22 Feb 2007 - Some milestones up to the Apgar score
(A quick first draft - to be updated)
1772-1775
Discovery of oxygen
1801
Erasmus Darwin (grandfather of Charles Darwin) wrote:
"The placenta is an organ for the purpose of giving due oxygenation to the blood of
the fetus; which is more necessary, or at least more frequently necessary, than even
the supply of food."
Erasmus Darwin (1801) Zoonomia; or, The Laws of Organic Life, Section XXXVIII
online at:
http://www.blackmask.com/thatway/books180c/zoon.pdf pdf
http://www.blackmask.com/thatway/books180c/zoondex.htm html
1846
First use of anesthesia in surgery, at the Massachusetts General Hospital
1847
Chloroform used as an anesthetic for childbirth.
1853
Queen Victoria delivered Prince Leopold with aid of chloroform anesthesia.
1850 textbook:
Churchill F On the Theory and Practice of Midwifery. London: Henry
Renshaw, 1850.
p 91 (#181 The umbilical cord, funis, or navel string)
“After birth of the child, the pulsation ceases in about fifteen or twenty minutes, and
that portion of the cord which remains attached to the umbilicus dies, and gradually
withers, until it falls off, in the majority of cases, on the fifth or sixth day.”
p 131 “…in ordinary cases, if we find that the cord is twisted around the neck,
all we need do is to draw down more of the cord, and either slip the lop over
the head or shoulders. If we cannot do this, we must loosen the cord as
much as we can, so as to prevent the strangulation of its vessels, and wait for
the uterus to expel the child.”
p 132 “If the child be healthy, and not have suffered from pressure, &c. it will
cry as soon as it is born, and when respiration is established, it may be
separated from its mother…”
1922
The umbilical cord clamp
Ziegler CE (1922) Additions to our obstetric armamentarium. Am J
Obstet Gynecol 3:46-53
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 the observation of Gunther (1957) that cessation of placental
transfusion was often apparent after a main reservoir had been filled. This
reservoir would appear to be the capillary system surrounding the alveoli of
the lungs (Jäykkä 1958, Mercer & Skovgaard 2002).
Placental blood is respiratory blood. Research by Redmond et al. (1965)
provided dramatic evidence that the infant's first breath redirects blood from
the placenta to the lungs.
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."
1938
Umbilical cord blood banking - innovation of the 1930s
Goodall JR, Anderson FO, Altimas GT, MacPhail FL (1938) An
inexhaustible source of blood for transfusion and its preservation.
Surgery, Gynecology and Obstetrics 66:176-178.
During the 1930s placental blood was adopted for use in transfusions. A
paper by Goodall et al (1938) begins with a viewpoint 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."
1938
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. A paper
by Frischkorn and Rucker (1939) paper would be as useful to include in a
Cochrane Review as any of the randomized-controlled trials of "delayed cord
clamping" so highly valued 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 watched 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.
1943
Autism in the 1940s
Leo Kanner (1943) described a group of children, in his practice at Johns
Hopkins University, who displayed a peculiar lack of awareness or interest in
other people. Developmental language disorder was a major component of
the disorder he described as a "disturbance of affective contact," or "infantile
autism." Kanner (1946) described the speech of children with autism as
"irrevelant and metaphorical," documenting the out-of-context use of phrase
fragments.
Could these children have been among the first infants subjected to immediate cord
clamping at birth in the 1930s? Now clamping the umbilical cord within
seconds after birth is routine. Why then aren't all children autistic?
Most infants do breathe immediately at birth, and as noted by Apgar, receive
a score of 8, 9, or 10. Autism now occurs in about 1 of 166 births. Is it
possible that 1 in 166 infants do not breathe within the first few seconds after
birth?
Autism is associated with many etiological factors, including prenatal
exposure to alcohol and other drugs such as valproic acid (depakote),
thalidomide, cocaine, misoprostol, prenatal rubella infection, and genetic
metabolic disorders such as phenylketonuria, fragile-X syndrome, tuberous
sclerosis, and adenylosuccinate lyase defect. Complications at birth are also
well documented in children with autism.
Brain systems involved in language development and social awareness must
be affected by all of the etiological factors associated with autism. The
inferior colliculus in the midbrain auditory pathway is the most metabolically
active site in the brain, and is likely affected by all of the etiological factors
associated with autism. The midbrain tectum is also where auditory and
visual stimuli evoke awareness and orientation to environmental events.
The inferior colliculi were prominently affected in monkeys subjected to
asphyxia at birth, and I suggested long ago (Simon 1976) that this might be
the locus of impairment underlying deranged language development in
children with autism.
1950
The 1950 edition of William's Obstetrics
provides the following comment:
"Clamping or ligating the umbilical cord should be
deferred until its pulsations wane or, at least, for one
or two minutes."
"There has been a tendency of late, for a number of
reasons, to ignore this precept. In the first place the
widespread use of analgesic drugs in labor has
resulted in a number of infants whose respiratory
efforts are sluggish at birth and whom the obstetrician
wishes to turn over immediately to an assistant for
aspiration of mucus, and if necessary, resuscitation.
This readily leads to the habit of clamping all cords
promptly."
Eastman HJ (1950) Williams Obstetrics, Tenth Edition, pp 397-398
1953
The Apgar score
"When mothers receive an excessive
amount of depressant drugs in the
antepartum period, it is a common
occurrence that the infants breathe once,
then become apneic for many minutes. . ."
“A satisfactory cry is sometimes not
established even when the infant leaves
the delivery room.”
Apgar V (1953) A proposal for a new method of evaluation of the newborn infant.
Current Researches in Anesthesia and Analgesia 32:260-267.
1958
Apgar et al., 1958:
Scoring at one minute was done because this
represented the time of most severe depression:
"In the Sloane Hospital the cord has been cut by this
time, and the infant is in the hands of an individual
other than the obstetrician. . .
In many hospitals, such is not the case. Those
obstetricians who practice slow delivery and delayed
clamping of the cord until pulsations of the umbilical
artery cease still have the infant in the sterile field.
However, if the obstetrician is reminded of the
passage of time by another observer, he may assign
a score even though the cord is still attached."
Apgar et al. (1958) JAMA 168:1985.
A quick first draft - in need of updating soon...