Nuchal Cord on Ultrasound is Not an Indication for Cesarean Section
A nuchal cord found on ultrasound alone is not an indication for cesarean section delivery. The presence of a nuchal cord, even when detected antenatally, should not alter the management of labor or the decision regarding mode of delivery 1, 2.
Understanding Nuchal Cord
- Nuchal cord refers to the umbilical cord wrapped around the fetal neck, which occurs in approximately 15-30% of all pregnancies 1
- Most nuchal cords are detected incidentally during routine ultrasound examinations 3
- Nuchal cords can be classified as:
- Single loop (most common)
- Double loops
- Multiple loops (three or more) 4
Evidence on Perinatal Outcomes
- Single or double nuchal cord loops are not associated with adverse perinatal outcomes such as:
- Intrauterine death
- Neonatal death
- Low Apgar scores at 1 and 5 minutes 1
- Only nuchal cord with three turns or more has been associated with:
- Higher incidence of meconium-stained liquor
- Increased neonatal unit admissions
- Suspected fetal distress during labor 1
Ultrasound Detection and Management
- The sensitivity of ultrasound in diagnosing nuchal cord is relatively low (approximately 37.5%) 3
- In cases detected before 36 weeks of gestation, the umbilical cord spontaneously unravels from around the fetal neck in approximately 83% of cases 4
- Routine antenatal ultrasound screening specifically for nuchal cord is not recommended as it does not change clinical management 2
Special Considerations for Multiple Loops
- While single and double loops generally do not require special management, triple nuchal cord (three loops) may warrant closer monitoring 4
- In a study of triple nuchal cord cases:
- Good perinatal outcomes were observed despite the presence of multiple loops
- However, this finding was associated with a higher rate of cesarean section, though this may reflect provider anxiety rather than true medical necessity 4
Recommendations for Clinical Practice
- Standard obstetric management with continuous fetal monitoring during labor is appropriate for most cases of nuchal cord 1, 2
- Vaginal delivery should be attempted as the first option, even with known nuchal cord 2
- Cesarean delivery should be reserved for cases with:
- Signs of actual fetal distress during labor (not just the presence of nuchal cord)
- Other obstetric indications unrelated to the nuchal cord 5
- In rare cases of multiple loops (≥3) detected at term, discussion with parents about risks and benefits of different delivery approaches may be warranted, but cesarean section is still not routinely indicated based solely on this finding 4
Conclusion
The evidence clearly demonstrates that nuchal cord identified on ultrasound alone is not an indication for cesarean section. Most fetuses with nuchal cord, even with multiple loops, can achieve successful vaginal delivery without adverse outcomes 1, 2. Management should focus on standard intrapartum monitoring rather than changing the delivery plan based solely on the antenatal detection of nuchal cord.