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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 15-18

Incidence of cord around the neck and its effects on labour and neonatal outcome


1 Department of Obstetrics and Gynaecology, Sardar Patel Medical College, Bikaner, Rajasthan, India
2 Department of Obstetrics and Gynaecology, P.B.M Hospital, Bikaner, Rajasthan, India

Date of Web Publication6-Feb-2017

Correspondence Address:
Ruchi Saxena
Department of Obstetrics and Gynaecology, Sardar Patel Medical College, Bikaner, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-8568.199535

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  Abstract 

Background: The umbilical cord is a narrow tube-like structure that connects the developing baby to the placenta. Most of the nuchal cords diagnosed in early pregnancy get spontaneously uncoiled. This study was carried out to show that such natural occurrence does not have significant effect on pregnancy, labour and neonates if proper intra-partum foetal heart rate (FHR) monitoring could be provided by a caregiver. Materials and Methods: This study was conducted in the Department of Obstetrics and Gynaecology at Sardar Patel Medical College, Bikaner (Rajasthan). For completing 100 cases with nuchal cord, we had to observe 506 cases and by which we took out the incidence of nuchal cord and which was separately categorised into single, double, triple and four and more than four groups. Results: The present study showed mean cord length also increases with number of loops (50.93 cm in single loop as compared to 72.33 cm) in cases with four loops and showed that patients having tight nuchal cord have higher incidence of caesarean as well as forceps delivery, but these were not statistically significant (P = 0.56 and P= 0.57) and Apgar score <7 at 1 min, FHR deceleration and meconium staining of liquor were statistically higher significant (P = 0.001,P= 0.0001 and P= 0.001, respectively). Conclusion: At present, expertise to diagnose multiple and tight loops on ultrasound are limited, which should be the aim for future. Multicentric and large studies are further required in association with more specific and sensitive diagnostic aid for tight and multiple loops so as to provide the best perinatal management with good foetal outcome.

Keywords: Entanglement, foetal, nuchal cord, pregnancy


How to cite this article:
Joshi K, Saxena R, Bhat M, Lomrod Y, Verma K. Incidence of cord around the neck and its effects on labour and neonatal outcome. Adv Hum Biol 2017;7:15-8

How to cite this URL:
Joshi K, Saxena R, Bhat M, Lomrod Y, Verma K. Incidence of cord around the neck and its effects on labour and neonatal outcome. Adv Hum Biol [serial online] 2017 [cited 2018 Nov 15];7:15-8. Available from: http://www.aihbonline.com/text.asp?2017/7/1/15/199535


  Introduction Top


Entanglement of umbilical cord around the foetal neck (nuchal cord) is a common finding at delivery. It is often assumed that nuchal cord causes cord compression and thus low birth weight and intra-partum complications. The assumption that nuchal cord entanglement could cause cord compression and thus intra-partum complication is not recent. About 20%–60% of all foetal deaths are attributed to foetal asphyxia. However, aetiology in all cases of foetal asphyxia is not exactly understood. Asphyxia is most frequently seen as a result of reduced placental circulation, but in rare cases, it might develop secondary to umbilical cord complications. Nuchal cord accident comprises 5%–18% of all foetal asphyxia cases, and 10% of stillbirth were due to umbilical cord complications.[1],[2]

A nuchal cord occurs when the umbilical cord becomes wrapped around the foetal neck 360°.[3] Nuchal cord is very common, with the prevalence rates of 6%–37%. Up to half of nuchal cords resolve before delivery.[4]

The umbilical cord is a narrow tube-like structure that connects the developing baby to the placenta. The cord is sometimes called the baby's 'supply line' because it carries the baby's blood back and forth, between the baby and the placenta. It delivers nutrients and oxygen to the baby and removes the baby's waste products. The umbilical cord begins to form at 5 weeks after conception. It becomes progressively longer until 28 weeks of pregnancy, reaching an average length of 22–24 inches.[5] As the cord gets longer, it generally coils around itself. The cord contains three blood vessels: two arteries and one vein.

In some cases, cord abnormalities are discovered before delivery during an ultrasound (USG). However, they usually are not discovered until after delivery when the cord is examined directly.

Long umbilical cords (>70 cm, 4% of cords) are documented to be directly associated with poor foetal outcome and associated with other umbilical cord accident, especially foetal entanglement, true knots (sometimes multiple) and torsion.

The primary misconception is that the child is being strangulated or suffocated by this cord around the neck. Since the foetus cannot breathe within the womb, the mother has to deliver all the oxygen and clear away all of the carbon dioxide for the infant. This exchange is accomplished in the placenta. Umbilical vessels within the umbilical cord are essential for foetal gas exchange that takes the place of breathing while the foetus is inside the womb.

It really does not matter if the cord is wrapped around the neck, or the shoulder or the leg, the results can be the same. Everything may be fine throughout the entire pregnancy; however, at the time of delivery, as the foetus moves down into the birth canal, the cord can become stretched or compressed. All of these problems are rare and unfortunate but natural processes. It is the task of the obstetrician to recognise the signs of foetal distress and to act swiftly before the reduction in oxygenation causes permanent injury.

During labour, the only indication of the umbilical cord being wrapped around the baby may be variable foetal heart decelerations on the foetal monitor. These are generally timed with contraction as that is the time the cord is stretched more tightly.

Nowadays, USG diagnosis of nuchal cord is increasing, but it is not very sensitive and specific for diagnosing nuchal cord. Most of the nuchal cords diagnosed in early pregnancy get spontaneously uncoiled. The alleviate fear in general population regarding adverse pregnancy and neonatal outcome this study was carried out to show that such natural occurrence does not have significant effect on pregnancy, labour and neonates if proper intra-partum foetal heart rate (FHR) monitoring could be provided by a caregiver.


  Materials and Methods Top


This study was conducted in the Department of Obstetrics and Gynaecology at Sardar Patel Medical College, Bikaner (Rajasthan). All patients having term pregnancy (36–40 weeks) admitted to the labour room with complaint of labour pains with following inclusion and exclusion criteria were included in the study.

Inclusion criteria

  • Cephalic presentation
  • Singleton pregnancy
  • Spontaneous onset of labour pain with intact membrane.


Exclusion criteria

  • Any antenatal complication such ass preeclampsia, eclampsia and other medical disorders such as diabetes, cardiac disease and pregnancy-induced hypertension
  • Premature rupture of membrane
  • Sonographically diagnosed nuchal cord
  • Post-date pregnancy.


For completing 100 cases with nuchal cord, we had to observe 506 cases and by which we took out the incidence of nuchal cord and which was separately categorised into single, double, triple and four and more than four groups.

For comparative study, we took 100 cases (control group) from patients not having nuchal cord (every 3rd case was taken from remaining 406 patients not having nuchal cord).

It was a randomised study comprising two groups.

  • Group A: Nuchal cord group (patients delivered baby with cord around the neck)
  • Group B: Patients delivered a baby without nuchal cord.


Profiles of the cases were recorded in prepared pro forma after taking proper history regarding presenting complaints, obstetric history, menstrual history, family and personal history.

Foetal monitoring was done using conventional means giving the emphasis on rate, rhythm and tone of foetal heart, especially before and after uterine contraction for indicating any abnormality in foetal heart indicating distress.

Statistical analysis (Chi-square method) to detect P value for various variables was done. Statistical significance was determined at the 5% level of significant (P < 0.05).


  Results Top


In the present study, the most cases occur in 21–25 years of age [Table 1]. Total incidence of nuchal cord in the study was 19.76%. Mostly, single loops were in 12.45% and minimum. Quadruple loops were in 0.59% cases [Table 2]. As the number of loops increases, proportion of cases having tight loops also increases [Table 3]. The present study showed mean cord length also increases with number of loops (50.93 cm in single loop as compared to 72.33 cm in cases with four loops) [Table 4]. The results showed only four patients have abnormal position of umbilical cord [Table 5].
Table 1: Distribution of cases according to age

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Table 2: Incidence of nuchal cord

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Table 3: Relationship between number of loops and their tightness

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Table 4: Number of cases with various of loops with different length of cord

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Table 5: Abnormal position of umbilical cord besides nuchal cord in test group

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The present study showed that patients having tight nuchal cord have higher incidence of caesarean as well as forceps delivery, but these were statistically not significant (P = 0.56 and P = 0.57) and Apgar score < 7 at 1 min, FHR deceleration and meconium staining of liquor were statistically higher significant (P = 0.001, P = 0.0001 and P = 0.001, respectively) [Table 6].
Table 6: Comparison between loose and tight nuchal cord subgroups

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  Discussion Top


Encirclement of umbilical cord around foetal neck (nuchal cord) is a rather common occurrence, and whether it is related to increased foetal morbidity and mortality is controversial. The pathophysiology of umbilical cord around the foetal neck and cord entanglement is that when the umbilical cord is acutely compressed, foetal arterial resistance and blood pressure abruptly increase causing bradycardia and fall in cardiac output. If the cord compression is not prolonged, the FHR and metabolic status can rapidly normalise because of diffusion of carbon dioxide across the placenta. Although the presence of a nuchal cord is not the matter of much apprehension and anxiety because of currently available obstetrical resources, appropriate and timely management of this situation are helpful in improving neonatal outcome.

In the present study, it was found that there were not any significant differences between the occurrences of nuchal cord in different age groups. The fact majority of cases belonged to age group 21–25 years was merely because the pregnancies are more common in this age group. Various studies [6],[7],[8],[9] also have not reported any relation of maternal age to occurrence of nuchal cord.

In our study, incidence of nuchal cord was 19.76% and single loop was the most common finding and number of cases decreased with higher number of loops. Incidence of nuchal cord reported by Spellacy et al.[6] was between 15.8 and 30%. Incidence of nuchal cord found in a study by Singh and Sidhu [9] was 18.57%.

Length of umbilical cord was one of the most important determinants for the occurrence of nuchal cord and number of loops. This fact has been observed by almost all the workers in various studies. In a study by Kan-Pun-Shui and Eastman [10] of 1000 cases, it was found that increasing length of umbilical cord was associated with increased number of loops. Chatterjee and Gupta [11] also observed that increase in the length of umbilical cord was also associated with increased number of loops. In our study, we found that the relation of length of umbilical cord to the occurrence of nuchal cord entanglement was highly significant (P < 0.001). This is because it is easier for a lengthy umbilical cord to be entangled in nuchal grooves because of its surplus mobility.

In our study, besides nuchal cord, we also found cord around trunk in three cases and around upper limb in one case. Only 4 cases out of 100 having other position than foetal neck explain that once the umbilical cord is entangled around the neck, it is difficult to be deentangled in utero because of a better grip than that of other parts of the body. We found no case having entanglement around trunk or limb in the absence of nuchal cord; therefore, the ultimate effect of this phenomenon could not be analysed.

In our study, percentage of caesarean and forceps delivery was more common in test as compared to control group although difference was not statistically significant. Similar finding was observed by Miser [7] that there was no significant difference in number of operative deliveries between nuchal cord and non-nuchal cord group. Larson et al.[12] also reported that caesarean delivery was not more common in multiple entanglement that the control group.

Thus, it is clear that proper intra-partum monitoring can improve the perinatal outcome irrespective of antepartum finding in relation to nuchal cord, bring it to almost same as in cases without nuchal cord.


  Conclusion Top


Although 15%–30% of pregnant women have cord around the neck of foetus, only a few of them have tight or multiple nuchal cord. It is only tightness of loop or multiple loops (≥) which adversely affect perinatal outcome such as intra-partum FHR deceleration, meconium staining of liquor, low Apgar score at 1 min and increased probability of operative delivery. Merely diagnosis of a single loose loop of cord around the neck on USG, per se is not an indication for an elective lower segment caesarean section. At present, expertise to diagnose multiple and tight loops on USG are limited, which should be the aim for future. Multicentric and large studies are further required in association with more specific and sensitive diagnostic aid for tight and multiple loops so as to provide best perinatal management with good foetal outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Singer DB, Macpherson T. Fetal death and macerated stillborn fetus. In: Wigglesworth JS, Singer DB, editors. Textbook of Fetal and Perinatal Pathology. Vol. 1. Boston: Blackwell Scientific Publication; 1991. p. 266-7.  Back to cited text no. 1
    
2.
Hansen HS, Hillersborg B. Antepartum looping of the umbilical cord. Acta Obstet Gynecol Scand 1988;67:475-6.  Back to cited text no. 2
    
3.
Fetus or Newborn Problems: Labour and Delivery Complications: Merck Manual Home Edition. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15543520. [Last retrieved on 2010 Mar 27].  Back to cited text no. 3
    
4.
Ultrasound Detection of Nuchal Cord Prior to Labour Induction and Risk of Caesarean Section. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15543520. [Last retrieved on 2010 Jul 09].  Back to cited text no. 4
    
5.
Cruikshank DW, Scott JR. Breech, other malpresentations, and umbilical cord complications. In: Cruikshank DW, Scott JR, editors. Danforth's Obstetrics and Gynecology. Philadelphia: Lippincott Williams and Wilkin; 2003. p. 381-95.  Back to cited text no. 5
    
6.
Spellacy WN, Gravem H, Fisch RO. The umbilical cord complications of true knots, nuchal coils, and cords around the body. Report from the collaborative study of cerebral palsy. Am J Obstet Gynecol 1966;94:1136-42.  Back to cited text no. 6
    
7.
Miser WF. Outcome of infants born with nuchal cords. J Fam Pract 1992;34:441-5.  Back to cited text no. 7
    
8.
Jauniaux E, Ramsay B, Peellaerts C, Scholler Y. Perinatal features of pregnancies complicated by nuchal cord. Am J Perinatol 1995;12:255-8.  Back to cited text no. 8
    
9.
Singh G, Sidhu K. Nuchal cord: A Retrospective analysis. Med J Armed Forces India 2008;64:237-40.  Back to cited text no. 9
    
10.
Shui KP, Eastman NJ. Coiling of the umbilical cord around the foetal neck. J Obstet Gynaecol Br Emp 1957;64:227-8.  Back to cited text no. 10
    
11.
Chatterjee AK, Gupta SS. Cord around the neck a study on 101 cases. J Obstet Gynecol India 1985;5:660-4.  Back to cited text no. 11
    
12.
Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiple nuchal cord entanglements and intrapartum complications. Am J Obstet Gynecol 1995;173:1228-31.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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