Ventilation before Umbilical Cord Clamping Improves Physiological Transition at Birth or “Umbilical Cord Clamping before Ventilation is Established Destabilizes Physiological Transition at Birth”

Bhatt et al’s paper provides a good argument for ensuring that ventilation is established before clamping the umbilical cord (1). The possibility that very early clamping could explain the increased occurrence of intraventricular hemorrhage was proposed in 1988 by Hofmeyr (2) who showed that in human babies there was a marked rise in arterial pressure when the cord was clamped as late as 35 s after birth. He proposed that the sudden rise in cerebral circulation was the underlying mechanism for the higher incidence of intraventricular hemorrhage after early cord clamping (ECC) in preterm neonates. Our computer simulation of transitional circulation supports Hofmeyr’s finding (3). The simulation demonstrates that a sudden rise in cerebral pressure and blood flow is inevitable if the placental circulation is closed before the increase in pulmonary blood flow has occurred as a result of respiration. In the experimental lamb, Bhatt et al. have now provided further evidence of this adverse effect of early clamping (4). The instability in the circulation shown in their lambs may also be the result of loss of the blood volume (5) known to be redistributed from the placenta to the neonate (placental transfusion) and from the loss of the oxygenated blood from the umbilical vein. Long-term harms for the neonate may also result from loss of the stem cells capable of quickly repairing vital organ injury. Charles White an eminent obstetrician in Manchester, England (6) could not have put it better in 1773 . . . the common method of tying and cutting the umbilical cord in the instant the child is born, is likewise one of those errors in practice that has nothing to plead in its favour but custom. Is it possible that this wonderful alteration in the human machine should properly be brought about in one instant of time, and at the will of a bystander? Let us leave the affair to nature, and watch her operations and it will soon appear that she stands not in need of our feeble assistance, but will do the work herself at a proper time, and in better manner. In a few minutes the lungs will gradually be expanded and the great alterations in the heart and blood vessels will take place. As soon as this is perfectly done, the circulation in the umbilical cord will cease itself. . . By this rash, inconsiderate method of tying the umbilical cord before the circulation in it is stopped, I doubt not but many children have been lost, many of their principal organs have been injured, and foundations laid for various disorders.