- Leonhard Schaffer, MD
Leonhard Schaffer, MD
- Associate Professor
- Head of Obstetrics
- Kantonsspital Baden AG
- Affiliated Hospital of the University of Zurich
- Roland Zimmermann, MD
Roland Zimmermann, MD
- Director & Professor
- Department Of Obstetrics
- University Hospital of Zurich, Switzerland
- Section Editors
- Susan M Ramin, MD
Susan M Ramin, MD
- Section Editor — Obstetrics
- The American Board of Obstetrics and Gynecology (ABOG)
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
A loop of umbilical cord around the fetal neck (nuchal cord) is a common finding at delivery. In most cases, it is not associated with a significant increase in the rate of any clinically important adverse fetal/neonatal outcome. In case reports and small case series, tight nuchal cords have been associated with adverse outcomes, including fetal asphyxia and demise, but causality has not been proven. This topic will discuss issues related to prenatal diagnosis of nuchal cords, pregnancy and intrapartum management, and potential outcomes.
The term nuchal cord describes an umbilical cord that passes 360 degrees around the fetal neck. Nuchal cords can be classified as :
●Single or multiple
●Loose or tight (ie, compressing the fetal neck)
●Type A or B (figure 1)
- Collins JH. Nuchal cord type A and type B. Am J Obstet Gynecol 1997; 177:94.
- Sherer DM, Abramowicz JS, Hearn-Stebbins B, Woods JR Jr. Sonographic verification of a nuchal cord following a vibratory acoustic stimulation-induced severe variable fetal heart rate deceleration with expedient abdominal delivery. Am J Perinatol 1991; 8:345.
- Clapp JF 3rd, Stepanchak W, Hashimoto K, et al. The natural history of antenatal nuchal cords. Am J Obstet Gynecol 2003; 189:488.
- Kobayashi N, Aoki S, Oba MS, et al. Effect of Umbilical Cord Entanglement and Position on Pregnancy Outcomes. Obstet Gynecol Int 2015; 2015:342065.
- Sheiner E, Abramowicz JS, Levy A, et al. Nuchal cord is not associated with adverse perinatal outcome. Arch Gynecol Obstet 2006; 274:81.
- Schäffer L, Burkhardt T, Zimmermann R, Kurmanavicius J. Nuchal cords in term and postterm deliveries--do we need to know? Obstet Gynecol 2005; 106:23.
- Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiple nuchal cord entanglements and intrapartum complications. Am J Obstet Gynecol 1995; 173:1228.
- Larson JD, Rayburn WF, Harlan VL. Nuchal cord entanglements and gestational age. Am J Perinatol 1997; 14:555.
- Tepper R, Kidron D, Aviram R, et al. High incidence of cord entanglement during early pregnancy detected by three-dimensional sonography. Am J Perinatol 2009; 26:379.
- Sørnes T. Umbilical cord encirclements and fetal growth restriction. Obstet Gynecol 1995; 86:725.
- Mastrobattista JM, Hollier LM, Yeomans ER, et al. Effects of nuchal cord on birthweight and immediate neonatal outcomes. Am J Perinatol 2005; 22:83.
- EASTMAN NJ. Coiling of the umbilical cord around the foetal neck. J Obstet Gynaecol Br Emp 1957; 64:227.
- Qin Y, Wang CC, Lau TK, Rogers MS. Color ultrasonography: a useful technique in the identification of nuchal cord during labor. Ultrasound Obstet Gynecol 2000; 15:413.
- Peregrine E, O'Brien P, Jauniaux E. Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section. Ultrasound Obstet Gynecol 2005; 25:160.
- Ranzini AC, Walters CA, Vintzileos AM. Ultrasound diagnosis of nuchal cord: the gray-scale divot sign. Obstet Gynecol 1999; 93:854.
- Pilu G, Falco P, Guazzarini M, et al. Sonographic demonstration of nuchal cord and abnormal umbilical artery waveform heralding fetal distress. Ultrasound Obstet Gynecol 1998; 12:125.
- Hanaoka U, Yanagihara T, Tanaka H, Hata T. Comparison of three-dimensional, two-dimensional and color Doppler ultrasound in predicting the presence of a nuchal cord at birth. Ultrasound Obstet Gynecol 2002; 19:471.
- Jauniaux E, Mawissa C, Peellaerts C, Rodesch F. Nuchal cord in normal third-trimester pregnancy: a color Doppler imaging study. Ultrasound Obstet Gynecol 1992; 2:417.
- Funk A, Heyl W, Rother R, et al. [Subpartal diagnosis of umbilical cord encirclement using color-coded Doppler ultrasonography and correlation with cardiotocographic changes during labor]. Geburtshilfe Frauenheilkd 1995; 55:623.
- Sherer DM, Manning FA. Prenatal ultrasonographic diagnosis of nuchal cord(s): disregard, inform, monitor or intervene? Ultrasound Obstet Gynecol 1999; 14:1.
- AIUM Practice Guideline for the Performance of Obstetric Ultrasound Examinations. http://www.aium.org/resources/guidelines/obstetric.pdf (Accessed on March 07, 2016).
- Lal N, Deka D, Mittal S. Does the nuchal cord persist? An ultrasound and color-Doppler-based prospective study. J Obstet Gynaecol Res 2008; 34:314.
- Henry E, Andres RL, Christensen RD. Neonatal outcomes following a tight nuchal cord. J Perinatol 2013; 33:231.
- Carey JC, Rayburn WF. Nuchal cord encirclements and risk of stillbirth. Int J Gynaecol Obstet 2000; 69:173.
- Jauniaux E, Ramsay B, Peellaerts C, Scholler Y. Perinatal features of pregnancies complicated by nuchal cord. Am J Perinatol 1995; 12:255.
- Sherer DM, Manning FA. Prenatal ultrasonographic diagnosis of conditions associated with potential umbilical cord compression. Am J Perinatol 1999; 16:445.
- Wang G, Bove KE, Stanek J. Pathological evidence of prolonged umbilical cord encirclement as a cause of fetal death. Am J Perinatol 1998; 15:585.
- Parast MM, Crum CP, Boyd TK. Placental histologic criteria for umbilical blood flow restriction in unexplained stillbirth. Hum Pathol 2008; 39:948.
- Tantbirojn P, Saleemuddin A, Sirois K, et al. Gross abnormalities of the umbilical cord: related placental histology and clinical significance. Placenta 2009; 30:1083.
- Ogueh O, Al-Tarkait A, Vallerand D, et al. Obstetrical factors related to nuchal cord. Acta Obstet Gynecol Scand 2006; 85:810.
- Osak R, Webster KM, Bocking AD, et al. Nuchal cord evident at birth impacts on fetal size relative to that of the placenta. Early Hum Dev 1997; 49:193.
- Lipitz S, Seidman DS, Gale R, et al. Is fetal growth affected by cord entanglement? J Perinatol 1993; 13:385.
- Carey JC, Rayburn WF. Nuchal cord encirclements and birth weight. J Reprod Med 2003; 48:460.
- Scheier M, Egle D, Himmel I, et al. Impact of nuchal cord on measurement of fetal nuchal translucency thickness. Ultrasound Obstet Gynecol 2007; 30:197.
- Schaefer M, Laurichesse-Delmas H, Ville Y. The effect of nuchal cord on nuchal translucency measurement at 10-14 weeks. Ultrasound Obstet Gynecol 1998; 11:271.
- https://fetalmedicine.org/nuchal-translucency-scan (Accessed on May 09, 2016).
- Mendez-Bauer C, Troxell RM, Roberts JE, et al. A clinical test for diagnosing nuchal cords. J Reprod Med 1987; 32:924.
- Sherer DM, Menashe M, Sadovsky E. Severe fetal bradycardia caused by external vibratory acoustic stimulation. Am J Obstet Gynecol 1988; 159:334.
- Simmons JN, Rufleth P, Lewis PE. Identification of nuchal cords during nonstress testing. J Reprod Med 1985; 30:97.
- Judge NE, Mann LI, Lupe P, Amini S. Clinical associations of variable decelerations during reactive nonstress tests. Obstet Gynecol 1989; 74:351.
- Sherer DM, Sokolovski M, Dalloul M, et al. Is fetal cerebral vascular resistance affected by the presence of nuchal cord(s) in the third trimester of pregnancy? Ultrasound Obstet Gynecol 2005; 25:454.
- Aksoy U. Prenatal color Doppler sonographic evaluation of nuchal encirclement by the umbilical cord. J Clin Ultrasound 2003; 31:473.
- Assimakopoulos E, Zafrakas M, Garmiris P, et al. Nuchal cord detected by ultrasound at term is associated with mode of delivery and perinatal outcome. Eur J Obstet Gynecol Reprod Biol 2005; 123:188.
- Ghosh GS, Gudmundsson S. Nuchal cord in post-term pregnancy - relationship to suspected intrapartum fetal distress indicating operative intervention. J Perinat Med 2008; 36:142.
- D'Antona D, Aldrich CJ, Spencer JA, et al. Effect of nuchal cord on fetal cerebral haemodynamics and oxygenation measured by near infrared spectroscopy during labour. Eur J Obstet Gynecol Reprod Biol 1995; 59:205.
- Kong CW, Chan LW, To WW. Neonatal outcome and mode of delivery in the presence of nuchal cord loops: implications on patient counselling and the mode of delivery. Arch Gynecol Obstet 2015; 292:283.
- González-Quintero VH, Tolaymat L, Muller AC, et al. Outcomes of pregnancies with sonographically detected nuchal cords remote from delivery. J Ultrasound Med 2004; 23:43.
- Zhao F, Geng Q, Kong F, Ning Y. Quantitative analysis of tightness of nuchal cord and its relationship with fetal intrauterine distress. Int J Clin Exp Med 2015; 8:17507.
- Reynolds L. Practice tips. "Somersault" maneuver for a tight umbilical cord. Can Fam Physician 1999; 45:613.
- Mercer JS, Skovgaard RL, Peareara-Eaves J, Bowman TA. Nuchal cord management and nurse-midwifery practice. J Midwifery Womens Health 2005; 50:373.
- Clapp JF 3rd, Lopez B, Simonean S. Nuchal cord and neurodevelopmental performance at 1 year. J Soc Gynecol Investig 1999; 6:268.
- Nelson KB, Grether JK. Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight. Am J Obstet Gynecol 1998; 179:507.
- Spellacy WN, Gravem H, Fisch RO. The umbilical cord complications of true knots, nuchal coils, and cords around the body. Report from the collaborative study of cerebral palsy. Am J Obstet Gynecol 1966; 94:1136.
- Greenwood C, Impey L. The association of nuchal cord with cerebral palsy is influenced by recording bias. Early Hum Dev 2002; 68:15.
- Nielsen LF, Schendel D, Grove J, et al. Asphyxia-related risk factors and their timing in spastic cerebral palsy. BJOG 2008; 115:1518.
- PRENATAL DIAGNOSIS
- Diagnostic performance of ultrasound
- Differential diagnosis
- NATURAL HISTORY
- POSSIBLE SEQUELAE DURING PREGNANCY
- Fetal demise
- Impaired intrauterine growth
- Abnormalities in tests for fetal evaluation
- - First-trimester combined test for Down syndrome screening
- - Antepartum fetal monitoring
- - Intrapartum fetal monitoring
- PREGNANCY MANAGEMENT
- During labor
- NEONATAL OUTCOMES
- Neonatal intensive care unit admission
- Long-term neurodevelopmental abnormalities
- SUMMARY AND RECOMMENDATIONS