average for 333 cases in which the cord was still pulsating when tied was 5,198,919;  the difference was 584,481.

Frischkorn and Rucker also measured residual blood left in the cord and placenta, and found only a slight correlation with time of cord clamping.  This could be expected from the variability in times pulsations continued from infant to infant.  Residual blood was significantly more related to red cell counts.

A use for discarded placental blood

During the 1930s  placental blood was adopted for use in transfusions.  A paper by Goodall et al (1938) begins with more information on childbirth teachings of the day:

"The teaching that, if the blood is left in the placenta, placental detachment from the uterine wall is hastened, has never had any scientific appeal to us.  Consequently, it became a problem to be proved or disproved.  So at every birth, on our service, the clamp on the cut cord was released with the cord in a pendent position and the placenta was emptied."

Further observations made by Goodall et al are of interest with respect to the pressure of blood left in the placenta after clamping.  They noted that during blood collection, the cord lay flaccid instead of quite turgid as was the case when waiting for delivery of the placenta with the clamp in place.  Separation of the placenta was not appreciably changed either, in elapsed time or completeness.  Another important discovery was also made:

"The blood pressure in the cord was great, projecting the blood frequently 3 feet distant, and the flow kept up a surprisingly long time."

This was when they asked themselves, "Why waste all this valuable material?"   So they set about finding means to preserve the lost blood.  Many articles on how to collect, store, and use placental blood appeared within the next two years.

Chapter in progress - here I sit on L2 in Countway Library, finding all of these studies going back over 130 years.  Who are these Cochrane Review experts?  Maybe I should apply for the job, and get paid to do all this work. 3/8/06

From:

http://placentalrespiration.net/ sprepu

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