Using the word “delayed” to describe the timing of physiological cord clamping creates linguistic biases against it’s acceptance

by faithgibson on May 8, 2014

in Contemporary Childbirth Politics

At the risk of being churlish, I must note that the word of ‘delayed’ relative to umbilical cord clamping is a term with built-in bias against acceptance by the medical profession, as well as the lay public.

Everyone knows that having one’s flight ‘delayed’ is never a good thing. Neither is having one’s doctor (or income tax refund) be delayed.

Obstetrically, ‘delayed‘ is sister to ‘prolonged‘ and close cousins to ‘failure’ to progress and ‘inadequate’ uterine forces.

The use of the term ‘delayed’ is itself inaccurate, since the biological norm is non-intervention in the still-pulsing umbilical cord during the physiological process of 3rd-stage placental-umbilical cord transfusion — a normal process following births in the mammalian species.

The correct term would be ‘physiological’ cord management. This describes a supportive relationship on the part of caregivers to the biological norms of childbirth. In that context, it is not statistically ‘normal’ for the umbilical cord of the neonate to be subject to medical interventions.

AGOG’s decision to use of the term ‘delayed’ infers that ‘immediate’ is the normal and proper practice. In this context, quickly clamping the still-pulsing cord is seen as the high moral ground, which makes’delayed’ clamping is a failure to follow the proper medical procedure and a potentially dangerous departure from the standard of care. Is it any wonder that obstetricians reject it, fearing malpractice claims for having delayed the approved procedure.

Unfortunately, this obscures the fact that nearly instantaneous cord clamping is a significant medical intervention that has been the recommended practice since the early 1900s. This was made necessary when hospitalized labor patients were routinely delivered under ether, chloroform or other anesthetic gases, all which were knowns to cause respiratory depression in the newborn.

Except for shortening fetal exposure to general anesthetic gases being administered to its laboring mother, there is no scientific foundation for imposed this non-physiological practice in place of the biologically normal one. As described by Dr. McAdams in contemporary times, it continues to be “routine in the United States despite little evidence to support this practice”.

In the non-medical world (historically and geographically) the mother gives birth, either catching the baby herself or easing it out into the waiting hands of a helper. After taking 20-30 seconds to fully comprehend the act of having given birth and catch her breath (metaphorically or literally) 99% of unanesthetized new mothers will reach down to pick up their newly born babies. In the next 3 to 6 minutes, while the mother is holding and looking at her new baby, the cord will of itself slowly become paler and smaller in diameter and stop pulsing.

In 20 or so minutes, the placenta will naturally be expelled and a family member (or other helper) will tie a piece of string around the cord and cut (or in absence of a knife, bit) the cord in two. This separates the baby from its placental system, which has become irrelevant.

Contrast the medical term “delayed” cord management, with ‘immediate’ clamping of a cord that is still pulsing and fat with fetal-blood. In biological terms, this would properly be described as ‘premature’ cord clamping.

This historical practice began in the early 1900s as an attempt to prevent newborns from additional (and detrimental) exposure the chloroform or ether that was being administered to their unconscious mothers. As a medical intervention, premature clamping and cutting was to be performed as quickly as possible to reduce the well-known respiratory depression associated with the maternal use of general anesthetic gases. (*Note 1912 quote from Dr. J. Whitridge Williams below)

This oral tradition was later bolstered by the idea that the normal or physiological’ jaundice of the neonate was also reduced by preventing the baby from receiving the ‘extra’ blood in the placental-umblical cord loop.

Reducing the number of red cells by approximately 30 to 40% does indeed eliminate many cases of observable jaundice in babies who would otherwise have appeared slightly to moderately jaundiced.

However, the idea that fetal blood in the placental-umbilical loop was an unnecessary by-product (or an error on Mother Nature’s part) was wrong. During fetal life the physiological diversion of its blood from not-yet-functioning lungs to the proxy lung of a placenta represents blood volume that will be needed as fetus becomes an air-breathing neonate who must have sufficient volume to perfuse the lungs while still being able to maintain a normal blood pressure to perfuse other vital organs.

This principle of preserving blood volume as a critical factor in maintaining normal blood pressure (a prerequisite for organ perfusion and brain function) is sees in surgical patient when their blood is diverted to a heart-lung bypass machine. This blood ultimately belongs to the patient and at the end of the operation it will, without questions, be returned in full (minus any additional blood used to ‘prime’ the pump!).

In 2014, we no longer need to protect babies from the detriment aspects of their routinely anesthetized mothers.

Inducing infant anemia via premature cord clamping as a medical ‘treatment’ to reduce physiological jaundice via premature cord clamping is goal of little worth and significant determent, especially for premature babies and distressed term neonates.

The notion that reduce physiological jaundice by artificially creating an non-physiological infant anemia stretches the bound of credulity to the breaking point.

Again I apologize for be churlish, but language does matter. As many others have noted, history is written by the winners. The obstetrical profession won the war between physiological management and routine medicalization of normal childbirth. This resulted in the terms “immediate” and “delayed” cord clamping for what actually is ‘premature’ CC and physiological management of the pulsing umbilical cord.

Given these facts, the early 1900s practice of premature clamping should no longer a routine or standard part of obstetrical care, wisely supplanted in 21st century America by physiological cord management.

*** 1912 Quote Dr. JW Williams: “In Johns Hopkins Hospital “no patient is conscious when she is delivered of a child. She is oblivious, under the influence of chloroform or ether.”

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