archives of gynecology and obstetrics volume 289 issue 4 2014 [doi 10.1007_s00404-013-3072-9]...

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M A T E R N A L - F E T A L M E D I C I N E

Is nuchal cord justified as a cause of obstetrician anxiety?

Yum Narang •

Neelam Bala Vaid •

Sandhya Jain •

Amita Suneja • Kiran Guleria • M. M. A. Faridi •

Bindiya Gupta

Received: 7 July 2013/ Accepted: 24 October 2013

Springer-Verlag Berlin Heidelberg 2013

Abstract

Purpose Birth asphyxia leading to acidosis comprises20–60 % of perinatal mortality. Nuchal cord (NC) is one of

the possible causes of birth asphyxia. Majority of fetuses

who are antenatally detected to have nuchal cord are able

to achieve successful vaginal birth. The purpose of this

study was to analyze the effect of nuchal cord on fetal acid

base status and perinatal outcome in vaginal deliveries.

Study design 150 parturients were equally divided into

three groups after vaginal delivery based on no NC, single

and multiple loops. Umbilical cord arterial blood was

analyzed for biochemical markers i.e. pH, PO2, SPO2,

PCO2, HCO3

-, standard base excess and lactate for aci-

dosis. Labor complications like abnormal FHR, meconium-

stained liquor, prolonged second stage, instrumental vagi-

nal delivery, third stage complications were compared. In

neonates, birth weight, Apgar score B7 at 5 min, NICU

admission and other morbidity and mortality during hos-

pital stay were compared among groups using suitable

statistical tests. Above parameters were also compared

between tight and loose loops.

Result Nuchal cord groups had significantly higher fre-

quency of labor complications than no NC group, espe-

cially tight loops. Neonates with NC had significantly

higher frequency of meconium-stained liquor, Apgar

score B7 at 5 min, deranged biochemical markers, NICU

transfer. However, none of the neonate had pH in acidosisrange and majority were discharged in healthy condition.

Conclusion Patients with NC are likely to have

uneventful labor and delivery as cord compression is

transient and most fetuses are able to compensate for

reduce umbilical blood flow. Routine antenatal ultrasound

scan is not advisable, as mode of delivery and labor

management does not change with detection of NC ante-

natally. Therefore, vaginal delivery with routine labor

protocol can be allowed in cases of nuchal cord.

Keywords Nuchal cord Umbilical arterial blood

Acidosis

Asphyxia

Perinatal outcome

Introduction

Umbilical cord provides nutrients and performs gaseous

exchange besides support and adherence to the fetus. A

long umbilical cord can facilitate movements and descent

during delivery but has the potential to entangle around the

neck, limb or torso [1].

Nuchal cord is defined as the umbilical cord being

wrapped 360 around the fetal neck [2]. It has been referred

to as ‘‘one of the dangers of eight month’’ by Hippocrates

in a book entitled ‘‘De Octimestripartu’’ [3]. It is estimated

that NC affects 23–33 % of all pregnancies [2]. Single loop

is seen in 23–34 %, two loops in 2.5–5 % and 3 loops are

found in 0.2–0.5 % of all pregnancies. More than three

loops are very rare and have been reported as isolated case

reports [2]. A maximum of nine loops have been reported

till date [4]. The loops may be loose which can be easily

slipped over fetal head or tight requiring clamping before

untwining during delivery.

Y. Narang N. B. Vaid S. Jain (&) A. Suneja K. Guleria

B. Gupta

Department of Obstetrics and Gynaecology, University College

of Medical Sciences and GTB Hospital, Dilshad Garden,

New Delhi, India

e-mail: [email protected];

[email protected]

M. M. A. Faridi

Department of Pediatrics, University College of Medical

Sciences and GTB Hospital, Dilshad Garden, New Delhi, India

1 3

Arch Gynecol Obstet

DOI 10.1007/s00404-013-3072-9



Birth asphyxia leading to acidosis comprises 20–60 %

of perinatal mortality, inclusive of preterm deliveries [3].

Question has been raised many a times regarding presence

of NC and its possible association with birth asphyxia as a

result of impaired blood circulation, leading to neonatal

morbidity and mortality. Fetal asphyxia results into fetal

heart arrhythmia, passage of meconium, respiratory and

metabolic acidosis [3]. The insufficiency in data regardingthe role of NC in fetal morbidity and mortality is a source

of anxiety and frustration to both parturient and healthcare

professional. There is an increasing incidence of elective

cesarean on antenatal diagnosis of nuchal cord through

ultrasound to avoid medico-legal litigation and even the

parents on knowing the presence of nuchal cord demand

cesarean section, out of undue anxiety. Antenatal detection

of nuchal cord through ultrasound has a sensitivity of

85 %, specificity of 89 % with an accuracy of 35 % at

finding single loop and 60 % at detecting multiple loops

[5]. However, it cannot give important information such as

tightness, length and number of cord loops accurately,which may have an effect on labor and delivery outcome.

More importantly, it cannot predict which foetuses are

likely to have problem and can be benefitted from active

intervention.

Pathophysiology

Nuchal cord may be partially or intermittently obstructed

during labor and delivery, resulting in fetal hypoxia. As

vein is more compressible than the artery, blood flow from

the placenta to the fetus is decreased more than the arterial

flow from the fetus to the placenta, resulting in loss of

blood from the fetus into the placenta [6]. To meet the fetal

oxygen demand and eliminate carbon dioxide, there is

increased extraction of oxygen and increased deposition of

carbon dioxide per unit of blood flow resulting in umbilical

artery desaturation, hypercapnia and respiratory acidosis.

However, if the cord compression is not prolonged, CO2

diffuses across the placenta. Metabolic acidosis develops in

the late stage of fetal hypoxia when oxygen supply to the

fetus becomes insufficient and anaerobic metabolism

occurs with production of lactic acid. When concentration

of lactate rises, the standard base excess (SBE) and abso-

lute base excess (ABE) levels decrease [6, 7].

Sustained or repetitive compression eventually leads to

fetal compromise. Cord compression, whether chronic,

intermittent or acute, ultimately stimulates the fetus to

shunt its blood flow, vasoconstricts its extremities and

protects itself through a centralized circulation (heart,

adrenal, brain). Baroreceptor and chemoreceptor responses

occur with release of catecholamine, cortisol, vasopressin,

angiotensins and other biochemical agents to initiate a fetal

response to developing hypoxia. Arterial lactate elevation

may be a measurable result of umbilical cord compression.

This protective mechanism over time can give way to

bradycardia, fetal hypotension and acidosis, depletion of

glycogen stores and blunting of cortisol response. Even-

tually fetal compensation will fail, peripheral vasodilata-

tion with heart failure, arrhythmias and fetal death will

occur. Clinical fetal signs which may be present in the

prolonged umbilical cord compression are hiccups,hyperactivity, decreased fetal movement and fetal heart

rate changes [8].

The present study was designed to study the effect of

nuchal cord on fetal acid–base balance, perinatal outcome,

intrapartum course in vaginal deliveries.

Materials and methods

This cross-sectional study was conducted as a postgraduate

thesis project in the labor room of Department of Obstetrics

and Gynaecology in collaboration with Pediatrics, in ourhospital in New Delhi. The research protocol was approved

by the Institutional Ethics Committee and informed con-

sent was obtained from all the participants. Patients were

recruited over the period of 4 months; February, March

2011 and August, September 2011 on 12 hourly basis in

accordance with the duties of the principle investigator

(Fig. 1).

All parturients admitted in labor room during the duty

hours of principle investigator were screened, and labor

was monitored as per departmental protocol. To obtain

predetermined 50 cases in each group, 2,000 deliveries had

to be followed, assuming an average incidence of 25 % for

single NC and 3 % for multiple NC. To minimize con-

founder bias, women with Obstetrical complications such

as polyhydramnios, oligohydramnios prematurity, twin

gestation, preeclampsia, placenta previa, premature rupture

of membranes, congenital anomaly were excluded. Medi-

cal conditions likely to affect pregnancy and labor such as

hypertension, diabetes, anemia, renal disease, etc. were

also excluded.

Three groups were formed at the time of vaginal

delivery (no NC, single NC and C2 NC), 50 cases in each

group, forming a total of 150 cases. Presence of NC,

number of loops, tightness, length of cord were noted. The

NC was labeled as loose when it could be slipped over the

head easily and tight when it had to be clamped before

untwining. Samples from umbilical artery were taken in a

pre-heparinised syringe (0.5 ml) within 10 min of birth and

analyzed for pH, PO2, SPO2, PCO2, HCO3

-, standard base

excess and lactate using a standard laboratory analyzer.

Labor events such as fetal heart rate (FHR), meconium

staining, duration of second stage of labor, mode of

delivery (normal or instrumental) and incidence of PPH

Arch Gynecol Obstet

1 3



were recorded. FHR was denoted clinically as non-reas-

suring, if there was any tachycardia, bradycardia or irreg-ularity. Second stage was considered as prolonged if [1 h

in multigravida and if [2 h in primigravida. Apgar score,

birth weight and need for NICU admission were compared

among groups. Also duration of hospital stay and any other

morbidity and mortality were noted.

This study focussed on the labor and delivery outcome

in apparently low risk obstetric patients delivering vagi-

nally, where NC was an incidental finding. Antenatal

detection of NC with ultrasound was not done. Assuming

that majority of deliveries with nuchal cord occur vagi-

nally, we wanted to purely evaluate its role in labor and

perinatal outcome in vaginal births. Cesarean section wasnot included to avoid bias, as the most common indication

for emergency cesarean section being fetal distress (FD)

which could be due to meconium staining, non-progress of

labor, uterine inertia, second stage arrest, cephalopelvic

disproportion, if associated with presence of NC, then NC

would be labeled as cause of FD and as indication of

cesarean section. Cases with severe fetal distress or other

complication would anyway have gone for a cesarean

section.

To compare the quantitative data unpaired ‘t ’ test was

used and for qualitative data, Chi-square and/or Fisher’sexact test were used. Biochemical markers were analyzed

using one-way ANOVA test, Bonferroni post hoc test, and

t test. Correlation between pH and lactate was done using

Pearson correlation.

Result

Analysis was done between nuchal and no nuchal cord

groups, single and multiple loops and loose and tight

loops

All demographic parameters were well matched in all groups.

Nuchal cord was significantly more frequent in multi parous

( p = 0.002) women compared to primigravida. Length of

cord was found to be significantly longer in nuchal compared

to no nuchal group (No NC* 48.20 ± 4.31 cm, single

NC* 53.32 ± 6.53 cm, and multiple NC* 52.80 ±

8.20 cm, respectively ( p value = 0.01).

Significant difference with respect to non-reassuring

FHR ( p = 0.006), meconium-stained liquor ( p = 0.004),

Fig. 1 Case recruitment

flowchart

Arch Gynecol Obstet

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and prolonged second stage ( p\ 0.001) was observed in

NC groups (single and multiple) compared to no NC group

but frequency was comparable among single and multipleNC groups. Need for operative vaginal delivery and

occurrence of post partum hemorrhage (PPH) were similar

in nuchal vs non-nuchal groups (Fig. 2).

Apgar score B7 at 5 min was significantly frequent in

nuchal group (single and multiple) compared to non-nuchal

group ( p = 0.022). Need for NICU admission was 23 % in

nuchal group vs 6 % in non-nuchal group but the p value

was border line 0.059. One neonate with single tight NC

died on day 2 in NICU, due to birth asphyxia and sepsis.

On comparing biochemical markers, significant differ-

ence in mean pH ( p B 0.001), PO2 ( p = 0.005), bicar-

bonate ( p = 0.005), SBE ( p = 0.014) and lactate ( p B0.001) levels were found in NC group as compared to no

NC group (Table 1; Fig. 3). pH and lactate were found to

correlate significantly only in multiple loops (r = -0.555,

p\ 0.001). The mean pH in no NC, single NC and

multiple NC was 7.35, 7.28 and 7.27, respectively. On

comparing loose vs tight loops, mean pH was 7.29 and

7.25, respectively. They were all in the pre-acidotic range,

even for the NC groups and did not reflect a severe

acidosis.

Fig. 2 Association of no NC,

single NC, C2 NC with labor

events. Group A no NC, Group

B single NC loop, Group C C 2

NC loops

Table 1 Outcome of infants born with nuchal cords

Biochemical marker

(mean)

Group A (no NC)

(n = 50)

Group B (single NC)

(n = 50)

Group C (C2 NC)

(n = 50)

p value Pair wise

p value

pH 7.35 ± 0.065 7.28 ± 0.068 7.27 ± 0.065 \0.001 A vs B\0.001

B vs C = 0.703

C vs A\0.001

PO2 (mmHg) 30.66 ± 4.99 28.44 ± 6.73 26.14 ± 8.47 0.005 A vs B = 0.326

B vs C = 0.290

C vs A = 0.004

SPO2 (%) 56.50 ± 10.6 53.3 ± 15.3 51.3 ± 13.0 0.149

PCO2 (mmHg) 43.0 ± 3.98 42.0 ± 6.711 43.8 ± 6.17 0.311

HCO3

- (mEq/l) 22.0 ± 1.29 21.5 ± 1.84 21.1 ± 1.98 0.023 A vs B = 0.364

B vs C = 0.682

C vs A = 0.019

SBE (mEq/l) -2.42 ± 1.23 -3.41 ± 1.51 -3.57 ± 3.10 0.014 A vs B = 0.061

B vs C[ 0.99

C vs A = 0.021

Lactate (mmol/l) 2.68 ± 1.15 3.94 ± 1.03 4.10 ± 1.05 \0.001 A vs B\0.001

B vs C = 0.845

C vs A\0.001

Arch Gynecol Obstet

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On comparing outcomes in loose vs tight cord non-

reassuring FHR, meconium staining, prolonged second

stage, operative vaginal delivery and PPH were many times

more in tight compared to loose cord group; the difference

was significant for meconium and highly significant for rest

of the parameters.

Apgar score B7 and need for NICU admission were

significantly more in tight nuchal group compared to loose.

However, the presence of NC was not found to affect birth

weight in any of the groups.

PH, SPO2, HCO3

-, SBE were all significantly lower in

tight nuchal group, whereas lactate was found to be sig-

nificantly higher in tight NC group (Table 2).

Discussion

Cord entanglement especially single loose loops are com-

mon findings in delivery and many studies in past have

suggested its presence as benign occurrence. However,

very few studies in past have actually compared outcomes

in single NC vs multiple NC and loose vs tight NC,

moreover Umbilical artery (UA) blood gas along with

lactate have been included in limited studies. In this study,

we aimed to analyze UA blood gas along with blood lactate

levels and its association with adverse labor event and

perinatal outcomes in no NC vs NC, single vs multiple and

loose vs tight loops.

Non-reassuring FHR and meconium-stained liquor were

found to be significantly higher in NC group. On intergroup

comparison between single vs multiple loops, no signifi-

cant difference was found. Hankins et al. [9] found severevariable FHR deceleration during 1st and 2nd stages of

labor and before expulsion in newborn with NC. Larson

et al. [10] reported significant difference in FHR and

meconium-stained liquor only in cases with multiple NC vs

no NC group. Martin et al. [6] reported higher occurrence

(60 %) of abnormal FHR in nuchal group vs none in no NC

group. In their study, Hoh et al. found that FHR variability,

with respect to amplitude (AMP) and mean minute range

(MMR), was lower in multiple NC group than in single or

no NC groups. They concluded that multiple NCs may be a

subliminal risk factor for the babies even though they

present no complications at delivery [11]. These resultscould be explained due to fetal asphyxia caused by

decreased blood flow. However, Mastrobattista et al. [12]

found comparable results among no NC, single and mul-

tiple NC groups with respect to frequency of non-reassur-

ing FHR, meconium-stained liquor and stated that an NC at

term is not associated with untoward pregnancy outcomes.

Schaffer et al. [13] reported that meconium staining and

unfavorable neonatal blood gases were significantly more

frequent in NC groups; however, clinical management at

delivery remained the same and neonatal primary adapta-

tion was not impaired.

Second stage of labor is said to be prolonged due to the

presence of NC, more so if the nuchal coil is tight or are

multiple, which could lead to slow descent [12]. We found

that 47 % (single and C2 loops) of parturients had pro-

longed second stage (nulliparous[2 h, multiparous[1 h)

compared to only 2 % in no NC group; the difference being

highly significant ( p\ 0.001); the difference was not

found to be statistically significant when single vs multiple

loops were compared ( p = 0.523). Probably, it is related to

the length of ‘linear’ segment of the cord (end of wrapping

to placenta) instead of number of coils around the neck.

Ogueh et al. [14] also reported that greater number of

parturients with NC had prolonged duration of second

stage.

Need for operative vaginal delivery was comparable in

all the groups. Similar findings with regard to normal

vaginal delivery vs instrumental delivery were suggested

by Ngowa et al. [15]. Assimakopoulos et al. [16] reported

increased rate of cesarean section and operative vaginal

delivery only in nulliparous women with NC. Schaffer

et al. [13] concluded that mode of delivery was unchanged

Fig. 3 Association of no NC, single NC, C2 NC with pH. Group A

no NC, Group B single NC loop, Group C C 2 NC loops

Table 2 Association of loose vs tight nuchal cord with biochemical

markers

Biochemical

markers

Loose nuchal cord

(n = 45)

Tight nuchal cord

(n = 55)

p value

pH 7.29 ± 0.05 7.25 ± 0.07 0.004

PO2 (mmHg) 28.11 ± 7.71 25.96 ± 7.50 0.056

SPO2 (%) 56.64 ± 13.4 48.87 ± 14.0 0.006

PCO2 (mmHg) 41.53 ± 5.69 44.10 ± 6.88 0.049

HCO3

- (mEq/l) 21.89 ± 1.96 20.87 ± 1.76 0.008

SBE (mEq/l) -2.89 ± 1.96 -3.98 ± 2.66 0.024

Lactate (mmol/l) 3.67 ± 0.79 4.38 ± 1.12 \0.001

Arch Gynecol Obstet

1 3



in NC groups in both term and post term deliveries. Pere-

grine et al. [5] found that women with NC had no signifi-

cantly higher risk of emergency cesarean section as

compared to no NC group.

Risk of abruption, cord tear, shoulder dystocia uterine

inversion and PPH due to NC has been mentioned in the

literature [12]. In our study, no such labor complications

were encountered except PPH which was comparableamong all groups. This probably could be due to that linear

segment of the cord was not too short in any of our cases.

Shortest length of the cord in present study was 38 cm in

single loop group with tight cord.

Birth weight was not significantly different in NC (sin-

gle and C2) compared to no NC group in this study. This

was consistent with previous clinical trials, where authors

could not find difference in mean birth weight in NC vs no

NC group. While Clapp et al. [17] stated that birth weight

could be affected if the NC persists for C4 weeks during

antenatal period. However, the presence of NC is mostly

transient, which could be one possible explanation forcomparable birth weight in our study. Also, umbilical cord

encirclements are associated with a relative lengthening of

the umbilical cord [18]. In our study, cord length was found

significantly longer in NC group ( p = 0.01). Because there

is positive correlation between cord length and fetal

weight, this association tends to offset the effects of the

encirclements, giving the newborns a more normal birth

weight [19]. Maximum cord length in this study was 72 cm

in a neonate with four nuchal loops.

Apgar score B7 at 5 min and NICU transfer was sig-

nificantly higher in NC group; however, all neonates were

discharged healthy within a week, except for one neonatal

death, due to birth asphyxia and sepsis.

The comparative study between two subgroups with

loose and tight NC showed significant higher frequency of

non-reassuring FHR, meconium-stained liquor, prolonged

second stage, operative vaginal delivery, PPH, Apgar

score B7 at 5 min and NICU transfer. Singh et al. [20]

found significant higher frequency of fetal distress and

primary cesarean section in tight NC group compared to

loose, whereas Ngowa et al. [15] did not find any signifi-

cant increase in the above parameters in tight NC group.

pH in NC groups was found to be comparatively lower than

no NC group, especially in tight and multiple NC group.

However, non NC group had pathological range bio-

chemical derangement. This finding probably suggests that

presence of NC interrupts umbilical blood flow to some

extent causing some biochemical derangement, more so in

multiple and tight NC. However, most with adequately

functioning placenta is able to compensate quickly; there-

fore, blood analysis from our study suggests that NC

groups were able to sustain and compensate reduced blood

flow, and thus were able to undergone vaginal delivery

with some hypoxia but were not strangulated dangerously

enough to cause metabolic acidosis, as non NC group had

metabolic acidosis in our study. Probably, those who were

not able to compensate must have had fetal distress with or

without metabolic acidosis landing into emergency CS.

Based on findings in the literature and our own study,

the points which need to be emphasized to allay anxiety of

patients on antenatal detection of NC are: (a) Most of NCdetected remote from term are transient and are harmless,

even at term it may be a normal part of intrauterine life,

with incidence as high as 33 %, (b) Ultrasound is not

100 % sensitive and accurate in detecting nuchal loops and

has a positive predictive value of 50–60 %. It cannot

accurately tell about the tightness and number of loops.

Hence, antenatal detection of NC does not warrant elective

cesarean section, (c) Majority are likely to undergo vaginal

delivery uneventfully with no significantly increased risk

of operative vaginal delivery or cesarean section over no

NC patients. Literature has ample evidence that NC does

not influence clinical management at delivery and neonatalprimary adaptation is not impaired.

There are isolated case reports or small series regarding

higher association of NC with certain obstetric conditions

and less favorable outcomes, such as breech presentation,

right-sided fetal position, a male fetus, increased or

reduced fetal activity, a long length and less vascular

coiling of the cord, abnormal umbilical artery Doppler

findings, abnormal ductus venosus velocity waveforms, a

posterior placenta, induction of labor, variable decelera-

tions of the fetal heart rate, meconium-stained amniotic

fluid, shoulder dystocia, operative vaginal delivery [21–

24], etc. Despite these reports, a nuchal cord is usually

associated with a normal neonatal and maternal outcome.

We do feel that a randomized double blind study could

give much more objective information on the effect of

nuchal cord on delivery. Another Limitation could be

antenatal detection of NC and follow-up in labor and

delivery to obtain additional information such as secondary

cesarean section rate, role of ultrasound in predicting out-

comes. More studies will be required targeting high risk

women (i.e. women with NC and another high risk factor)

in which the ultrasound diagnosis of NC is revealed or

concealed from the clinicians, to investigate true role of

NC without bias.

Conclusion

Nuchal cord has been found to be a common occurrence in

pregnancy and mostly benign in nature. Patients are likely

to have uneventful labor as cord compression is transient

and most foetuses are able to compensate for reducing

umbilical blood flow and deliver uneventfully. Routine

Arch Gynecol Obstet

1 3



antenatal ultrasound scan is not advisable, as the mode of

delivery and labor management does not change on

detection of NC antenatally. In addition, it is not able to

reliably predict which foetuses are likely to have problem

and can be benefitted from active intervention. Therefore,

vaginal delivery with routine labor protocol should be

followed in cases of nuchal cord.

Acknowledgment We have no financial relationship with any

organization that sponsored the research. We have had full control of

all primary data and that we agree to allow the Journal to review the

data if requested.

Conflict of interest None.

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archives of gynecology and obstetrics volume 289 issue 4 2014 [doi 10.1007_s00404-013-3072-9]...

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