Loose Nuchal Cord Research Articles

Influence of tension of the nuchal cord to the developmental output in a one-year-old child.

ObjectiveInfluence of nuchal umbilical cord tension in a newborn on the developmental outcome at the end of the first year.Methodsand subjects of research: The research is prospective, conducted in northern Bosnia and Herzegovina (Una Sana Canton), for a period of five years. In the research study, we included newborns with a nuchal cord (tight and loose) and newborns without a nuchal cord (control group). We were tracking and recording the Apgar score and the conventional cardiotocography (CTG) findings in both groups. The development of newborns was monitored by the Munich Functional Scale and the development was evaluated at the end of the first year of life.ResultsStatistically, there was a significant presence (P< .001) of Apgar score lower than 7 in newborns with nuchal cord concerning the control group. There were significantly lower Apgar score findings in newborns with a tight nuchal cord compared to ones with a loose nuchal cord (P<.001). Pathological cardiotocographic findings were monitored and the statistical significance in neonates with a nuchal cord concerning the control group. Cardiotocographic data in a neonatal group with tight nuchal cord were statistically significantly lower concerning cardiotocographic data in neonates with a loose nuchal cord (P<.001). Infants at the age of 1 year born with tight nuchal cord were found to have a significant developmental delay compared to those born with loose nuchal cord and control group (P<.001).ConclusionThe nuchal cord is the risk factor for later developmental deviation. Early diagnosis of the nuchal cord, especially tight cord around the neck (nuchal cord), is important for the prevention of later morbidity.

Nuchal Cord and Perinatal Outcome at the Yaounde General Hospital, Cameroon

The aim of this study was to determine the incidence of nuchal cord at delivery and perinatal outcome. We conducted a retrospective descriptive study from 1992–2008 at the Yaounde General Hospital. Obstetrical and neonatal variables were compared in the loose and tight nuchal cord groups and a control group (no nuchal cord). Of 9275 deliveries recorded, 16.2% had a nuchal cord. Of these nuchal cords, 75.81% were loose and 24.18% were tight. Cesarean delivery rate was lower in the loose and tight nuchal cord groups when compared with control group (P <.001;P < .05). Low Apgar scores < 7 at the 1st and 5th minutes were less in the loose nuchal cord group when compared with control group (P = .06, P = .7). In tight nuchal cord group, low Apgar score < 7 at the 1st minute was significantly higher, when low Apgar score < 7 at the 5th minute was non significantly higher when compared with control group (P < .001, P = .14). Transfer rate to neonatology unit was lower in the loose and tight nuchal cord than in the control group. Loose nuchal cord may not be associated with adverse perinatal outcome. However, tight nuchal cord may be associated with increased risk of low Apgar score < 7 at the 1st minute. Consequently, the ultrasound diagnosis of a nuchal cord at the end of pregnancy should not be the indication of elective cesarean delivery.

Legal Briefs: An Infant with an Omphalocele Ends Up with Organ Transplants

A 2,226-g female infant with a prenatal diagnosis of an omphalocele was born at 33 3/7 weeks’ gestation to a 43-year-old gravida 4, para 1, aborta 3 woman. The pregnancy was unremarkable except for the known abdominal defect containing a portion of the liver and preterm labor. Before delivery, the woman had received nifedipine for tocolysis, antibiotics as a result of preterm labor, and 1 dose of antenatal steroids. However, labor progressed and the infant was born via cesarean delivery. The infant emerged active and had Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. A loose nuchal cord was noted at delivery. The umbilical cord gases were normal. The physical examination showed a normal-appearing infant with a soft abdomen without distention and an omphalocele. The surgery team determined that a silo was not necessary because the defect was “small,” with only a portion of the liver as the contents in the sac, and a “large abdominal domain.” The neonatology team covered the omphalocele with xeroform and placed a Replogle tube and peripheral intravenous line. Echocardiography and ultrasonography of the head were performed, and no cardiac or brain abnormalities were found. Fifteen hours after birth, the infant was brought to the operating room (OR) for omphalocele excision with reduction and primary closure. During the 3½ hours in the OR, the surgeons noted that the abdominal cavity was actually too small to fit the large anterior lobe of the liver that was within the sac. Because of this complication, the surgical team digitally stretched the abdomen to provide more space to accommodate the entire liver. During the procedure, a small amount of bleeding occurred on the inferior border of the liver segment, which was compressed with gauze. When the bleeding stopped, the anterior lobe of the liver was …

PO-0662 Umbilical Cord Blood Gases Analysis In Pregnancies Complicated By Nuchal Cord

Introduction Cardio-pulmonary compromise in fetus and newborn secondary to loose or tight nuchal cord at or prior to delivery is an important area for research. Our aim in this study is to evaluate umbilical arterial (UA) and venous (UV) pH, pO 2 , pCO 2 , base deficit and the umbilical veno-arterial difference (Uv-a) in these parameters in newborns born following nuchal cord. Methodology UA and UV pH, pO 2 , pCO 2 , and base deficit of 47 newborns born following tight nuchal cord, 44 newborns born following single loose nuchal cord and 44 newborns born without nuchal cord were compared across. Results Mean UA pH (7.25 vs. 7.28) was lower in the nuchal cord group and mean UA pCO 2 (58.11 vs. 54.38) was higher in the nuchal cord group; however the difference was not statistically significant. No difference was found in pO 2 or base deficit across groups. However, nuchal cord to control group comparisons of U v-a pH and U v-a pCO 2 change were both significant (p 2 differences between control and tight nuchal cord were observed. U v-a pO 2 difference and U v-a base deficit difference was also non-significant across groups. Discussion UA acidosis was observed in group with nuchal cord, as seen by lower mean UA pH and elevated UA pCO 2 (statistical non-significance could be due to low power) and U v-a difference in pH and pCO 2 (statistically significant). Large prospective studies would be needed to clearly understand the patho-physiology of acidosis in newborns born following nuchal cord.

Is nuchal cord a perfect scapegoat: A retrospective analysis from Northwest India?

Background: Entanglement of the umbilical cord around the fetal neck (nuchal cord) is quite a common fi nding at delivery. It is often assumed that nuchal cord causes cord compression and thus low birth weight and intrapartum complications. Aim: The aim of this article is to study the eff ect of nuchal cord on the mode of delivery, complications and fetal outcome. Materials and Methods: A retrospective study was carried out on 386 deliveries, 60 of them with nuchal cord, during 1 year from November 2009 through October 2010. Their mode of delivery, complications and fetal outcome were studied and a comparison was established between nuchal cord group and the rest of the deliveries. Nuchal cord group was subdivided into loose nuchal cord (cord could easily be uncoiled before complete delivery of the baby) group and tight nuchal cord (cord was needed to be clamped and cut before delivery of the baby) group. Furthermore, the mode of delivery and fetal outcome were compared between these subgroups. Statistical analyses were performed using SPSS statistical soft ware version 12.0 (Chicago Illinios, USA). The results were expressed as percentages. Test for significance was done using Chi-square, and a P<0.05 was considered as significant. Results: The nuchal cord group did not have any signifi cant diff erence in the mode of delivery or fetal outcome compared with the control group. However, the subgroup having tight cord around the neck had significantly higher proportion of low Apgar scores and meconium staining at birth. Conclusions: Nuchal cord does not increase the chances of cesarean delivery. However, tight cord around the neck may result in low Apgar scores and increased incidence of fetal distress leading to cesarean section. Keywords: Apgar score, cesarean delivery, meconium staining, north west India, nuchal cord, perinatal outcome

Neonatal outcomes following a tight nuchal cord

The best practices for the care of a neonate born after a tight nuchal cord have not been defined. As a step toward this, we compared the outcomes of neonates born after a tight nuchal cord vs those born after a loose nuchal cord vs those born after no nuchal cord. This was a retrospective comparison using electronic data of all deliveries during a 6-year period (2005 to 2010) in a multihospital healthcare system in the western United States. At the time of delivery, each birth was recorded as having a tight nuchal cord, a loose nuchal cord or no nuchal cord. Nuchal cord was defined as a loop of umbilical cord ≥360° around the fetal neck. 'Tight' was defined as the inability to manually reduce the loop over the fetal head, and 'loose' as the ability to manually reduce the loop over the head. Of 219,337 live births in this period, 6.6% had a tight nuchal cord and 21.6% had a loose nuchal cord. Owing to the very large number of subjects, several intergroup differences were statistically significant but all were judged as too small for clinical significance. For instance, those with a tight nuchal cord had a very slightly older gestational age, a very slightly lower birth weight, a preponderance of male fetuses, primagravid women, singleton pregnancies and shoulder dystocia (all P<0.001). Term neonates with a tight nuchal cord were slightly more likely to be admitted to a Neonatal Intensive Care Unit (6.6% vs 5.9% admission rate, P=0.000). Those with a tight nuchal cord were not more likely to have dopamine administered or blood hemoglobin measured on the first day, nor were they more likely to receive a transfusion or to die. The subset of very low birth weight neonates with a tight nuchal cord, compared with those with no nuchal cord, were of the same gestational age and birth weight, with the same Apgar scores, and were not more likely to have severe intraventrucular hemorrhage, retinopathy of prematurity or periventricular leukomalacia, or to die. The presence of a tight nuchal cord is not uncommon, occurring in 6.6% of over 200,000 consecutive live births in a multihospital health system. No differences in demographics or outcomes, judged as clinically significant, were associated with a tight nuchal cord. Thus, we speculate that the best practices for neonatal care after a tight nuchal cord do not involve an obligation to conduct extra laboratory studies or extra monitoring solely on the basis of the report of a tight nuchal cord.

Strip of the Month: April 2011

Strip of the Month: April 2011

Strip of the Month: March 2010

Strip of the Month: March 2010

Dinoprostone Compared With Misoprostol for Cervical Ripening for Induction of Labor at Term

H.L. is a 25‐year‐old woman, gravida 2 para 1‐0‐0‐0 admitted to the birth unit at 38 and 6/7 weeks' gestation for induction of labor because of an obstetric history of a previous intrauterine fetal demise (IUFD) at term. The previous pregnancy occurred 5 years before this pregnancy, and the etiology of the IUFD was not determined. The current pregnancy was uncomplicated. Maternal serum alpha‐fetoprotein and gestational diabetes screening were normal. Serial sonograms and the biweekly nonstress tests (NST) that were first performed at 32 weeks' gestation showed no abnormalities. The cervical examination on admission was 1 cm dilated, 50% effaced, medium consistency and posterior, −3 station, vertex presentation, equivalent to a Bishop score of 3, with membranes intact. The NST conducted on admission was reactive and she had no significant uterine activity. After informed consent and consultation between the midwife and attending obstetrician, the plan to administer 25 mcg of misoprostol (Cytotec) per vagina, every 4 hours, for up to 6 doses, was initiated. H.L. began feeling mild contractions after receiving her third dose of misoprostol; however, her cervical examination remained unchanged. A routine change in the inpatient obstetric providers resulted in a change from continued vaginal misoprostol to use of vaginal 10 mg dinoprostone (Cervidil) for cervical ripening. This change in medical induction agents was based on the belief and experience of the incoming midwife that dinoprostone is a better ripening agent, and the fact that there had been no cervical change after 3 doses of misoprostol. Two hours after insertion of the dinoprostone, H.L. had a period of tachysystole. The dinoprostone was removed from the vagina, oxygen via face mask was started, and 0.25 mg of terbutaline was given subcutaneously. After 6 hours of rest and observation, the cervical examination was 2 cm dilated, 70% effaced, −2 station. An oxytocin infusion was started at 1 milliunit per minute, and was increased to a maximum of 2 milliunits per minute with adequate uterine contractions. After 2 more hours, H.L.'s cervical examination was 2 to 3 cm dilated, 70% effaced, −1 station, with bulging membranes. Membranes were artificially ruptured at this time, and the fluid was noted to be clear. After an hour and a half of intense, frequent contractions, H.L. requested an epidural. A cervical examination revealed labor had progressed to 6 to 7 cm, 100% effaced, and 0 station. Twenty minutes later—coincidentally, the same time as the arrival of the anesthesiologist—H.L. sat up and began spontaneous pushing efforts. She was examined and found to be fully dilated. Following a 6‐minute second stage of labor, a 7 lb, 2 oz male was born spontaneously and without difficulty, with a loose nuchal cord, and Apgar scores of 9 and 9, at 1 and 5 minutes, respectively. The placenta was delivered spontaneously and grossly intact after a 7‐minute third stage of labor. There were no lacerations or excessive uterine bleeding. The postpartum and neonatal periods progressed well.

Nuchal cords: sharing the evidence with parents

The presence of a nuchal cord, where the umbilical cord is around the neck at the point of birth is a common occurrence, and checking for, and managing a nuchal cord has become part of routine midwifery practice. Whilst a tight nuchal cord is associated with some short-term morbidity, it is unclear whether such outcomes are actually a result of the presence of the nuchal cord itself, or as a result of clamping and cutting the cord. The action of looping a loose nuchal cord over the baby's head before the emergence of the body may also interfere with the normal physiology of birth. In addition women's experience of birthing a baby with a nuchal cord has not been explored. The association of nuchal cords with danger is embedded within our culture and influences parent's perceptions. Therefore, childbirth education needs to address the issues surrounding this commonly occurring situation.

Nuchal cord: A retrospective analysis

Background: The nuchal cord is often blamed for problems that are encountered during delivery and is often cited as a major cause of fetal distress and perinatal mortality. However, the actual significance of nuchal cord on the outcome of an infant is controversial. A retrospective study was done to investigate the actual frequency of nuchal cords encountered in a hospital setting and to determine its effect on an infant as it passes through the birth canal and immediately after delivery. Methods: A retrospective study was carried out in 350 deliveries (out of total 367 deliveries) including 65 cases of nuchal cord from July to December 2005. Nuchal cord group was divided into loose nuchal cord (cord could easily be uncoiled before delivery of the newborn) group and tight nuchal cord (cord was needed to be clamped and cut before delivery) group. The mode of delivery, complications and fetal outcome of nuchal cord groups was compared with rest of the deliveries. Seventeen cases (including three cases of nuchal cord) having complications as intrauterine growth retardation, oligohydramnios (AFI <5), antepartum haemorrhage, severe pregnancy induced hypertension and maternal medical complications were excluded. Result: We found that the loose nuchal cord group did not have any significant difference in mode of delivery or fetal outcome as compared to control group however the group having tight cord around the neck had significantly higher proportion of fetal distress and low Apgar scores at one minute. Conclusion: Loose nuchal cord doesn't increase the chances of cesarean delivery whereas tight cord around the neck may result in lower Apgar scores at one minute and increased incidence of fetal distress.

Answers to MCQs

The nuchal cord is often blamed for problems that are encountered during delivery and is often cited as a major cause of fetal distress and perinatal mortality. However, the actual significance of nuchal cord on the outcome of an infant is controversial. A retrospective study was done to investigate the actual frequency of nuchal cords encountered in a hospital setting and to determine its effect on an infant as it passes through the birth canal and immediately after delivery.A retrospective study was carried out in 350 deliveries (out of total 367 deliveries) including 65 cases of nuchal cord from July to December 2005. Nuchal cord group was divided into loose nuchal cord (cord could easily be uncoiled before delivery of the newborn) group and tight nuchal cord (cord was needed to be clamped and cut before delivery) group. The mode of delivery, complications and fetal outcome of nuchal cord groups was compared with rest of the deliveries. Seventeen cases (including three cases of nuchal cord) having complications as intrauterine growth retardation, oligohydramnios (AFI <5), antepartum haemorrhage, severe pregnancy induced hypertension and maternal medical complications were excluded.We found that the loose nuchal cord group did not have any significant difference in mode of delivery or fetal outcome as compared to control group however the group having tight cord around the neck had significantly higher proportion of fetal distress and low Apgar scores at one minute.Loose nuchal cord doesn't increase the chances of cesarean delivery whereas tight cord around the neck may result in lower Apgar scores at one minute and increased incidence of fetal distress.

Relationship between umbilical cord morphology and nuchal cord entanglement

Acta Obstet Gynecol Scand 2002; 82: 32–37. © Acta Obstet Gynecol Scand 2003 Objective. To determine whether tightening of nuchal cord entanglement is more likely to occur where normal cord coiling is absent and there is deficient Wharton's jelly. The study was carried out in the delivery suite of a university teaching hospital, using a prospective matched controlled-pairs survey. Methods. Midwives identified index cases with nuchal cord entanglement at the time of delivery. The next delivery of equivalent gestation (± 1 week) without cord entanglement was taken as the control. Only singleton pregnancies with cephalic presentation undergoing spontaneous labor were studied. Placental insertion, nuchal entanglement (tight or loose), length, presence of knots, umbilical coiling index (UCI), and the amount of Wharton's jelly were recorded. Results. Longer cords were more frequent amongst male infants and were predisposed towards entanglement. There were no significant differences in the amount of Wharton's jelly, or in the UCI between tight and loose nuchal cord groups. The only measurement that differed significantly was the total cord length, with shorter cords predisposed towards tightening. Conclusion. Whilst nuchal cord entanglement amongst male babies is frequently associated with long and straight umbilical cords, tightening is more likely to occur if the cord is of short or normal length. Neither low UCI nor low percentage of Wharton's jelly are predisposed towards tightening of cord entanglement.

Relationship between umbilical cord morphology and nuchal cord entanglement.

To determine whether tightening of nuchal cord entanglement is more likely to occur where normal cord coiling is absent and there is deficient Wharton's jelly. The study was carried out in the delivery suite of a university teaching hospital, using a prospective matched controlled-pairs survey. Midwives identified index cases with nuchal cord entanglement at the time of delivery. The next delivery of equivalent gestation (+/- 1 week) without cord entanglement was taken as the control. Only singleton pregnancies with cephalic presentation undergoing spontaneous labor were studied. Placental insertion, nuchal entanglement (tight or loose), length, presence of knots, umbilical coiling index (UCI), and the amount of Wharton's jelly were recorded. Longer cords were more frequent amongst male infants and were predisposed towards entanglement. There were no significant differences in the amount of Wharton's jelly, or in the UCI between tight and loose nuchal cord groups. The only measurement that differed significantly was the total cord length, with shorter cords predisposed towards tightening. Whilst nuchal cord entanglement amongst male babies is frequently associated with long and straight umbilical cords, tightening is more likely to occur if the cord is of short or normal length. Neither low UCI nor low percentage of Wharton's jelly are predisposed towards tightening of cord entanglement.

Color ultrasonography: a useful technique in the identification of nuchal cord during labor.

To compare the accuracy of intrapartum ultrasound with and without color Doppler for identification of nuchal cord displacement during labor. 180 normal pregnant women, admitted in labor, or for induction to labor, were examined independently by two researchers, using either conventional real-time gray-scale imaging or color Doppler imaging. A repeat examination was performed by the other researcher using the other ultrasound modality. Nuchal cord displacement was classified as either negative, definite or suspicious. Nuchal cord at birth was classified as either tight or loose. Sixty-two (34%) cases examined using the two ultrasound imaging modalities presented with nuchal cord at delivery. The sensitivity of color Doppler was 96.8%. The accuracy of color Doppler in detecting nuchal cord during labor was significantly better (P < 0.05) than gray-scale imaging alone. The results of a restricted sequential t-test analysis of 53 un-tied pairs showed an overall preference in favor of color Doppler assessment: statistical significance (P < 0.01) was reached after 41 un-tied pairs. The tight and loose nuchal cord could not be distinguished by ultrasound. Color Doppler imaging can provide useful additional information to gray-scale imaging in the detection of nuchal cord displacement during labor.

Lipid peroxidation in cord blood: the effects of umbilical nuchal cord.

To examine the relation between cord entanglement around the fetal neck and umbilical arterial measures of free oxygen radical activity at birth. Prospective observational study of the lipid peroxide levels in umbilical cord arterial blood. Delivery suite of Prince of Wales Hospital, Hong Kong. Women with a singleton pregnancy, at term (37 to 42 weeks of gestation), cephalic presentation, spontaneous or induced labour and an initially normal fetal heart rate tracing. A series of 230 singleton deliveries had determination of two lipoperoxides in umbilical arterial cord blood: malondialdehyde and organic hydroperoxide. Umbilical pH, PO2, PCO2 and base excess were also measured in both umbilical cord arterial and venous blood. Umbilical cord blood gases and arterial malondialdehyde and organic hydroperoxide levels. Forty-nine cases of nuchal cord were observed: 14 tight and 35 loose. Tight nuchal cord was associated with a low 1-min Apgar score and increased lipid peroxide levels. Loose nuchal cord was associated with larger amniotic fluid volume and significantly decreased lipid peroxide levels. This study suggests that tight nuchal cord is associated with increased free oxygen radical activity in the fetus, but that loose nuchal cord carries no adverse effects.

Nuchal cord as a cause of neonatal anemia.

Nuchal cord was documented in 437 neonates consecutively admitted to the newborn nursery at The University of Texas Medical Branch Hospital, Galveston. The prevalence of anemia in the nuchal cord group (venous hemoglobin level of less than 13.2 g/dL or hematocrit of less than 39.2%) was compared with that in a control group. None of the controls was anemic. Five of 27 neonates with tight nuchal cord and four of 30 with loose nuchal cord were anemic. Anemia in the tight nuchal cord group was usually observed early, and in three infants was manifest by hypotension, necessitating transfusion. Anemia associated with loose nuchal cord occurred later and was asymptomatic. This study emphasizes the increased risk of anemia associated with nuchal cord and demonstrates the need for hemoglobin and hematocrit determinations in neonates with this obstetrical complication.