The obstetric clamp
Wechsler (1912) published a brief note in the
American Journal of Obstetrics and Diseases of
Children on use of an obstetric clamp, stating:
"I desire to present to the profession a little
device for use on the cord instead of the usual
ligature." [1, p85].
Wechsler reported that on a recent visit to Vienna, he
had witnessed the method of clamping and dressing
without ligature in the Schauta Clinic. The clamp is
pictured and noted to be smaller than the "ordinary
Hemostat" used in Vienna. The rationale for use of a
clamp was that it lessens the danger of infection. Its
use was described as follows:
"Clamping the cord is accomplished in the
following way:
1. Wait until pulsation has ceased;
2. Clamp cord about one inch from umbilicus;
3. Cut cord even with clamp.
The infant is then removed by the nurses and
the clamp allowed to remain on stump of cord for
fifteen minutes, or about the time the placenta
has been expelled then the clamp is ready to
taken off." [1, p86]
In the same journal ten years later, Zeigler (1922)
published an article on instruments used in obstetrics,
and commentd on use of a clamp 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." [2]
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 [3]. This
reservoir would appear to be the capillary system
surrounding the alveoli of the lungs, as described by
Jäykkä (1958) and Mercer & Skovgaard (2002) [4, 5].
Placental blood is respiratory blood. Later research
by Redmond et al. (1965) provided dramatic evidence
that the infant's first breath redirects blood from the
placenta to the lungs [6].
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."
In a presentation in April 1925 at the meeting of the
New Orleans Gynecological and Obstetrical Society,
Dicks (1925) promoted use of a clamp to prevent
infection. He described his procedure as follows:
"After the cord and surrounding skin are painted
with one-half strength tincure of iodine and
pulsation has ceased, the Martinez clamp, which
of course, has been sterilized, is placed on the
cord as near the skin margin as possible in the
long axis of the body. The jaws are closed
slowly; if this is done too rapidly there is some
danger of rupturing the cord below the clamp.
The cord is then cut off close to the jaws of the
clamp, and an alcohol spong applied for a few
minutes to dehydrate it. A gauze roll is place
about the body, including the clamp. Twent-four
hours later the instrument is removed and that
portion of the cord which has been compressed
and which is as thin as a piece of parchmentcan
either be trimmed off at onece or left to fall off,
which it does within a few days." [7, p 708].
Among the discussants of this paper, WE Levy
commented:
"I am rather inclined to disagree with those who
advocate the use of a clamp. To me the ligation
of the cord is one of the simples processes in
obstetrics, and why complicate whqat is
inherently simple? I quite agree that the cord
should be tied as close as possible to the skin
margin, but a piece of tape does that just as well
as n instrument. The clamp crushes and
macerates the tissues, and macerated tissue, as
is well known, is prone to develop bacteria. This
also holds true of the so-called milking of the
cord, which frequently breaks down the outer
surface and so favors the entrance of infection."
[7, p740]
Of note is that during the early twentieth century, use
of sterile techniques and antiseptic agents became
increasingly important. However, waiting for
pulsations of the umbilical cord to cease before
ligating it in the traditional way, or by use of the newly
introduced clamp, remained the standard of care.
The comment by Levy above provides evidence that
milking the cord to maximize transfer of blood to the
baby was a technique used by some.
- Wechsler BB (1912)
Umbilical clamp.
- Ziegler CE (1922) Additions
to our obstetric
armamentarium.
- Gunther (1957) The transfer
of blood between baby and
placenta in the minutes after
birth
- Jäykkä (1958) Capillary
erection and the structural
appearance of fetal and
neonatal lungs
- Mercer & Skovgaard (2002)
Neonatal transitional
physiology: A new paradigm.
- Redmond et al. (1969)
Relation of onset of
respiration to placental
transfusion.
- Dicks JF (1925) Treatment of
the umbilical cord by short
ligaion and the use of a
clamp.
- Wechsler BB. Umbilical clamp. Am J Obstet Dis Women Child 1912; 60:
85-6.
- Ziegler CE. Additions to our obstetric armamentarium. Am J Obstet
Gynecol 1922; 3:46-53.
- Gunther M. The transfer of blood between baby and placenta in the
minutes after birth. Lancet. 1957 Jun 22;272(6982):1277-80.
- Jäykkä S. Capillary erection and the structural appearance of fetal and
neonatal lungs. Acta Paediatr. 1958 Sep;47(5):484-500.
- Mercer JS, Skovgaard RL. Neonatal transitional physiology: A new
paradigm. J Perinat Neonatal Nurs. 2002 Mar;15(4):56-75.
- Redmond A, Isana S, Ingall D. Relation of onset of respiration to
placental transfusion. Lancet. 1965 Feb 6;1:283-5.
- Dicks JF. Treatment of the umbilical cord by short ligation and the use of
a clamp. Am J Obstet Gynecol 1925 Nov; 10(5):706-8. Discussion
pp739-40.