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Arch Gynecol Obstet

DOI 10.1007/s00404-013-3072-9

MATERNAL-FETAL MEDICINE

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 comprises
2060 % 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 acidosis. Labor complications like abnormal FHR, meconiumstained liquor, prolonged second stage, instrumental vaginal delivery, third stage complications were compared. In
neonates, birth weight, Apgar score B7 at 5 min, NICU
admission and other morbidity and mortality during hospital 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 frequency of labor complications than no NC group, especially tight loops. Neonates with NC had significantly
higher frequency of meconium-stained liquor, Apgar
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: sumeet_singla@rediffmail.com;
drsandy2010@rediffmail.com
M. M. A. Faridi
Department of Pediatrics, University College of Medical
Sciences and GTB Hospital, Dilshad Garden, New Delhi, India

score B7 at 5 min, deranged biochemical markers, NICU


transfer. However, none of the neonate had pH in acidosis
range 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 antenatally. 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 2333 % of all pregnancies [2]. Single loop
is seen in 2334 %, two loops in 2.55 % and 3 loops are
found in 0.20.5 % 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.

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Arch Gynecol Obstet

Birth asphyxia leading to acidosis comprises 2060 %


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 regarding
the 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 absolute 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

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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. Eventually fetal compensation will fail, peripheral vasodilatation 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 acidbase 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 our
hospital in New Delhi. The research protocol was approved
by the Institutional Ethics Committee and informed consent 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 confounder bias, women with Obstetrical complications such
as polyhydramnios, oligohydramnios prematurity, twin
gestation, preeclampsia, placenta previa, premature rupture
of membranes, congenital anomaly were excluded. Medical 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


Fig. 1 Case recruitment
flowchart

were recorded. FHR was denoted clinically as non-reassuring, if there was any tachycardia, bradycardia or irregularity. 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 vaginally, where NC was an incidental finding. Antenatal
detection of NC with ultrasound was not done. Assuming
that majority of deliveries with nuchal cord occur vaginally, we wanted to purely evaluate its role in labor and
perinatal outcome in vaginal births. Cesarean section was
not 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 Fishers
exact 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),

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Arch Gynecol Obstet


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)
pH

Group A (no NC)


(n = 50)
7.35 0.065

Group B (single NC)


(n = 50)
7.28 0.068

Group C (C2 NC)


(n = 50)

p value

7.27 0.065

\0.001

Pair wise
p value
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

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 multiple
NC 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.

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On comparing biochemical markers, significant difference in mean pH (p B 0.001), PO2 (p = 0.005), bicarbonate (p = 0.005), SBE (p = 0.014) and lactate (p B
0.001) 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.

Arch Gynecol Obstet

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
pH

Loose nuchal cord


(n = 45)

Tight nuchal cord


(n = 55)

p value

7.29 0.05

7.25 0.07

0.004

PO2 (mmHg)
SPO2 (%)

28.11 7.71
56.64 13.4

25.96 7.50
48.87 14.0

0.056
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

3.67 0.79

4.38 1.12

\0.001

Lactate (mmol/l)

On comparing outcomes in loose vs tight cord nonreassuring 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 significantly higher in tight NC group (Table 2).

Discussion
Cord entanglement especially single loose loops are common 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 significant difference was found. Hankins et al. [9] found severe
variable 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 results
could be explained due to fetal asphyxia caused by
decreased blood flow. However, Mastrobattista et al. [12]
found comparable results among no NC, single and multiple NC groups with respect to frequency of non-reassuring 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 adaptation 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 prolonged 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

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Arch Gynecol Obstet

in NC groups in both term and post term deliveries. Peregrine et al. [5] found that women with NC had no significantly 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 comparable
among 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 (single 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 for
comparable 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 significantly 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 significant 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 biochemical 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; therefore, 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

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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 NC
detected 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 5060 %. 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 neonatal
primary 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 decelerations 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 outcomes. 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

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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