3 -  Childbirth protocols
The American College of Obstetrics and Gynecology
(ACOG) disputes the idea that complications at birth
are a risk factor for brain injury [1a].  However, Iffy et
al (1994, 2001) reviewed nine cases of cerebral palsy
associated with premature cutting of the umbilical
cord, and made special note that this mistake is only
reported in malpractice reviews, not in medical
journals [1b, c].  Every time the fetal life-line is cut
before the infant's first breath, it should be reported in
the medical literature, and outcome monitored at least
through the child's first year or two in school.

It is appalling to read, in the second edition of a book
on obstetric protocols, that the umbilical cord should
be clamped as soon as possible after birth [2a], and
this protocol has found its way into several recent
textbooks [3].  The American College of Obstetrics
and Gynecology (ACOG) reiterated this practice in
2006 [2b]  If followed too literally, clamping of the cord
before the first breath could not only obstruct the shift
of placental blood to the lungs, but also leave the
infant in a state of hypovolemic shock.  Reports on
transfusions and blood volume expanders needed for
infants in neonatal intensive care units indicate that
hypovolemia may not be an infrequent problem [4].  
Waiting for the infant to cry is hopefully instinctive for
most obstetricians and midwives before clamping the
cord.  Traditional textbooks were explicit on this point.

Clamping the cord immediately at birth assumes that
the "normal" infant breathes immediately at birth.  
Statistical evidence supports this assumption; but
what about the statistical outliers?  Until the lungs can
take over the respiratory function of the placenta,
shouldn't placental circulation be allowed to
continue?  Is it abnormal for the lungs not to take on
respiratory function right away?  Should babies born
by Cesarean delivery be expected to immediately give
up the need for ongoing placental circulation?

Recent articles  by Baskett et al. (2006) and Milsom et
al. (2002) indicate concern over "respiratory
depression" at birth [5].  As in the case of obstetric
complications in autism, some predisposition in the
mother or fetus is looked for to explain why an infant
may not breathe immediately at birth.  The statistics
for occurrence of "respiratory depression" are
strikingly similar to current autism prevalence numbers.

Apgar introduced her system for scoring the condition
of the newborn in 1953, noting that when mothers
receive an excessive amount of depressant drugs
during labor, it is common for an infant to breathe
once, but then become apneic for many minutes [6a].  
“A satisfactory cry is sometimes not established even
when the infant leaves the delivery room.”

Five years later, Apgar (and her colleagues) wrote
that 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," [6b].

"Slow delivery" was Apgar's term for the traditional
practice of waiting for pulsations in the umbilical cord
to cease.  This tradition was replaced by an
increasing trend during the 1930s and 1940s to clamp
the umbilical cord as soon as possible after birth.  
Pulsations are from the infant heart and, by nature's
plan, continue until transition from placental to
pulmonary respiration is complete (with closing of fetal
shunts in the heart).

Apgar et al. (1958) stated, "All infants with a score of
8, 9, or 10 are vigorous and have breathed within
seconds of delivery."  This became widely viewed as
normal, and that the transition from fetal to neonatal
respiration should take place within seconds of
delivery.

Many research papers are now advocating "delayed
clamping" of the cord, against the teaching of recent
textbooks, and as if immediate clamping of the cord
were the longstanding tradition [7].  Studies going
back over 130 years provide evidence for the
importance of postnatal placental circulation, and
should be cited in ongoing research on neonatal
status.

How many women, who entrust safe delivery of their
infant into this world to obstetricians, have any
knowledge of how soon the umbilical cord will be
clamped?  Perhaps some information is obtained if
they have opted for umbilical cord blood banking.  
How safe is this, and how many women have been
fully informed of how the procedure might disrupt an
otherwise normal birth?

Some of the infants who exhibit "respiratory
depression" at birth go on to develop autism.  
Difficulty learning to speak can be understood in
terms of ischemic impairment of brainstem nuclei in
the auditory pathway.  Evidence has too long been
ignored that auditory nuclei like the inferior colliculi
are damaged by oxygen insufficiency at birth.

Ignoring (even avoiding) the problem of birth injury is
hindering progress toward preventing the life-long
tragedy of cerebral palsy, autism, and other
developmental disorders.  Perhaps if long-term care
insurance were required of every citizen from birth,
actuarial scientists would make it a priority to find out
(more quickly than government-funded peer-reviewed
researchers) the causes of disability due to brain
damage.
1.  Perinatal complications and
cerebral palsy
  1. Hankins (2003) The long
    journey: defining the true
    pathogenesis and
    pathophysiology of neonatal
    encephalopathy and cerebral
    palsy.
  2. Iffy L, Varadi V (1994)
    Cerebral palsy following
    cutting of the nuchal cord
    before delivery.
  3. Iffy et al (2001) Untoward
    neonatal sequelae derived
    from cutting the umbilical
    cord before delivery.

2.  Obstetric protocols
  1. Turrentine JE (2003) Clinical
    Protocols in Obstetrics and
    Gynecology, Second Edition.
  2. ACOG Committee on
    Obstetric Practice (2006)
    ACOG Committee Opinion
    No. 348, November 2006:
    Umbilical cord blood gas and
    acid-base analysis.

3.  Textbooks promoting
immediate clamping of the
umbilical cord
  1. Hibbard, BM (1988)
    Principles of Obstetrics.
  2. Chamberlain G, Gibbins CR,
    Dewhurst (1989) Illustrated
    Textbook of Obstetrics
  3. McGregor Kelly, J (1994)
    General Care (chapt 22) in
    Avery GB, /fletcher MA,
    MacDonald MG, eds .  
    Neonatology,
    Pathophysiology and
    Management of the Newborn,
    Fourth Edition.
  4. Chanberlain G & Bowen-
    Simpkins P (2000) A Practice
    of Obstetrics and
    Gynecology, a Textbook for
    General Practice and the
    DRCOG. Third Edition.
  5. Gabbe SG, Niebyl JR,
    Simpson JL (2002)  
    Obstetrics: Normal and
    Problem Pregnancies, Fourth
    Edition.

4.  Neonatal transfusions
  1. Mercer JS, Skovgaard RL.
    (2002) Neonatal transitional
    physiology: a new paradigm.
  2. Murray NA, Roberts IA (2004)
    Neonatal transfusion
    practice.

5.  Respiratory depression
  1. Baskett TF et al. (2006)
    Predictors of respiratory
    depression at birth in the
    term infant.
  2. Milsom I, et al. (2002)
    Influence of maternal,
    obstetric and fetal risk factors
    on the prevalence of birth
    asphyxia at term in a
    Swedish urban population.

6.  The Apgar score
  1. Apgar V (1953) A proposal for
    a new method of evaluation
    of the newborn infant.
  2. Apgar V et al. (1958)
    Evaluation of the newborn
    infant – second report.

7.  Umbilical cord clamping
  1. Baenziger O et al. (2007)The
    influence of the timing of cord
    clamping on postnatal
    cerebral oxygenation in
    preterm neonates: a
    randomized, controlled trial.
  2. Ultee K et al, (2007) Delayed
    cord clamping in preterm
    infants delivered at 34 to 36
    weeks gestation: A
    randomized controlled trial.
  3. van Rheenen PF et al (2006).
    Delayed umbilical cord
    clamping for reducing
    anaemia in low birthweight
    infants: implications for
    developing countries.
  4. Levy T, Blickstein I (2006).
    Timing of cord clamping
    revisited.
  5. Philip AGS, Saigal S (2004)
    When should we clamp the
    umbilical cord?
References
Full References
1.  Perinatal complications and cerebral palsy
  1. Hankins GD, Koen S, Gei AF, et al. Neonatal organ system injury in acute birth asphyxia
    sufficient to result in neonatal encephalopathy. Obstet Gynecol 2002;99:688–91.
  2. Iffy L, Varadi V. Cerebral palsy following cutting of the nuchal cord before delivery. Med
    Law. 1994;13(3-4):323-30.
  3. .Iffy L, Varadi V, Papp E. Untoward neonatal sequelae deriving from cutting of the umbilical
    cord before delivery. Med Law. 2001;20(4):627-34.

2.  Obstetric protocols
  1. Turrentine JE. Clinical Protocols in Obstetrics and Gynecology, Second Edition.  The
    Parthenon Publishing Group, Boca Raton, London, New York, Washington DC, 2003..
  2. ACOG Committee on Obstetric Practice (2006) ACOG Committee Opinion No. 348,
    November 2006: Umbilical cord blood gas and acid-base analysis. Obstet Gynecol. 2006
    Nov;108(5):1319-22.

3.  Textbooks promoting immediate clamping of the umbilical cord
  1. Hibbard, BM (1988) Principles of Obstetrics. London; Boston: Butterworths.
  2. Chamberlain G, Gibbings CR, Dewhurst J. (1989) Illustrated Textbook of Obstetrics.
    Philadelphia: Lippincott.
  3. McGregor Kelly, J (1994) General Care (chapt 22) in Avery GB, Fletcher MA, MacDonald
    MG, eds .  Neonatology, Pathophysiology and Management of the Newborn, Fourth
    Edition. Philadelphia: Lippincott.
  4. Chanberlain G & Bowen-Simpkins P (2000) A Practice of Obstetrics and Gynecology, a
    Textbook for General Practice and the DRCOG. Third Edition.  Edinburgh; New York:
    Churchill Livingstone.
  5. Gabbe SG, Niebyl JR, Simpson JL (2002)  Obstetrics: Normal and Problem Pregnancies,
    Fourth Edition. New York: Churchill Livingstone.

4.  Neonatal transfusions
  1. Mercer JS, Skovgaard RL (2002) Neonatal transitional physiology: A new paradigm.  
    Journal of perinatal and Neonatal Nursing 15:56-75.
  2. Murray NA, Roberts IA (2004) Neonatal transfusion practice. Arch Dis Child Fetal
    Neonatal Ed. 2004 Mar;89(2):F101-7.

5.  Respiratory depression
  1. Baskett TF, Allen VM, O'Connell CM, Allen AC. (2006) Predictors of respiratory depression
    at birth in the term infant. BJOG. 2006 Jul;113(7):769-74.
  2. Milsom I, Ladfors L, Thiringer K, Niklasson A, Odeback A, Thornberg E. (2002) Influence
    of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a
    Swedish urban population. Acta Obstet Gynecol Scand. 2002 Oct;81(10):909-17.

6.  The Apgar score
  1. Apgar V (1953) A proposal for a new method of evaluation of the newborn infant. Current
    Researches in Anesthesia and Analgesia 32:260-267.
  2. Apgar V, Holaday DA, James LS, Weisbrot IM (1958) Evaluation of the newborn infant –
    second report. JAMA 168(15):1985-1989.

7.  Umbilical cord clamping
  1. Baenziger O, Stolkin F, Keel M, von Siebenthal K, Fauchere JC, Das Kundu S, Dietz V,
    Bucher HU, Wolf M.The influence of the timing of cord clamping on postnatal cerebral
    oxygenation in preterm neonates: a randomized, controlled trial.
  2. Pediatrics. 2007 Mar;119(3):455-9.
  3. Ultee K, Swart J, van der Deure H, Lasham C, van Baar A. Delayed cord clamping in
    preterm infants delivered at 34 to 36 weeks gestation: A randomized controlled trial. Arch
    Dis Child Fetal Neonatal Ed. 2007 Feb 16; [Epub ahead of print]
  4. van Rheenen PF, Gruschke S, Brabin BJ. Delayed umbilical cord clamping for reducing
    anaemia in low birthweight infants: implications for developing countries. Ann Trop
    Paediatr. 2006 Sep;26(3):157-67.
  5. Levy T, Blickstein I.Timing of cord clamping revisited. J Perinat Med. 2006;34(4):293-7.
  6. Philip AGS, Saigal S (2004) When should we clamp the umbilical cord? NeoReviews Vol.
    5 No.4 2004 e142, http://neoreviews.aappublications.org/cgi/reprint/5/4/e142
. . . . .
top
Immediately after the delivery
of the neonate, a segment of
umbilical cord should be
double-clamped, divided, and
placed on the delivery table
pending assignment of the
5-minute Apgar score.
Could this practice be
responsible for the increased
prevalence of autism?
ACOG Committee Opinion
No. 348, November 2006
top
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