|[Part 1, Part 2]|
A major error in modern obstetrical practice is routine premature clamping of the umbilical cord. Some sections require medical knowledge for full comprehension and the language is very technical, but overall, medical jargon is avoided or explained in terms that most expectant parents can understand.
The error was defined very clearly over 200 years ago:
"Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child."
Erasmus Darwin, (Charles Darwin's grandfather) Zoonomia, 1801
Despite repeated publications illustrating the effects of the error, and official notification, medical academia and its peer review press have yet to acknowledge the possibility of any error. Public exposure and knowledge of the issue is intended to accelerate correction of the error.
The nature of the injury caused by this practice unhappily precludes a cure; for the unfortunate parents of an impaired child, the knowledge may assuage any guilt they may have and give them reassurance regarding future births.
Modern obstetrics ignores the normal functions of the cord and placenta from the moment that the child is born, and in most hospitals the umbilical cord is clamped and cut at the earliest convenient time after birth. 
At premature births and when the newborn is depressed or "at risk," immediate cord clamping is routinely performed in order to rush the child to a resuscitation table and to obtain cord blood samples for medico-legal purposes.  Placental blood, which ought to have been in the child, is either thrown away or used to provide stem cells or other commercial products.
Doctors are taught (and believe) that delayed cord clamping / placental transfusion gives the baby too much blood, (hypervolemia) while neonatal intensive care units (NICU) are filled with weak, fast - clamped newborns exhibiting signs of severe blood loss  - pallor, hypovolemia (low blood volume) anemia, (low blood count) hypotension (low blood pressure), hypothermia (cold), oliguria (poor urine output), metabolic acidosis, hypoxia (low oxygen supply), and respiratory distress (shock lung) - to the point that some need blood transfusions and many more receive blood volume expanders.  
At this point, an explanation of the terms anemia, polycythemia, hypovolemia and hypervolemia is required. Blood is a mixture of red cells and plasma, a fluid. Blood is usually about half cells and half plasma. When blood contains too few cells, the term anemia is used; the blood is "dilute."
Polycythemia means there are too many red cells - "concentrated" blood. The "-volemia" terms refer to the total volume of blood in the child's heart and blood vessels; blood vessels are elastic and are constantly filled by the heart pumping blood through them, like a long, circular balloon.
Too much blood volume (hypervolemia) overworks the heart and overfills the "balloon." Too little blood volume (hypovolemia) lets the balloon and the heart collapse; it makes no difference if the blood is diluted or concentrated.
Anemia and polycythemia are about the quality of blood; hypo- and hyper-volemia are about quantity of blood. An anemic baby may be hypervolemic - too much fluid, and a polycythemic child may be hypovolemic - dehydrated. A normal child that suffers acute blood loss will have a normal blood count and low blood volume (hypovolemia.)
During recovery from the hemorrhage, blood volume is restored with fluid (plasma), and the child becomes anemic (diluted blood) as it takes much longer to restore the lost red cells. Early infant anemia is a strong indication that the child has suffered significant previous blood loss.
Before birth, the cord and placenta "breathe" for the baby.
Humans and all other mammals have evolved, over millions of years, a very safe mechanism for closing umbilical cords at birth without interrupting "breathing," and ensuring optimal survival of their offspring.
An occasional natural accident such as a ruptured cord may rarely occur, but it is biologically impossible for that mechanism to routinely give a child too much, or too little, blood; mammals that routinely give their offspring the wrong amount of blood for survival become extinct in one generation.
Erasmus Darwin's late clamping method is safe because the tie is placed on vessels that the child has already closed physiologically (by natural constriction) after it has received the right amount of blood; the tie does no harm because it virtually does nothing.
Safe cord closure at birth involves closing the placental life support system and starting the child's life support systems without significant interruption of life support during the changeover process. Oxygen supply and blood to carry the oxygen are crucial to life support; blue blood contains little oxygen, red (pink) blood is saturated with oxygen. Brain cells die quickly from lack of oxygen; they do not regenerate, and asphyxiation (choking / lack of oxygen) for about six minutes will cause permanent brain damage. 
Normal Cord and Placental Function after Birth (No Cord Clamp Used)
Before birth, the lungs are filled with fluid and very little blood flows through them; the child receives oxygen from the mother through the placenta and cord. This placental oxygen supply continues after the child is born until the lungs are working and supplying oxygen - that is, when they are filled with air and all the blood from the right side of the heart is flowing through them.
When the child is crying and pink, the cord vessels clamp themselves. During this interval between birth and natural clamping, blood is transfused from the placenta to establish blood flow through the lungs. Thus the natural process protects the brain by providing a continuous oxygen supply from two sources until the second source is functioning well.
Placental blood transfusion occurs by gravity or by contraction of the mother's uterus which forces blood into the child.  Transfer of blood into the child through the cord vein can occur after the arteries are closed (no cord pulsation). The transfusion is controlled by the child's reflexes (cord vessel narrowing) and is terminated by them when the child has received enough blood (cord vessel closure).
The switch from placental to pulmonary oxygenation also involves changing the fetal circulation to the adult circulation - the one-sided heart (body blood flow only) changes to a two-sided heart (blood flows through the lungs, then through the body.) Ventilation of the lungs and placental transfusion effect this change.
This is a very basic account of a very complex process.  It all happens usually within a few minutes of birth, and when the cord pulsations have ceased and the child is crying and pink, the process is complete. Clamping the cord during the changeover process disrupts these life support systems and may cause serious injury.
The Effects and the Injuries of Immediate Cord Clamping (ICC)
The American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynecologists of Canada (SOGC) advocate immediate cord clamping at birth   before the child has breathed. This instantly cuts off the placental oxygen supply and the child remains asphyxiated until the lungs function. Blood, which normally would have been transfused to establish the child's lung circulation,  remains clamped in the placenta, and the child diverts blood from all other organs to fill the lung blood vessels. 
After immediate clamping, the normal term baby usually has enough blood to establish lung function and prevent obvious brain damage, but it is often pale, weak, and slow to respond. Occasionally, a child will cry as soon as the head is delivered, and the uterine contraction that delivers the child may also squeeze in some placental transfusion before the fast clamp can be applied; however, cord clamping before the first breath  always causes some degree of asphyxia and loss of blood volume:
1. It totally cuts off the infant brain's oxygen supply from the placenta before lungs begin to function.
2. It stops placental transfusion - the transfer of a large volume of blood (up to 50% increase in total blood volume) that is used mainly to establish circulation through the child's lungs to start them functioning.
Cerebral Palsy Can Result From Premature Cord Clamping
While ICC is a danger to all newborns, if a child is born asphyxiated and depressed following fetal distress from cord compression (e.g. a tight cord around the neck)  immediate cord clamping may very well be fatal. 
A child deprived of oxygenated placental blood before birth is in dire need of oxygenated blood after birth. Immediate clamping in such circumstances  often produces a hypovolemic and asphyxiated child who cannot begin to breathe adequately to relieve the asphyxia; oxygen in the lungs will never reach the brain if the newborn does not have enough blood to flow from lungs to brain. 
The medical term for the condition that causes cerebral palsy (CP) is hypoxic, ischemic encephalopathy. (HIE) Hypoxic means lack of oxygen - the child has no placental oxygen supply; ischemic means lack of blood flow - half of the child's blood is in the placenta; encephalopathy means brain damage.
HIE is often treated with blood transfusion or blood volume expanders after a large part of the child's own oxygenated blood has been discarded with the placenta. In addition, babies with HIE usually develop anemia.
The obvious correct way to resuscitate the depressed child is to keep the cord and placenta functioning while ventilating the lungs.  If a child is born depressed with a knot in the cord, should the knot be loosened or tightened? 
A newborn depressed from lack of blood and lack of oxygen  is quickly restored to normal with a large transfusion of oxygenated placental blood and is unlikely to develop HIE.  Rapid restoration of oxygenation is crucial in preventing brain damage in the depressed child, and that child must have enough blood to transport oxygen to the brain.
If hypoxic brain damage has occurred before birth, placental oxygenation and transfusion will not cure it after birth - nothing will - but progression of the damage will be prevented. Blood transfusion given after the child has developed HIE will not restore the dead brain cells. Blood transfusions given in the NICU are usually examples of "too little and much too late."
Fetal distress (intra-partum asphyxia ) from cord compression, such as occurs with a cord prolapsed during labor (a cord squeezed between the head and the cervix,) may be rapidly reversed by relieving the compression - elevating the presenting part (head) or changing the mother's position.
The fetal heart rate and monitor tracing soon return to normal, and at delivery by emergency c-section, the child may show no sign of asphyxiation. The same result can be obtained at birth in a child asphyxiated with a tight cord around the neck by reducing (unwinding) the cord and allowing the placental circulation to resuscitate the child. 
The current standard obstetrical practice is to clamp the cord immediately to obtain a cord pH  - this maximizes the asphyxiation and hypovolemia, and accelerates HIE; the life-saving blood in the placenta is thrown away while parts of the child's brain die.
Learning Disorders and Mental Deficiency
The varying degrees of cerebral palsy and spastic paralysis are usually evident soon after birth in the movement and reflexes of the child, but lesser degrees of hypoxic, ischemic brain damage may remain hidden for years.  Iron deficiency anemia in infants is associated with learning disorders and behavioral problems to the point of mental retardation when these children reach grade school;  the degree of mental retardation increases with more severe degrees of infant anemia. 
At birth, no newborn is anemic; adequate iron is supplied from the mother regardless of her iron status. Any newborn that receives a full placental transfusion at birth has enough iron to prevent anemia during the first year of life.  It is, therefore, reasonable to conclude that full placental transfusion will prevent the mental retardation, behavioral disorders and learning disabilities that occur following infant anemia.
The immediately clamped newborn may be missing one third to one half of its normal blood volume and is very prone to develop infant anemia,  and as shown previously, it is also at risk for hypoxic, ischemic brain damage at birth.
While some studies on treatment of the anemia in infancy have shown some behavioral improvement, most studies show no improvement or prevention of the brain dysfunction following correction of anemia,  making it difficult to establish a cause and effect relationship between anemia and brain dysfunction.
In HIE and CP (severe brain dysfunction) anemia develops AFTER the brain is damaged. Moderate hypovolemia and hypoxia at birth will produce infant anemia; it may also cause undiagnosed minor brain damage  that will later produce behavioral defects.
Evidence strongly points to infant anemia and behavioral brain dysfunction having a common cause - immediate cord clamping; in other words, both anemia and brain dysfunction are effects, not a cause and an effect.
In a comprehensive review of cord clamping in 1982, Linderkamp concluded: "immediate clamping can result in hypovolemia and anemia. ... A medium placental transfusion appears to be more appropriate in order to avoid the risk of hyperviscosity, whereas iron deficiency in later infancy is probably less dangerous."
And in a similar review in 1981, Peltonen stated: "Closing of the umbilical circulation before aeration of the lungs has taken place is a highly unphysiological measure, which should thus be avoided. Although the normal infant survives without harm, under certain unfavorable conditions, the consequences may be fatal." Within a few years, reports of these unharmed, "normal," anemic infants being mentally retarded in grade school began to appear in the literature.
While Linderkamp never proved that "hyperviscosity," (a hematocrit of >65%) was any risk at all to a newborn, Peltonen's remarks were based on his observations of newborns' chests viewed under a fluoroscope, and he described incomplete filling of the cardiac ventricles (decrease in heart size) following immediate clamping; his use of the word "fatal" indicates that, after immediate clamping, he witnessed a cardiac arrest that was not reversed.
His blunt advice to avoid the procedure (he mentions no exceptions) emphasizes that the "normal" child may not be free from risk. He did not advise repeating his experiment; ACOG and SOGC   do. Cardiac arrest, or inadequate cardiac output for a few minutes, will produce permanent brain damage.
Immediate cord clamping is clearly identified as a cause of newborn neurological (brain) injury ranging from neonatal death through cerebral palsy to mental retardation and behavioral disorders.
Immediate cord clamping has become increasingly common in obstetrical practice over the past 20 years; today, rates of behavioral disorders (e.g., ADD/ADHD) and developmental disorders (e.g., autism, Asperger's, etc) continue to climb and are not uncommon in grade school.
Copyright George M. Morley. February 26, 2002
In the February 2000, I formally requested that ACOG's ethics and practice committees revoke ACOG Educational Bulletin 216 that was published in 1995. Reference #8 above points out that ACOG has been unable to provide an informed consent for immediate cord clamping.
In the February 2002 edition of Obstetrics & Gynecology, ACOG quietly announced, in very small print on a back page (361), that Bulletin 216 has been withdrawn from circulation. I have yet to receive a formal reply from ACOG.
For the past seven years, thousands of obstetricians have been taught that immediate cord clamping is an acceptable, standard obstetrical procedure, and millions of newborns have been subjected to it.
Without any attempt at warning the profession, ACOG has quietly relieved its officials from further responsibility for an injurious procedure that is widely and naively performed by many practicing obstetricians. It would be ethically and morally appropriate for ACOG
To Announce To Every Obstetrician In Very Large Print:
1. That immediate cord clamping is no longer officially sanctioned as standard care.
2. That the person who clamps the cord before the lungs are oxygenating the child should have sound, documented, clinical justification for doing so and
3. That the person who clamps the cord immediately or prematurely is individually responsible and liable for the resulting injuries.
George Malcolm Morley, MB, Ch.B., FACOG
Dr. Morley graduated from Edinburgh University Medical School in 1957, completed a residency in OBGYN in 1962, and practiced obstetrics and gynecology until his retirement in 1999. He is board certified in OBGYN, and a Fellow of the American College of Obstetrics and Gynecology.
Criticism, comment and refutation on this article is encouraged and may be sent to:
G. M. Morley
P.O. Box 181
Northport, MI 49670
[Part 1, Part 2]
Life is difficult enough without having to struggle with giving newborns additional challenges to contend with. It would seem more than prudent to select a "naturally oriented" maternity care provider who will not use a cord clamp too soon and will avoid many of the other detrimental practices of modern obstetrical care.
The mission of Cordclamping.com is to educate physicians, midwives and patients about normal placental function during the third stage of labor and the injuries caused by interrupting it, as well as to ensure the structural and functional integrity of every newborn's brain by the correct use of the cord clamp.
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