Iatrogenic Resuscitation

Current Resuscitation Practice

When any “at risk” child is delivered, the cord is clamped and cut immediately and prompt airway clearing and ventilation are done on a warmer. This is not revival; it is rapid, forced removal from placental life support to hasty pulmonary respiration. It results in major disruptions of perinatal physiology and neonatal life support systems.

When a child is born depressed, “asphyxiated”, atonic and unable to breathe, the pathology is not due to cardiac or pulmonary failure, the defect is in the placenta and / or umbilical cord; the most common cause is intra-partum cord compression.

If the cord is still pulsating, failure is not total – the cord is maintaining life, and placental / cord function should be restored, not amputated, in order to maximize revival of the child. This principle is used successfully to correct fetal distress in utero – changing maternal position to relieve cord compression. Iatrogenic resuscitation (IR) discards this advantage.

IR disrupts much of the anatomy and physiology involved in the normal transition from placental to independent life support:

· Immediate cord clamping terminates placental respiration, imposing complete asphyxia on the neonate ’til pulmonary function is established.

· Immediate cord clamping prevents placental transfusion, a loss of up to 50+% of the neonate’s blood volume, resulting in:

1. Drastic reduction in venous return to the heart and reduction in cardiac output – see the precipitous fall in the heart rate at cord clamping in [A].

2. Loss of the “jaykka” effect in expanding alveoli.

3. Diminished pulmonary perfusion and possible non-closure of the foramen ovale – persistent fetal circulation.

4. Diminished perfusion of all neonatal life support systems – heart, lungs, brain, kidneys, gut and respiratory muscles.

· The warmer deprives the child of the “cold crying” and “cold pressor” reflexes.

· Ventilation relaxes pulmonary arterioles, but diverting blood volume into the lung vessels may collapse the systemic circulation – hypovolemic shock.

The effects of immediate clamping (hypovolemia) are apparent on many newborns:

i. Pallor, lethargy, weakness

ii. Hypoglycemia: liver ischemia reduces production of glucose.

iii. Hypotension.

iv. Kidney failure/low urine output.

v. Severe anemia and blood transfusion.

vi. Hypovolemic neonates may become hypothermic.

vii. The “shock lung syndrome” [RDS] and hyaline membrane disease.

viii. Retraction respiration, ischemic encephalopathy and brain damage.

All these complications may be avoided by resuscitating the depressed neonate with the placental circulation intact and by allowing the umbilical vessels to close physiologically, permitting full placental transfusion.

Note:

If a neonate is born limp, ashen pale, without reflexes, meconium stained, a cord pulse rate of 60 b.p.m. and a firm, true knot in the cord, would you:

1. Clamp the cord immediately to obtain a cord pH?

2. Or would you loosen the knot?

www.cordclamping.com Neonatal Resuscitation: Life that Failed.

Figure 1. Myers RE. Perinatal brain damage. American Journal of Obstetrics and Gynecology 1972 112:246-276.30

Copyright September 2004 G. M. Morley MB ChB FACOG