From the Guidelines
Nuchal cord strangulation at delivery should be managed by attempting to slip the cord over the baby's head or, if too tight, to clamp and cut the cord before delivering the shoulders, prioritizing the baby's safety and minimizing the risk of complications. When a nuchal cord is identified during delivery, it is crucial to assess the situation quickly and decide on the best course of action. The standard approach is to attempt to slip the cord over the baby's head, and if this is not possible due to the cord being too tight, the next step is to clamp and cut the cord before delivering the shoulders 1. For loose nuchal cords, the "somersault maneuver" may be used, where the baby's head is kept close to the perineum while the body is delivered through the loop of cord. Some key points to consider in the management of nuchal cord strangulation at delivery include:
- Monitoring of fetal heart rate during labor to detect any signs of distress that might indicate cord compression
- Assessing the baby for any signs of hypoxia or injury after delivery
- Being prepared for potential complications, although serious outcomes are rare with proper management
- Considering the plan for umbilical cord management before delivery, taking into account individual maternal and infant circumstances, as suggested by recent guidelines 1. Healthcare providers should remain calm when encountering a nuchal cord, as most can be managed effectively without emergency interventions, focusing on minimizing morbidity, mortality, and improving the quality of life for the baby.
From the Research
Nuchal Cord Strangulation at Delivery
- Nuchal cord, or cord around the neck of an infant at birth, is a common finding that occurs in 20% to 30% of births 2.
- The incidence of nuchal cord increases with advancing gestation age, and it is estimated to occur in about 10-29% of fetuses 3.
- Most nuchal cords are not associated with perinatal morbidity and mortality, but a few studies have shown that nuchal cord can affect the outcome of delivery with possible long-term effects on the infants 3.
- Tight nuchal cords can cause problems by compressing the umbilical cord, obstructing blood flow, and leading to hypovolemia, acidosis, and anemia 3.
- Severe antenatal strangulation and sudden fetal death can occur due to nuchal cord, as reported in a case study where multiple loops of nuchal umbilical cord were found around the fetal neck 4.
Management and Outcomes
- Management of nuchal cord can vary from clamping the cord immediately after the birth of the head and before the shoulders to not clamping at all, depending on the provider's learned practices 2.
- Cutting the umbilical cord before birth is an intervention that has been associated with hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, and cerebral palsy 2.
- A study found that entanglement of umbilical cord around the fetal neck was not related to adverse perinatal outcomes such as acidosis and low APGAR scores 5.
- However, the number of entanglement was significantly related to fetal distress, and there was a significant male dominance in the study group 5.
Clinical Implications
- Obstetric providers need to learn management techniques to handle the birth of an infant with a nuchal cord 2.
- Emergency physicians must be prepared for nuchal cord and other complications during precipitous and difficult deliveries 6.
- The diagnosis of tight nuchal cord can be challenging, and it may not be discovered during pregnancy US scan monitoring or emergency US scan 4.