Management of Nuchal Cord During Labor
The recommended approach for managing nuchal cord during labor is to avoid routine cutting of the cord before delivery of the shoulders and instead use the somersault maneuver followed by delayed cord clamping to optimize neonatal outcomes.
Understanding Nuchal Cord
- Nuchal cord (umbilical cord wrapped around the baby's neck) occurs in approximately 20-30% of all births 1
- Can be classified as:
- Loose nuchal cord - can be easily uncoiled before delivery
- Tight nuchal cord - requires intervention during delivery
Assessment During Labor
- Suspect nuchal cord when:
- Non-engaged fetal head despite adequate labor progression
- Decreased fetal movements
- Meconium-stained amniotic fluid
- Fetal distress or variable decelerations on monitoring
- Malpresentation 2
Management Algorithm
For Loose Nuchal Cord:
- Continue with normal vaginal delivery
- Gently slip the cord over the baby's head after delivery of the head
- Implement delayed cord clamping (≥30 seconds) as recommended by ILCOR 3
- Complete delivery as usual
For Tight Nuchal Cord:
- Use the somersault maneuver - maintain the baby's head close to the perineum while delivering the shoulders and body, allowing the baby to somersault through the loop of cord 1
- Avoid immediate cord clamping and cutting before delivery of shoulders unless absolutely necessary
- If somersault maneuver is not possible and there is evidence of fetal compromise, then clamp and cut the cord
- Be prepared for potential resuscitation needs
Evidence-Based Rationale
Cutting the umbilical cord before complete delivery has been associated with serious complications including:
- Hypovolemia
- Anemia
- Shock
- Hypoxic-ischemic encephalopathy
- Cerebral palsy 1
Studies show that loose nuchal cord does not significantly impact mode of delivery or fetal outcomes compared to controls 4
However, tight nuchal cord is associated with:
- Higher rates of fetal distress
- Lower Apgar scores at one minute 4
Special Considerations
- Multiple loops of nuchal cord (more than one complete wrap) may require more careful management
- Excessively long umbilical cords (>100 cm) are associated with increased risk of multiple nuchal loops 5
- In cases with oligohydramnios and known nuchal cord, avoid vibratory acoustic stimulation as it may induce severe variable decelerations 6
Monitoring Recommendations
- Continuous fetal monitoring during labor for cases with known or suspected nuchal cord
- Be vigilant for variable decelerations, which may indicate cord compression
- Prepare for potential need for expedited delivery if persistent fetal distress occurs
Pitfalls to Avoid
- Premature clamping and cutting of the cord before delivery of shoulders
- Excessive traction on the cord during delivery
- Failure to recognize multiple loops of nuchal cord
- Delaying intervention when there are signs of significant fetal compromise
By following this evidence-based approach to nuchal cord management, providers can optimize outcomes while minimizing unnecessary interventions that could potentially harm the newborn.