The missing peripartum deleterious process may be early cord clamping
Article first published online: 11 JUN 2013
© 2013 RCOG
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 120, Issue 8, pages 1030–1031, July 2013
How to Cite
Hutchon, D. (2013), The missing peripartum deleterious process may be early cord clamping. BJOG: An International Journal of Obstetrics & Gynaecology, 120: 1030–1031. doi: 10.1111/j.1471-0528.2012.03500.x
- Issue published online: 11 JUN 2013
- Article first published online: 11 JUN 2013
- Manuscript Accepted: 4 JUL 2012
Yeh et al.1 conclude that there may be other intrapartum deleterious processes involved that influence the degree of acidaemia that is tolerated.
Examination such as magnetic resonance imaging (MRI) or computed tomography (CT) can only place the timing of the insult approximately, so the insult could be many minutes on either side of birth.
We consider that early cord clamping (ECC) should be considered as a possible candidate. Recent work has confirmed the extent of hypovolaemia caused by early clamping.2 The baby in this series who received the largest transfusion of 204 ml was a candidate for severe hypovolaemia with ECC. Hypovolaemia is well recognised to result in a reduction in cardiac output and in ischaemic circulation.
Early cord clamping (ECC) prevents the baby transferring from placental respiration to pulmonary respiration at its own pace. ECC cuts off the supply of oxygen and renders the baby increasingly asphyxial.3
Cord compression during the second stage of labour may increase hypovolaemia after ECC, resulting in a baby that responds poorly to resuscitation because of the failure of adequate placental transfusion, with the result that the baby urgently requires an emergency transfusion of un-crossmatched O-negative blood.4 The paediatrician, faced with a severely hypovolaemic baby, is in no position to raise the issue of the timing of cord clamping at that stage.
Early cord clamping is now being taken seriously, and the Australian Placental Transfusion Study has the potential to show a reduction in cerebral palsy in babies randomised to delayed cord clamping (http://au.news.yahoo.com/thewest/lifestyle/a/-/health/13945545/cord-clamping-delay-may-prevent-complications). The current teaching of the physiology of transition at birth is inaccurate. The 24th edition of Ganong’s Review of Medical Physiology starts ‘At birth, the placental circulation is cut off and the peripheral resistance suddenly rises. Meanwhile the infant becomes increasingly asphyxial’.3 It is well known that in a healthy baby the cord circulation continues for several minutes, as demonstrated by Farrar et al.2 Ganong is typical of most physiology texts. This teaching results in the general thinking that the effects of ECC on physiology are trivial, or even beneficial.
If the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for the management of the third stage of labour and documentation of the timing of cord clamping is followed, and the Resuscitation Council (UK) advice for cord clamping to be delayed by at least 1 minute in healthy babies is followed, we may be on the way to determining the role of ECC in little more than a year. In the meantime, how can we deal with babies who are in need of resuscitation? These may be the babies who will benefit most from a normal volume of blood and a few minutes more of placental oxygenation. Van Rheenen provides one possible solution,5 and we provide another, as reported in the RCOG Membership Matters. Both these interventions should be subjected to randomised controlled trials.
- 3Barrett KE, Barman SM, Boitano S, Brooks HL. (Eds) Ganong’s Review of Medical Physiology. New York, NY: Mcgraw Hill Lange, 2012.
- 4Neonatology, in Obstetrics by TEN TEACHERS. London, Hodder Arnold, 2011..