How the Cord Clamp Injures Your Baby's Brain

By George M. Morley, M.B., Ch. B., FACOG
http://www.cordclamping.com

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. [1][2]

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. [3][4] 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 [5] - 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. [2] [5]

Explanations

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. [6]

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. [7] 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. [8] 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 [3] [4] 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,
[9] remains clamped in the placenta, and the child diverts blood from
all other organs to fill the lung blood vessels. [1]

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 [9]
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) [10] immediate cord clamping may very well
be fatal. [9][1]

A child deprived of oxygenated placental blood before birth is in dire
need of oxygenated blood after birth. Immediate clamping in such
circumstances [11] 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. [12]

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.
[1][9][12] If a child is born depressed with a knot in the cord, should
the knot be loosened or tightened? [11]

A newborn depressed from lack of blood and lack of oxygen [10] is
quickly restored to normal with a large transfusion of oxygenated
placental blood and is unlikely to develop HIE. [12] 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 [13]) 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. [1]

The current standard obstetrical practice is to clamp the cord
immediately to obtain a cord pH [3][4] - 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. [6] 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; [14] the degree of mental
retardation increases with more severe degrees of infant anemia. [15]

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. [13] 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, [13]
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, [16] 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 [6] 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 [3] [4] 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.

Continued in the next issue of the Newsletter

Cordclamping.com

Copyright George M. Morley. February 26, 2002

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Footnote:

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

Email: obgmmorley@aol.com