Respiratory status
Taylor et al. (1963) questioned the safety of allowing
a placental transfusion. [1] They cautioned that a
rapid and large transfusion might overload the
circulation of a newborn. They claimed that theirs
was a "minority opinion" favoring early clamping,
although by the early 1960s clamping and assigning
Apgar scores was already common practice.
Taylor et al. observed respiratory status in 182 full-
term and 340 premature infants assigned to groups
for early or delayed cord clamping. The cord was
clamped within one minute in the early-clamped
group, and to minimize placental transfusion the
infant was held above the perineum after delivery. In
the late-clamped group the cord was clamped
between 1 and 3 minutes and to maximize placental
transfusion the infant was held below the perineum.
A full 3 minutes was allowed to elapse before
clamping for most of the late-clamped group.
Selection of patients for their groups is disturbing (if
not despicable):
"The original plan was to study only infants born
of ward mothers. Ward patients were assigned
in rotation to Service I or II when first seen at the
hospital...
...It became necessary to include private
patients in the premature group to increase
enrollment; the planned randomoization of
these infants as to time of cord clamping failed."
[1, pp893-4]
In the 1960s health insurance was not provided by
employers, and obstetric care was not normally
covered in any insurance policies. I was a ward
patient. My husband was a graduate student, and
income from my work was our primary support with
much disapproval and reprimand from everyone,
including the obstetric residents in the clinic. In the
1960s women with young children or more than four
to six months pregnant were not supposed to work
[2]. This attitude was very detrimental to the care
received by many of us who could not afford the fees
of private and more experienced doctors.
Taylor et al. stated that their interest was in the
effect of early versus delayed cord-clamping on the
"clinical condition" of the newborn. Their measures
of clinical condition were respiratory rate and
presence or absence of retractions. They
concluded from these observations, "that the time of
cord clamping had little effect on neonatal survival."
No deaths occurred among full-term infants in the
study by Taylor et al. However, in contrast to the
research cited of von Engel (1885) and Bound et al.
(1962) [3, 4], more deaths of premature infants
occurred among those with delayed clamping of the
umbilical cord. On the other hand, at autopsy
atelectasis and hyaline membrane disease of the
lungs was found more often in premature infants with
early clamping of the cord.
Taylor et al. commented that the disagreement
between their findings and those of von Engel and
Bound et al. was unexplained, but they proceeded to
criticise the experimental design of these two earlier
studies. They also noted again that they had been
unable to enforce randomization of premature
infants selected for early or delayed clamping of the
cord.
Randomized controlled trials continue to be held in
highest esteem, but this needs to be questioned.
Understanding of the physiology of fetal to neonatal
transition should guide obstetric practice, not
"evidence" obtained from random treatment of our
children according to one protocol or another.
Taylor et al. cited the editorial in the Lancet [5] that
accompanied the papers by Bound et al. (1962) and
Secher and Karlberg (1962) [4, 6], and noted that
the editorial provided a review of research on
placental transfusion. The editorial cited a review by
Köstlin (1898) of nearly sixty publications in the
nineteenth century or earlier, plus papers by Budin
(1875), von Engel (1885), Jäykkä (1954), Gunther
(1957), Mahaffey and Rossdale (1959), and an
unpublished version of the paper by Taylor et al.
(1963) [7-11].
Taylor et al. also cited McCausland (1949), who had
surveyed mid-twentieth century obstetric practice
and found that 59 percent of obstetricians still
practiced delayed clamping of the cord and 38
percent stripped blood from the cord into the infant
[12]. Taylor et al. offered the following opinion:
"Proponents of delayed clamping of the cord
suggest that the placental transfusion (which
may exceed 30 percent of the infant's estimated
blood volume) benefits the infant by filling his
expanding pulmonary vascular bed, by initiating
or aiding initial lung expansion, by prevention of
'hematogenic shock,' and by increasing
hemoglobin concentration and supply of body
iron." [1, p893]
Their view, on the contrary, was that allowing
placental transfusion led to temporary hypertension
in contrast to early-clamped infants for whom no
significant elevation of blood pressure occurred.
This reflects a belief that placental blood is not part
of the total volume of fetal blood.
The placenta provides oxygen to the fetal circulatory
system. Pulmonary blood volume is minimal during
fetal life, but after birth no one would suggest that
pulmonary blood is separate from that circulating
through other organs of the infant. If placental blood
is not transferred to the infant at birth, what will be
the source of blood going to the newly inflated
lungs? It will have to be drawn from other organs
including the brain.
Is any more experimentation with human subjects
really warranted?
(in progress)
to
- Taylor PM, Bright NH,
Birchard EL. Effect of early
versus delayed clamping of
the cord on the clinical
condition of the newborn
infant.
- Friedan, B (1963) The
Feminine Mystique.
- von Engel G (1885) Über
den Zeitpunkt der
Abnabelung.
- Bound JP et al. (1962)
Prevention of pulmonary
syndrome of the newborn.
- Anonymous [Lancet editorial]
(1962). Placental
Transfusion.
- Secher O, Karlberg P (1962)
Placental blood-transfusion:
For Newborns delivered by
Cæsarean Section.
- Köstlin R. Ueber das
Zustandekommen und die
Bedeutung der postnatalen
Transfusion.
- Budin, P (1875) A quel
moment doit-on pratiquer la
ligature du cordon ombilical?
- Jäykkä S (1954) A new
theory concerning the
mechanism of the initiation
of respiration in the
newborn; a preliminary
report.
- Gunther M (1957) The
transfer of blood between
baby and placenta in the
minutes after birth.
- Mahaffey LW, Rossdale PD
(1959) A convulsive
syndrome in newborn foals
resembling pulmonary
syndrome in the newborn
infant.
- McCausland AM et al. (1949)
Management of cord and
placental blood and its effect
upon the newborn; part I.
- Taylor PM, Bright NH, Birchard EL. Effect of early versus delayed clamping
of the cord on the clinical condition of the newborn infant. Am J Obstet
Gynecol. 1963 Aug 1;86:893-8.
- Friedan B. The Feminine Mystique. New York : Norton, 1963.
- von. Engel G (1885) Über den Zeitpunkt der Abnabelung. 1885;
Centralblatt für Gynäkologie 46: 721-727.
- Bound JP, Harvey PW, Bagshaw HB. Prevention of pulmonary syndrome of
the newborn. Lancet. 1962 Jun 9;1:1200-3.
- Anonymous (editorial). Placental Transfusion. Lancet 1962 Jun 9; 279
(7241):1222-1223.
- Secher O, Karlberg P. Placental blood-transfusion: For Newborns
delivered by Cæsarean Section. Lancet 1962 Jun 9; 279(7241):1203-1205.
- Köstlin R. Ueber das Zustandekommen und die Bedeutung der postnatalen
Transfusion. Zeitschrift für Geburtshülfe und Gynäkologia 1898; 39:98-136.
- Budin, P (1875) A quel moment doit-on pratiquer la ligature du cordon
ombilical? Progres Medical 3:750-751, 765-767, (1876) 4:2-3.
- Jäykkä S. A new theory concerning the mechanism of the initiation of
respiration in the newborn; a preliminary report. Acta Paediatr. 1954 Sep;
43(5):399-410.
- Gunther M. The transfer of blood between baby and placenta in the
minutes after birth. Lancet. 1957 Jun 22;272(6982):1277-80.
- Mahaffey LW, Rossdale PD. A convulsive syndrome in newborn foals
resembling pulmonary syndrome in the newborn infant. Lancet. 1959 Jun
13; 1(7085):1223-5.
- McCausland AM, Homes F, Schumann WR. Management of cord and
placental blood and its effect upon the newborn; part I. California Medicine
1949;71(3):190-196.