To get this blog going I decided to write about a slight obsession of mine: The fear of, and routine midwifery management of nuchal cords at birth (umbilical cord around the neck). It was this issue that started me down the track of my PhD (which has grown and evolved since). I have written and presented about this topic and have bored the pants off many a person who has made the mistake of mentioning the subject. So, despite telling my colleagues that I had put away my ‘nuchal cord’ soap box I am bringing it out to launch this blog. The content of this post is based on a literature review I carried out. If you are interested in finding out more, or seeing the reference sources for the following information you can download a journal article here or the full literature review here.
Why and how babies end up wearing their cord around their neck
The presence of a nuchal cord is a very common occurrence during birth. Around a third of all babies are born with the umbilical cord around their neck. How and when it ends up there will be different for individual babies. Interestingly it is more common with boy babies – perhaps because they are more likely to have longer cords. It also becomes more common with increasing gestation – I suppose there is more time to get wrapped the cord. If a nuchal cord does not occur in pregnancy it can occur during labour. As the baby moves through the pelvis he/she rotates and can spin the cord around their neck. See this post to see how rotation works.
A versatile scapegoat
The nuchal cord has become the perfect scapegoat because it lays blame with the mother/baby rather than the careprovider/system. The result is that fear about nuchal cords is embedded within our culture. Whenever I read a story about an unexpected birth outside of hospital it always seems to involve a nuchal cord. The story being about how lucky the baby was to survive the dangers of a nuchal cord away from the experts who can manage such a complication. In addition, I have heard too many birth stories where the resulting complications were blamed on the presence of a nuchal cord.
Before I tackle some of the myths – some quick anatomy and physiology: The umbilical cord is designed to be worn around the neck without causing a problem. The cord is covered in Wharton’s jelly and coiled. This protects the 3 blood vessels from the kind of stretch and compression involved in being attached to a mobile baby. The umbilical cord is also long enough (average 55cm) to be comfortably wrapped around the neck with plenty of left over length.
Pregnancy
There is no research to support the idea that nuchal cords are associated with babies dying during pregnancy. Unfortunately some babies do not make it, and die before labour begins. There is often no known reason for this which can add to the devastation. When these babies are born they are often found to have the cord around their neck (like a 3rd of all babies). Although I can understand the need to find a reason and to pick the obvious, I don’t think this is helpful in the longer term. Parents need honest answers about the loss of their baby, even if the answer is ‘we don’t know’.
Labour
During labour a nuchal cord does not cause a problem. The baby is not ‘held up’ by the cord because the whole package – fundus (top of the uterus), placenta and cord are all moving down together. The uterus ‘shrinks’ down (contracts) moving the baby downwards, along with their attached placenta and cord. It is not until the baby’s head moves into the vagina that a few extra centimetres of additional length are required (see ‘birth’ below). However, when a c-section is done for ‘fetal distress’ or ‘lack of progress’ during labour, the presence of a nuchal cord is often used as the reason… “ah ha, look – your baby was stressed because the cord was around his neck” or “…the cord was stopping her from moving down”. The cord is unlikely to have had anything to do with the stress or lack of progress. Most likely other interventions carried out during labour led to the end scenario (eg. the use of syntocinon and/or ‘failure to wait’).
Birth (the last bit of labour)
The nuchal cord remains around the baby’s neck as his head moves out of the uterus and through the vagina. Usually the cord remains loose as there is lots of ‘give’ in it. A loose nuchal cord does not cause any problems. Blood continues to flow through the vessels just as it did during pregnancy and labour.
Occasionally a cord becomes stretched and tight during this last bit of labour – as the head is born. Either there is not enough ‘give’, or the cord is trapped against the pelvis by the baby’s body. This may happen with a shorter than average cord that is wrapped around the neck a number of times. However, the baby is not ‘strangled’ because he/she is not breathing oxygen. Their oxygen is provided by the cord, not their airway. Whilst the cord is stretched and compressed the blood vessels transfer less blood (but still some). This results in short-term hypoxia (reduced oxygen supply) which resolves once the cord is loosened after birth and full blood flow resumes. These babies may arrive a little compromised but quickly recover – if the cord is left alone. Unfortunately the way in which the situation is managed (see below) can create further problems. The resulting need for resuscitation is then blamed on the nuchal cord rather than what was done to it by the care provider.
Risks associated with clamping and cutting a tight nuchal cord
Once the cord is clamped, blood flow between the baby and placenta ceases, reducing the baby’s blood volume and oxygen supply. This makes resuscitation more necessary and difficult once the baby is born. Any delay in the birth of the baby (eg. shoulder dystocia) will further increase the risk of hypoxia. While waiting to be born the baby now has NO blood supply rather than a limited one. There have been successful malpractice actions against obstetricians in the US who cut nuchal cords prior to shoulder dystocia.
One study (Sadan et al. 2007) found that neither cutting nor leaving a nuchal cord adversely affected the outcome for babies. However, they did not look at tight nuchal cords, and the cords were cut after the anterior shoulder had birthed.
For a baby with a tight nuchal cord the worst thing you can do is clamp and cut!
Risks associated with pulling and looping a loose nuchal cord
A far more common practice is pulling and looping a loose nuchal cord. Most care providers do this and I was taught to do this when I trained. However, handling the cord stimulates the umbilical arteries to vasoconstrict reducing blood flow. Loosening the cord will usually involve some traction which can risk tearing the cord and subsequent bleeding (from the baby). As a student midwife I snapped a cord while looping it over the baby’s head. Luckily my mentor clamped the ends quickly but not before I got blood sprayed in my eyes! I later discovered that babies can be born with the cord around their neck. They either birth through the loop or they come out with it still wrapped.
Checking for a nuchal cord
So, if you are not going to cut or loop a nuchal cord what’s the point in digging about to see if it is there? Checking for a cord interferes with the physiological process of birth. It also reinforces the notion that this is a birth complication that endangers the baby, rather than a common situation. Telling the woman to stop pushing and putting your fingers into her vagina can be disempowering and painful.
Suggestions
- Talk to parents before birth about the possibility and normalcy of a nuchal cord.
- During birth DO NOTHING.
- IF the cord is preventing the baby descending once the head is born (extremely rare) use the ‘somersault technique’ (Schorn & Blanco 1991) – see below.
- Once the baby is born unwrap the cord (the mother/family can do this).
- If the baby is compromised at birth encourage the parents to talk to their baby whilst the placental circulation re-establishes the normal blood volume and oxygen for the baby (do not cut the cord to remove baby for resus).
The baby in the photo above was born at home into water. His cord was tightly around his neck twice. The midwife is in the process of unwinding the cord whilst bringing him to the surface and into his mother’s arms. He took around a minute to start breathing whilst his placental circulation re-established his blood volume and oxygen. His father gently blew on his face and he took his first gasp.
You can read mothers’ experiences of having their babies nuchal cords cut and the consequences here and here.
You can see a lovely example of a baby being born with a loose nuchal cord (and in the caul) on Pamela Hines’ website.
Gloria Lemay has posted some photos of a baby being born with a multiple nuchal cord here. Birth Without Fear have some photos of a homebirth baby with a multiple tight nuchal cord that caused the baby some stress at the end of labour. He recovered well because his cord was left intact.
Cord Clamping.com discuss nuchal cords here.
The somersault manoeuvre
I have only had to use this twice in hundreds of births.
Cut and paste of comments on previous blog site:
Carolyn Hastie
Lovely post Rachel and great start to your blog!
Would be good to add a ‘follow’ button, so those of us who want to can follow your work. You can also add an email subscription link.
Saturday, July 24, 2010 – 04:36 PM
Amy Holmes
thanks for the info rachel. I guess its a mind set ‘dont touch’ and once you get that mind set , it is easy to continue. The hard thing is educating midwives who are supporting you in a birth about keeping you hands off, and allowing the placenta to support the new babe
Saturday, July 24, 2010 – 06:06 PM
Pernille Powell
Ahhh, Rachel, you know I love you!!! What an absolutely fantastic distraction from your pHd. This blog simply has my name on it. It might help so I wont bother you several times a week with all my birth thoughts
You’re a gem
Pernille
Saturday, July 24, 2010 – 08:42 PM
Anna Robins
This is fantastic Rachel. Loving your procrastination ideas. Nuchal cord might be old news for you but there are so many doctors and midwives out there who still check for them and loop them over. Interesting your story of the snapped cord – this is a real fear of mine, when I have been instructed to loop the cord, it just doesn’t feel right!! Thankyou for sharing your experiences, this will arm me with reasons not to practice ‘checking and looping’. Look forward to more blogs.
Sunday, July 25, 2010 – 08:36 AM
Anonymous
What a great way to start a truely interesting blog. Congratulations Rachel. Lovely. Plus gorgeous photos. Always a bonus!
Sunday, July 25, 2010 – 01:46 PM
Rachel
Thanks everyone for stopping by and commenting. I will try and post something each week. You can subscribe the RSS on the front page of the blog and choose email notification if you prefer.
Pernille – you can still email me questions. I’m always happy to discuss birth stuff x
Sunday, July 25, 2010 – 05:39 PM
Thanks for linking to my blog. Good for you for getting started on your blog.
Gloria Lemay, Vancouver BC
Thanks Gloria
I’ve also linked to your fantastic audio in my ‘pushing’ post.
Rachel, thank you for visiting my blog. I have so much to learn, still (probably obvious in my post
, which was just written because I was annoyed at all the fear about nuchal cords), but it is good to see your research confirm what I already instinctively knew: that we can trust birth to work right nearly all the time, nuchal cords or not. I am really looking forward to reading the .pdf and saving it for my midwifery studies.
Manhattandoula – our instincts are almost always right ; )
My second daughter was a homebirth in water with a nuchal cord. She performed the “sommersault maneuver” you describe all by herself. The midwife told me to stop pushing so she could get the cord over the neck – it was tight enough that the first attempt to slip it over was unsuccessful; however, I couldn’t keep the contractions from coming. My daughter shot out, sommersaulted through the loop of the cord, and we brought her up to the surface. It was surprising, but perfect!
What a coincidence! My daughter, also born at home in water, did the same thing. I didn’t even realise that there was an issue with the cord, until my midwife told me after the birth, “She somersaulted out, that’s why you tore.”
My brother’s cord was cut by a physician prior to a shoulder dystocia. He has developmental delays and learning disabilities resulting from it. My mom told me they had to cut the cord because it was too tight for him to be born, then he got stuck. He was born blue and had to be resuscitated.
I am sorry to read this Danielle. I wonder how many other children have ongoing problems that have been blamed on a nuchal cord rather than the management of it.
Awesome, Thank so much for sharing this. Very important info, even for midwives
This is great. I don’t know how many times that the first thing a parent will say about a home birth to me is “we never could have done that our son had a cord around his neck!” and….. I hope that you continue to help bring light on this scare tactic.
Thanks Tracy
When people tell me that they had to have a c-section/forceps/intervention because the cord was around their baby’s neck I sometimes answer: ‘Really? My daughter was born at home with no problems BECAUSE the cord was around her neck’. Either way the cord is not related to the outcome but it is used as a ‘because’ for intervention, so why not for a good outcome?
love this, sharing it on facebook. what about a baby that gets tightly wound up inside and this prevents it from descending? a friend had a home birth planned but at her last ob app the baby was literally all tied up and the placenta was at the top so would possibly have caused an abruption. her midwife didnt want to risk it and recommended a section. also i know from spiritual midwifery and ina mays guide that she used to loop the cord, do they still do that on the farm?
Hi Bonnie
Hmmm I’m not saying the obs lied but:
- The placenta is usually at the top.
- I have never heard of a placenta abrupting due to this situation.
- If the cord really was that tangled the baby would have unwound during labour (they are clever like that) or the labour wouldn’t have progressed = transfer and c-section.
- Obs come up with some odd ‘reasons’ not to homebirth.
It would have been interesting to see the outcome if she had believed in her ability to birth and not relied on an ‘expert’ in surgical solutions.
As for Ina May – I’m not sure what they do on the farm now. As midwives our practice should be constantly evolving in response to knowledge.
Years ago, my doula trainer attended an attempted VBAC with CNMs in attendance. After a straightforward (and med-free) dilation phase, mom pushed and pushed and pushed with absolutely no descent by baby, with normal heart tones, even when they resorted to purple pushing. Mom decided on a repeat cesarean, and when the OB got inside, they were all amazed. This little acrobat had twisted itself in the cord so tightly and so intricately, there was no way it would have been birthed vaginally. It was around the neck, chest, waist, arms and legs, and under and around and through and back again! Baby was engaged, but high enough that even after several hours of pushing, the skull wasn’t molded at all, baby was so tightly wrapped. As far as I know, in her 30 years of doula and birth work, that’s the only time anything like that has occurred.
My last baby was a homebirth, waterbirth and the midwife got there shortly after the birth. The cord was around the neck and our baby did the manuever you mentioned naturally on his own. Then we unwrapped the cord and it wasn’t cut for at least 20 minutes. He’s a robust toddler now.
IMHO This could use an explanation for how the uterus/fundus/placenta follows the baby out and therefore means even a short cord is long enough.
Also a discussion of the risks of a long but non-wrapped cord.
And perhaps something on wharton’s jelly / cords coiling.
Thanks mystic eye
I stuck to the risks / management of nuchal cord to avoid the post becoming too long. There is a little more about why a baby might become entangled in my journal article (all a bit referency and boring).
The fundus/placenta does follow baby out, but in extremely rare cases the cord is only long enough (or wound multiple times) to let the baby get his/her head out and requires the somersault technique for the body. The posters above have experienced their own baby’s using the ‘technique’.
Hmm hadn’t considered the risks of a long but non-wrapped cord. Clever babies winding themselves up to prevent cord prolapse : ) ?
The anatomy and physiology of the umbilical cord is an entire post in itself… maybe one day I’ll get round to it.
R x
I just discovered this blog and I’m LOVIN’ it! Your knowledge and experience will be a great resource.
In response to nuchal cords, here’s another extreme example of our culture’s misunderstanding of this normal occurence. When an acquaintance of mine was telling me about the birth of her daughter, she mentioned how it was scary b/c the cord was around baby’s neck, etc, even from the OB’s perspective. Then she went onto to say that she found out that when she was born, the same thing happened (and also to her siblings during their births) and quickly drew the conclusion that it must be genetic!! What?! I gently tried to dispel this, but I don’t think she believed me.
I have heard over and over again of “scary” birth stories where the cord was wrapped around the neck/body, etc. You are so right that it’s high time for this myth to be dispelled! I am grateful that you have such an extensive body of knowledge on this subject.
I love a good nuchal cord post. I commented on Gloria’s post about how it’s something I’m regularly debunking for people and here’s another read I can give them, so thanks!
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Hi – love your blog.
Just wanted to comment that my last babe had tight nuchal cord. Resulted in slow to breathe, low apgar, transfer to SCN etc mentioned above.
In my case I had a midwife assisted homebirth. No interventions of any kind. Short, easy labour. Baby born on land. Waters broke spontaneously quite late. Baby monitored by doppler intermittently with no sign of problem. Cord was not cut until the placenta was delivered. I am certain I felt the point when the cord tightened around his neck just as he started to crown. He tugged his head forward in an unusual way.
In my case cord clamping was not the issue but short/tight cord appeared to be. Anecdotal I know but I thought I would mention it!
Thanks Shann. Birth stories (anecdotes) are always welcome. Well done to your midwife for leaving your baby’s cord intact – he would have had a much harder time recovering without his placental circulation. This situation is rare and as you demonstrated a baby can be born with a tight nuchal cord without needing to cut it.
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Thanks so much for all your hard work. Also, thank you for making it available to us. My baby born with the cord around her neck just turned 30!! (and is perfectly normal). She was the second of my six and the only one with a nuchal cord. I distinctly felt her roll during labor, and told the midwife. ( This was back in Australia in a training hospital.) The midwife had recorded the baby facing down, then up, then down again on successive checks. The resident doctor was called in, and the midwife talked him through the birth, allowing him to unloop the cord after my daughter’s head and shoulders were born (I distinctly felt the double ‘pop’, ‘pop’). For me there was one stitch, and for her; a purple face, which took an hour to become the same color as the rest of her body. Always I have assumed she wrapped it around during the labor, but maybe she actually unwrapped one loop!!
3 out of my 5 birth centre & home births had cords around the neck. Most were loose and were born through the loop, except for one, where it was very tightly around the neck. She was born with bruising on her face and red spots on her eyes, and took a while to start breathing. The midwives think that she started off posterior presentation, but turned during birth, which caused the extra pressure. But all babies perfectly fine, cord cut long after birth, and no problems. People kind of gasp when I tell them about the cords around the necks, and ask if I had to transfer to hospital or something. I only recently learned that nuchal cords were considered to be a problem, so I would usually just dumbly looked at the questioner and said, “Transfer to hospital? Why? The birth was just fine…”
In 2300+ births in 32 years I have seen a nuchal cord cut 3 times. Twice when I was an apprentice and really had no say in the matter, though the second one seemed needed to me, the moment the cord was cut the baby fell out of the vagina (mom was squatting). The only time I have ever cut a cord before the birth of the baby was with a cord looped 5 times around the baby’s neck. The somersault maneuver didn’t move the baby even a millimeter. I clamped and cut the cord and unwound the 5 loops and the baby was born easily (was the mother’s 5th child). I did have to work a little bit to get him breathing, but he recovered well and was nursing within the hour.
I have only needed to use the somersault maneuver a couple of times, works like a charm.
What great stats to share! That sounds about right. I’m not into the 1000s but out of the 100s of births I’ve attended I’ve only used the summersault manoeuvre twice and never had to cut a cord… yet. The baby with the 5x cord must have been spinning inside his/her mama!
I found this anecdote very interesting. I have a good friend who had an emergency C-section due to a stuck baby with a cord wrapped 4 times around his neck. It was a first birth, and I don’t think the baby made it far enough down the birth canal that there were many options. That’s my understanding at least, and how the hospital made it seem. So after reading this article, my thought was, “well there have got to be SOME exceptions.” And this anecdote does seem to be the rare exception. This article does make me wonder, however, if there were other options in my friend’s case had she been with a midwife rather than a doctor at a hospital.
I loved this article, and thought it was incredibly important. The first time I had any idea that a nuchal cord was normal, and not necessarily dangerous, was when I read “Spiritual Midwifery” during my 3rd trimester. When I initially started reading about pregnancy and labor, I was suspicious of resources that didn’t seem “mainstream”, assuming that mainstream sources would give the most balanced information. But the more I learn, the more incredulous I am about how misleading mainstream sources are.
My DD2 was born at home in water with 2 tight nuchal cords, my midwife used the summersault maneuver as i pushed and unwrapped her so she could reach the surface.
everything was absolutely perfect!
My last (fifth) baby had a loose nuchal cord, followed by descending shoulders and stuck baby. Somersault technique was instantly successful, but my little one had bloodshot eyes from the pressure. Otherwise, he’s a normal, healthy 18-yr-old.
Hi!
Thanks for your blog
My son had a loose nuchal cord during birth (UC) and that didn’t stress me at all… I wish more people knew that, that would be less stress for mothers to be.
My friend kept the cord attached for days and kept the whole thing including placenta,wrapped in salt, and carried it around with the baby, so baby could get the full nourishment.
This is called a ‘lotus birth’. It is more of a spiritual practice as the baby does not get any nutrients from the placenta once it has ceased circulating. The idea is that the baby choses when to release their placenta rather than having it cut away. You can find out more here: http://www.lotusfertility.com/Lotus_Birth_Q/Lotus_Birth_QA.html
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I love this blog! I’m a childbirth educator in NYC and I reassure expecting couples about the dreaded cord around the neck all the time. I wanted to ask you to clarify something if I may. I’m little confused about whether the unraveling of a nuchal cord should be done as the head emerges or after the baby has been fully born. When do you do it? Another question: I am sometimes asked by students what they should do if they end up delivering before the EMTs/midwife arrives. Is there nuchal cord advise you’d give here? Also, what about breech babies and the nuchal cord, do some babies never go down due to a tangle of the cord or a “short” cord? (So many questions, sorry! I think there’s a lot of mythology around this cord, and it DOES frighten women.)
Unraveling the cord can happen after the baby is born. Much less invasive than pulling and fiddling when the head is born and interrupting the mother’s instincts. If it is loose the baby may birth through the loop and not need unraveling. I don’t check for cord because I don’t do anything with it, and I sometimes don’t actually see the baby coming out (dark room, waterbirth, in another room). I wait, and if the mother wants help unraveling her baby, I’ll give her a hand.
If the baby is born before the midwife arrives – just leave the cord and unravel once baby is out. I think it is important to address this issue with parents to avoid unnecessary panic if/when they see a nuchal cord. The article you can download from this post is about sharing information with parents re. nuchal cords.
I’ve never heard of a breech baby being held up by their cord. Not sure how this would work because the uterus (with placenta attached) moves down with the baby. However a nuchal cord provides a perfect scapegoat for all manner of birth outcomes – although is not associated with any.
Usualy when parents are aware of the facts re. nuchal cord they are no longer frightened. A 3rd of them will experience a nuchal cord during birth so they need to feel OK with it. It is our job as educators to try and erradicate fear with knowledge.
my wife delivered a baby boy few days back. pre delivery every test including ultrasound (color dropper) was fine. but during birth baby was in “Abnormal Presentation” facing up-words..nurse pushed down the baby forcefully to make normal delivery possible.
During baby had “cord around neck” and could not breath for 5 min, my baby was on ventilator for 5 days and could not survive..
plz let us know who is to blame, n what precautions we should take in future..??
I am very sorry you lost your son. I can understand your need to find answers but I cannot know what was happening during the birth. I hope the health professionals present take the time to debrief with you and explain what happened from their perspective. I am not sure which country this occurred in… I can share some information with you that may help you process what happened and ask some questions of those involved.
Facing upwards is not an abnormal presentation and fairly common – you can read more in this post: http://midwifethinking.com/2010/08/13/in-celebration-of-the-op-baby/
The cord around the baby’s neck was more than likely just incidental, and nothing to do with the outcome as one third of baby’s are born with the cord around their neck with no problems.
No force should be needed for a normal birth to take place. I am not sure if you mean force was applied on your wife’s abdomen or on the baby? Was the baby’s umbilical cord left intact so that he could be resuscitated by the placental circulation? http://midwifethinking.com/2010/08/26/the-placenta-essential-resuscitation-equipment/
What were you told about the cause of death? There maybe no-one to blame. Some babies don’t make it. I hope you get your answers.
Thanks for the reply.
1. This took place in India.
2. The force was applied on my wife’s abdomen so that baby move downwards..is it recommended..??
3. the Dr. informed me that during birth cord was tightly around baby neck..(baby could not breath for 5 min and resume breathing after 5 min), however 4 days old color dropper ultrasound showed no cord around neck..is it possible..??
4. The child specialist said “oxygen could not be supplied to brain hence he developed swelling on head” and expired after 5 days on ventilator..:(
5. about umbilical cord left intact, no info was supplied..
with this info. are u able to determine root cause…??
Without being there or talking to the health professionals there I will not be able to determine the root cause.
1. I do not have much knowledge about maternity care in India
2. Fundal pressure is not recommended and can be dangerous. More info here: http://www.scienceandsensibility.org/?tag=fundal-pressure
3. The cord can become wrapped around the baby’s neck as they rotate through the pelvis in labour. This is why there is no point in doing an ultrasound to see if the cord is around the neck. It also doesn’t matter in terms of labour outcome. A tight cord will not stop the baby breathing. The baby doesn’t breath until after birth (usually within the first minute). Until the baby breathes they are receiving oxygen via the umbilical cord just like they do in the uterus. This is why it important not to cut the cord until the baby is breathing on their own.
4. A healthy baby can cope without oxygen for around 7 minutes. So, unless the baby was stuck for this long with his head out and body in – the significant lack of oxygen either occurred earlier in the labour or after the birth (eg. by cutting the umbilical cord before he was breathing). Babies can survive a sudden reduction in oxygen at the end of labour because this is fairly common.
I think you need to ask the Dr for more information about what happened and why.
hi amit.. m really sorry to know about ur loss… read ur post in d ddun page on fb.. i hv jst completed my mbbs n am an intern rite nw.. so i dnt hv much experience.. bt what i can make out of what u said above is that ur baby was in breech presentation.. which is fairly common.. n i guess what was done by puttin pressure on ur wifes abdomen is a procedure called external version which is done to convert the breech presentation into a vertex (head) presentation.. this is also a common procedure which has its risks.. the most common of which is strangulation by the nuchal cord.. which happened in ur case i guess.. i dont know whethr the doctor is to be blamed in dis case bcoz i am not sure whether they took the necessary precautions..
Hi Smriti
I think Amit’s wife was in labour when this happened so I don’t think the baby was breech. Fundal pressure is sometimes used to ‘speed up’ the birth or in the case of shoulder dystocia. However, it is not recommended. An external cephalic version (ECV) should take place with a highly skilled practitioner using ultrasound and with immediate access to c-section.
The cord cannot ‘strangle’ the baby as the baby is not breathing. The most common complication of (ECV) is fetal distress or placental abruption. Umbilical cords are usually long enough to allow movement, even when multiple. We need to stop blaming nuchal cords for ever poor outcome and increasing the fear for parents. Nuchal cords are normal.
Hello, very interesting article, which I am sure I have shared before on the internet.
I am wondering now about how this relates to a breech baby. What are your thoughts please?
No difference really. The baby+cord+placenta+fundus all move down together. In fact the cord can be shorter as it doesn’t have to go from the head up the body and into the uterus like it does when baby is head down. You can pictures of a breech with nuchal cord here: http://londonbirthpractice.co.uk/joomla/educational/breech/home-breech-birth-photo-series_2.html
Of ocurse, I’ve seen those pics before, have probably shared on Facebook on more than one occasion in the past…. So, a breech baby with a tight white cord after a fairly normal and uneventful labour would probably do worse after immediate cord cutting than leaving it? We really, REALLY need more breech birth training
Any baby does better when their cord is left alone – especially a compromised baby. And yes we really do need more breech birth training. It has become a lost art.
Homebirth with my son. 38 hours of labor, he was accynclitic with his hand by his chin AND the cord was looped around his neck/shoulders AND the cord was tearing away from the placenta. it was successful! in a hospital, i would have been sectioned after the first 12 hours of labor for sure and who knows what they would have done had they known the other issues! more people need to know this is OK. thanks for sharing
Congratulations to you and your nuchal/shoulder cord baby!
i dont think the fear is about baby being strangled of ‘air’ but of blood supply. if the cord gets to tight around the neck it slows blood flow to the brain does it not? have u ever seen kids play that game when you were younger where they put tight pressure on a persons arteries on the neck and theyblack out? baby still needs blood flow to the brain does it not? ..
i dont think the fear is about baby being strangled of ‘air’ but of blood supply. if the cord gets to tight around the neck it slows blood flow to the brain does it not? have u ever seen kids play that game when you were younger where they put tight pressure on a persons arteries on the neck and they black out? baby still needs blood flow to the brain does it not? .
Hi Shannon
I wrote the sentence about ‘air’ because I have heard a few birth stories involving the ‘baby had the cord around the neck and couldn’t breathe so they cut it’. I think some parents do think it is the lack of air that is the problem – at least some of the parents I talk to do. The cord would have to be very tight to compress the vessels in the baby’s neck. Compared to the neck the cord is soft and pliable. When the cord is pulled tight at the end of birth the vessels in the cord are compressed which causes the reduction in oxygen. The baby and uterus are stronger than the cord so if it really was tight enough to ‘strangle’ it would snap with a contraction – it is the weakest point.
thank you for clarifying. i to believe that there is to much fear around the cord/neck but was unsure about this one point. when would it be dangerous if at all? if it was wrapped tightly 3x or something?
Yes, if it is very tight and the vessels are compressed there is a decrease of blood flow and oxygen. If this is prolonged ie. for minutes this can result in a baby who needs resus. However, the most important thing is to leave the cord intact to assist with the resus. So in extremely rare cases it can be dangerous (I’ve never personally experienced this) but what is more dangerous is the cutting of the cord.
Basically the biggest danger related to a nuchal cord is the way it is managed.
I think it’s great to reduce unnecessary fear and never feel for a nuchal cord. However I do believe occasionally the cord can cause real problems – possibly not the right forum to go into these but Anne Frye discusses them. I have known some myself. A lit review is helpful but we do need to still respect the occasional rare unexpected outcome. IS
Hi Nicky – If you read the post it does acknowledge that a tight nuchal cord can result in hypoxia. I do respect the occasional rare unexpected outcome but really feel that we need present the situation of a nuchal cord as normal and reduce fear. If we focussed on all the rare complications that are associated with childbirth we would end up like OBs doing all kinds of interventions to avoid tiny risks. A literature review can help to place the fear into context but practitioners also need to be able to manage the rare situation where a nuchal cord can create problems.
The CNM who caught my baby clamped and cut the cord within seconds of birth even though we had agreed on delayed cord clamping. When I asked her about it she said that she had to cut the cord because it was wrapped very tight. I was a little peeved about it then, but after reading this I’m even more so. Thankfully, no problems (that I know of anyway) from the immediate cord clamping, but it’s one of the few dark spots on an otherwise beautiful birth.
I was wondering, would a tightly wrapped cord be more likely to present problems in labor if the amniotic sac is ruptured? During my labor they really wanted to break my water because I was progressing so slowly, but I was insistant that they leave it alone. I remember it seemed really important to me at the time. After I found out about the tight nuchal cord I thought it must have been my mama intuition telling me to leave the waters intact to ease the pressure on the cord.
Without the waters there can be pressure on cord whether it is wrapped around the baby or not – so your intuition was probably right.
My 3rd child, a son, was born at home (as was one of his sisters) this past January. He had a triple nuchal cord. He literally came shooting out and I caught him. The 3 fantastic midwives who attended the birth spun him every which way to untangle him and then put him down on my wife. It was a little scary while it was happening, but the midwives remained cool and calm and went about their business.
His APGARs were 8 and 9 and the cord was not clamped or cut until well after the placenta was delivered. His 4 year old sister cut the cord!
Thanks for a great article on dispelling this myth.
My son had a Nuchal cord x2 as well as a true knot. Does the presence of a true knot make any difference? I’m thinking no, but the doctor was adament that my son would likely have not survived had I tried to labor with him. I was desperately trying for a VBAC after twins but am certain the doctor simply did not want to allow me to VBAC.
It is such a shame you were mis-informed. A true knot is unusual but lots of babies have been born with them. Usually no one knows until after the birth. Certainly not an indication for c-section. You should complain.
I just want to give the anecdotal info that TWO of my home water-birthed babies have had true knots in their very long cords. One of them came 4 weeks early, was 20 inches long, and a mere 5# 4 oz. Between me and my wonderful midwife, we think she just *knew* to come early because of that knot causing her troubles in adding pudge.
Out of my 6 babies, three have been born at home into the water. One had a short nuchal cord (he sumersaulted himself as soon as he was in the water, and still had one loop remaining), and then these two true knots. The other three, sadly, I have no idea about, since the doctor who delivered them apparently didn’t think highly enough of my intelligence to let me in on it.
See Michele’s comment re. Her birth with a knot in the cord.
My 3rd, and most recent, child was born at 35 weeks. His heart rate would drop during each contraction but thankfully I have a great OB who agreed to let me labor on my own and only do a c section if the baby was truly in danger. I progressed quickly and delivered my son after 1.5 hours of labor (3cm to delivery). I delivered my son myself as my husband left the room to get the nurse who had gone to get the doctor. The cord was wrapped around his neck and he still, even at 35 weeks, scored 10 on both of his APGARs. Thank you for sharing this wonderful information…hopefully more mothers will choose to educate themselves before birthing their children.
Just so you know, I’m pretty sure that most babies heart rate drops during contractions. It’s just whether they go up again in between that is the difference between normal and cause for concern. Congrats on your little one!
I was planning a homebirth and at 40 weeks, not in labour and not fully engaged with a foetal heart rate of over 190bpm I had a C/S. My independent midwife told me it was because my son’s cord was around his neck twice and was preventing him from engaging and causing his high heart rate.
I have always believed that the C/S was necessary because the cord was causing the high heart rate problem, but now I’m not sure after reading this article. Did I really need the C/S?
I can’t really comment without having been there. I have not heard of a situation where the cord caused a high heart rate. However I would be concerned about a rate consistently over 190.
Do you have any ideas on what would cause a heart rate that high given I was not in labour?
A significantly high HR can indicate a reduction in oxygen = heart beats faster to get oxygen around body. It usually happens when a baby has been stressed for a long time in labour (which you weren’t) and is usually preceded by hours of HR dips with contractions. Or with an abruption (placenta separates before birth). Or with a high maternal temperature and/or infection. Either way it is not a good sign and your mw did the right thing by referring you to an OBs. I’m not sure what the cause was in your case. How was your baby at birth?
My son is fine (I’m not, I have PTSD from the way I was treated). His agpars were 8 and 9. I always assumed that once the pull on the cord was released he was able to get the cord blood he needed and his heart rate came back to normal. We did get him a lotus birth in theatre so he got all of his cord blood which I think helped his Agpar scores.
I didn’t have an infection or a high temperature. I wasn’t dehydrated, and I never had any bleeding through the pregnancy. I was in good health – which the hospital destroyed by cutting me open.
I recently obtained my son’s medical records, whom had a tight double nuchal cord cut minutes before birth. The day before onset of labour I presented at the hospital with leaking amniotic fluid. They monitored me for half an hour before I went back home. Reviewing his medical record I see this his heartrate on this day was persistantly between 170-180bpm and in ’90s during tightenings. There was no mention of this to me at the time though – the tracing done the next day while I was in labour is missing from his records – the notes say they were sighted but not by whom and no figure/record/signature. I shouldn’t be surprised though since it turns out his record states “loose cord around neck, unlooped and clamped after birth” when they actually freaked out about a double looped, tight cord, tugged on it, pushed a whole hand inside the birth canal to pull on it, then clamped and cut it. Then freaked out even harder since his shoulders hadn’t rotated and I couldn’t just :”push him out!”. I am actually disgusted that the procedure that created a resuscitation situation and low Apgars by 5mins is ‘hidden’ and lied about in his records. How can researchers produce the type of evidence that will convince all in the birth industry to stop this routine, dangerous practice. And how can children like my son be tracked for outcomes beyond birth if the timing and circumstances of cord cutting is not included in formal birth records!!
Anyway, I just thought it was interesting how he most probably already had a tight cord late pregnancy that may have been causing a higher heart rate going in to labour.
Medical records often don’t reflect what happened. Practitioners know that records hold a lot of weight legally and document accordingly. The old ‘if it isn’t written it didn’t happen’ that is drummed into midwifery students to encourage good record keeping works both ways. I am sorry your birth story has been re-written.
My boy was born safely at home with a nuchal cord and a loose knot too. There were no issues at all. It was a calm birth. I love sharing these little details with people so they know what trained professional midwives can easily handle and whats safe in a homebirth. I’m usually amused by the dramatic OMG reactions I get from people who don’t understand natural birth. Thanks for this fascinating info! A doula friend, Shelby, posted it on Facebook and I’m going to share it too!
So am I understanding right, that a tight nuchal cord is basically no excuse for it being cut? Or is incredibly, incredibly rare, but yes, it can be needed?
I just about cried when I read this article. DS1′s cord was cut before he was out. He was in distress (and they ‘forgot’ to turn the syntocinon off, or get me up off the bed), they gave me an episiotomy. His head was out. They cut his cord, then he was born. He had lots of breathing issues, and then had lots of feeding issues. Apgar at 1 minute was 4 (he got a 1 for hr & 1 for respiritory).
Hi Misskalypso
Sorry about what happened with your son, happened at my son’s birth too.
Same apgar at 1 minute, he was a 6 by 5 mins.
The story is here:
http://giftedbirthsupport.com/2011/06/01/birth-story-nuchal-cord/
Never say never. However, if a cord was so tight it was holding a baby up it would probably tear during a contraction – the uterus and baby are stronger than the cord. I can’t think of any situation when cutting off a baby’s blood volume would be an answer (doesn’t mean one doesn’t exist). Your’s and giftedbirthsupport’s stories are all too common unfortunately… and unnecessary.
I did some research after my son was born, and found stats that while many babies are easily born with a nuchal cord, a nuchal cord x 3 only occurs in 2-3% of births and almost always results in complications during delivery. Did you find the same in your research? Wouldn’t the length of the cord factor heavily into how this affected delivery?
I had a planned home birth. My waters broke immediately and then I started a 30-hour labor at home. Eventually transferred to the hospital where I pushed for 4 hours with no progress. After 40 hours of labor, I gave in and had a C-section. Baby had nuchal cordx3 which was rationale given as to why he could not descend.
Have you had/heard of any experiences like this?
A multiple tight cord is rare (as you found in your research). In relation to vaginal birth the complications associated with this unusual situation are probably related to clamping the cord and interrupting the natural recovery. In situations like yours it is difficult to pinpoint ‘why’ since babies have been born vaginally with multiple nuchal cords – see egs in post. And lots of babies are born by c-section for ‘prolonged second stage’ without nuchal cords. There is no research to support one leads to the other but in theory a short, multiple, tight cord could prevent descent but the tension on the cord would probably create heart rate abnormalities… Just speculating as I really don’t know
I am a doula and recently at a hospital birth, the baby was coming quickly, the nurse wanted mom in bed on her back, mom crawled in on hands and knees… nurse tried hard to get mom to turn over, mom refused. I encouraged nurse that the baby would come out – baby was born before Dr arrived. Baby was 10 1/2 lbs, nuchal cord x4 + a true knot! I thought it was great, but the nurse was freaking out, (she didn’t check for a cord when only head was out, didn’t know at all till baby was completely out). She cut and clamped the cord immediately after birth so the baby could go to the warming bed for ‘resuscitation’. IMHO, I think the fact that the mom birthed on hands and knees, let the baby come as easily as he did, and with the Dr. not being there, IF mom had been on her back with the nurse trying to pull on the head to complete the delivery (standard around here), the 10.5 lb baby with the nuchal cord x4 there might have been birth complications… I’m glad I helped mom follow her instincts and go to hands and knees on the hospital bed.
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Hello.
I’m hoping that you could shed some light on whether or not a c-section was necessary for the birth of my daughter. Here are the facts:
-had a very healthy pregnancy
-the baby was still up high, never engaged but was head down
-was 2 weeks overdue, but was being monitored three times a week and everything looked fine
-After being 42 weeks pregnant, I was bullied into induction, although I was not confident at all about it
-I was given cytotec (did NOT want that) at the hospital. Four hours later, was given pitocin, and was on it with no epidural for 2 1/2 days. I only dilated to 3cm but baby never engaged, still head down, and every time I had a contraction, baby’s heartbeat went down drastically, but it did go back up ok.
Doctor on call broke my water without telling me and saw miconium, baby was in distress. I had to make a decision: c-section or keep waiting and hoping something would happen. I wanted to keep going, but I was scared into thinking she could die or have permanent brain damage. (My husband was very scared, and my close friend, who was there for support, also worked there as a nurse in the birth unit and knew something wasn’t right.)
I decided to proceed with the c-section. I was so scared, hated the medicine.
When they opened me up and tried to get her out, she was trapped up high under my ribs, and when they got her, she had the cord wrapped around both arms in a figure-8 harness and once around her neck. They had to give her a little help with breathing, but she ended up being ok. While I was still on the table, everyone said I made the right decision because there was no way she was coming out vaginally wrapped up like that and that’s why she wasn’t descending.
———————————-
K, so I just need to know if this was just a “fluke” like my friend called it. Will it happen again? Could I have done something differently, like fetal positioning? It has been two years, and I’d really like to try and have another baby. Please help.
Ashleigh – Your baby was entangled in her cord and it was more than just a simple nuchal cord. From what you have written it sounds like an extremely rare case of true cord entanglement. There is nothing you could have done to prevent it and your c-section was most likely necessary. It was a ‘fluke’ and is extremely unlikely to happen again.
Thank you for this post! I love your blog and have been gradually digging backwards through it to occupy myself during the insomnia of 39wks pregnancy.
Over the last week I am pretty sure my (cephalic) baby has spun at least 360degrees and this, combined with my mother-in-law’s tales of my husband being born with cord “wrapped around his neck” and a story on my birth board about a 3x wrap, had started to concern me.
I have a great rapport with my lovely, non interventionist, homebirth mw who spent some time on the Albany team and now feel really confident to discuss the issue fully with her next time I see her, incorporate our conclusions in my birth plan, and prep my birth partners for the possibility. Thanks again for giving me that confidence.
I am so pleased you are approaching birth with information rather than fear. I would love to know if your baby does have the cord around his/her neck – pop back and let us know (if you get time). My own daughter was born at home with the cord wrapped around her neck… she is very proud of this
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My youngest son was born 2 weeks early after a worrying third trimester with reduced fetal movement. We’d had monitoring four times and experienced one decel, but he managed to pass the other times so they put it down to temporary cord compression. After each monitoring I was unhappy, my baby didn’t behave the same way my others had (he was my 14th), And though he ‘passed’, I wasn’t confident he was alright.
Going into labor two weeks early was unheard of for me, my pregnancies had got progessively longer with my 13th going 10 days passed due. I labored all day and baby was more active than usual. We headed to the hospital when I felt birth was imminent. In hospital I remained active, walking and rocking and I spent a lot of time in the shower. As second stage began I climbed onto the bed, kneeling over the back to deliver the way I had with my last 8 babies. After some hard pushes the membranes ruptured and meconium was seen, my mw turned to push the emergency button and then turned back to see my son land on the bed. I was urgently told to lift my leg and turned to see her unwrapping little Eli from his cord. It had been wrapped around his neck not once or twice but four times! We then discovered a true knot in it.
He was fine, his apgars were 9 and 9 and he weighed in at 6lb 6oz. My smallest baby. My biggest had been 9lb 12oz so he seemed so tiny.
His story is proof that cutting a nuchal cord isn’t necessary, I guess his fast birth made it impossible anyway, but his story also is warning that drs and mws should always listen to a mothers concerns, especially one who has experienced pregnancy before. It is believed that Eli may have been swimming in mec for weeks before his birth, it took weeks to get it out of his skin, and I believe that his growth had also been restricted.
Interestingly my first son, a father now himself, also had the cord around his neck four times but he was born by emergency caesarian for fetal distress. We have since looked at my notes and it seems I was induced for pre eclampsia that didn’t exist and then caesered for fetal distress that didn’t exist! Fortunately I went on to have vbacs, 13 of them
You are so right – mother’s are the experts on their own body/baby. You knew you son was not ‘alright’.
I wonder if you have the record for the most VBACs by one woman!
Thank you so much for this, I’m sharing it on Facebook.
I am curious about a true knot in a baby’s cord. Does it post a risk and how often are true knots present without risk to baby’s well-being.
Hi Lisa
A true knot does increase the risk of the baby running into problems associated with reduced/interrupted blood flow http://www.springerlink.com/content/d4h5527365437160/
However, most babies with knots are fine and the knot is not noticed until after the birth. Michele (see comment above) gave birth to a baby with a nuchal cord and true knot.
Now there is the questions of the truly short cord – and is there such a thing?. The only problem I have is that I palpated a first time mother recently whose baby was at 40 weeks it was breech – but I made no mention as her. I was acting as a counsellor friend and educator. I am her Lactation Consultant not her midwife and was leaving for 2 months that week. I alerted her obs via her midwife who was going to arrange to perform an external version. This meant going to one of our unpopular hospitals a long way from home with a probable operative outcome. The mother chose a Caesarean birth at the hospital she was comfortable with. Home birth was not on her agenda until now. Following the birth it was stated there was a short cord. An ultrasound was performed priorand confirming the breech. There was a special mention made that the experienced technician could not sight the cord. Was this a case of a short cord not allowing a head down presentation? I do not know the answer except that the breech could have been born vaginally..
Breech babies are often breech for a reason – and a very short cord could have been the reason. They can come out vaginally with a short cord in the breech position… if they get the opportunity.
I had never heard of a really short cord causing a problem until I talked to my midwife about her 4th birth- her baby was born in an extremely fast labor with a cord so short that she pulled the placenta off on her way out, resulting in some major bleeding. Baby was born unassisted within about 15 minutes- almost like she knew that she needed to do it quickly!
Almost anything is possible with birth, it seems, but there is just a lot more fear than is really warranted.
Two comments: I don’t know of any literature that suggests sort cords cause breech presentations. If you think about it logically the distance from umbilicus to breech is considerably less than the distance from umbilicus to vertex, ergo a short cord would actually encourage a cephalic presentation – unless the cord insertion is below the fetal umbilicus at presentation. That would be a scarily low lying placenta. Most breeches are probably random presentations, some are related to the shape of the uterus (breeches are more common in bicornuatae uteri for example).
Second: I’m personally uncomfortable with the patient autonomy issues raised by the the educator failing to inform the client but instead going to her midwife to inform her Ob. I wouldn’t recommend that as standard practice as it raises some ethical issues in addition to removing the decision making from the mother.
Nice blog – The amount of misinformation about umbilical cord issues in the Obstetrical community is rather stunning – even for a community where misinformation, or more accurately misapplication of information is rampant.
You are right (you have had me testing things out with my doll and placenta). Short cord would not encourage a breech position. Maybe I’m getting mixed up with anecdotal short nuchal cords
David Hayes A long reply which I hope spells out there is more to a midwife’s assessment skills of breech presentation than just the examination or knowing about the cord length. Emotional and physical health and happy baby outcomes involve much much more.
I appreciate your comments and you have replied with the answers that suit the reason I put my question. That is I am always prepared to learn something new. Unless there is an ultrasound the cord position is not always assessable and even then the technician could not see one at all.
As for the ethical issues – this woman was my friend’s daughter and I am not eligible currently to be her midwife although I am eligible due to International qualifications to be her Lactation Consultant. The daughter relied on me a lot for advice and support as did the mother (stressed and stress producing for reasons other than the birth – the history being known to me and shared with her known midwife by the woman.). The daughter had called in with a state of high anxiety produced by lack of sleep due to husband’s (reasons are not uncommon but long hours and first time pregnancy for both). I decided her need for sleep was a high priority There were some resolvable problems with communication etc – So far my advice has been reliable for her thus far as evidenced by her calls for many other different minor problems about breastfeeding and company. Our friendship has developed over years..
I assessed the situation as (1) I was sure this was a breech with narrow presenting part way in to pelvis with head under the ribs confirmed by comparative grip.and strong fetal heart high on the left side, at 40 weeks in a primigravida — The presenting head in the pelvis can usually be felt easily partly in the brim in a first pregnancy. The woman was tender to touch due to a previous over zealous palpation the week before.. It was not my place to confirm this breech. The breech had not been picked up by the hospital. This is called co-operation between health carers. The examination was the first time she had wanted the examination. I would say her instinct were at high volume – some women just know.
She is not my client. (2) I also knew that she was seeing the doctor and midwife in two days time. I alerted them to her state of anxiety. I knew that this news would be handled with the skill required. Knowing your midwife and your hospital is easy in rural communities. We also know those that are out of date and one we label the “butcher shop”.
Of course I was facing a dilemma but I made a judgment call because I knew that on top of her current anxiety she needed sleep more than she needed another problem. She rang to tell me shad had a good night’s sleep. I also made certain of apology to her the day when the breech was confirmed. I am an experienced examiner. My clinical practice covers over 30 years in the filed as well as teaching and re-teaching the art of palpation to hundreds at higher degree level combined with another 18 years of practice.. I observe more with my eyes and ears and combine this with knowledge. I do not put my hands on unless asked or necessary. I chose to graduate as a Masters in Bioethics 14 years ago because of the all too common ethical dilemmas up to date midwives and students face in the highly operative and chemical interventionist hospital arenas.
The fact that the doctor with whom she was well connected at the hospital was prepared to arrange with an experienced colleague at a hospital 1 and half hours away to perform an external cephalic version was good news. The woman therefore had choices. I was leaving the next day for overseas. The woman I consider to be strong and capable of making her own decisions with the ability to read and discover all sides to the choice.
The short cord was not the problem but was discovered after the event. The placenta is normally situated high in the uterus in primigravida and a short cord has been, although rare, responsible for early detachment of the placenta during birth with a resulting severe intrapartum maternal haemorrhage. In retrospect one could be relieved that this did not occur. A short cord usually results in the baby choosing a position facing the placenta. An experienced midwife would be alert to the possibility in a multiparous woman of the placenta being low lying This may result in the baby lying in the transverse and t may bring prolapsed cord. A low lying placenta may also be “praevia’ or coming first which has problems of maternal haemorrhage at the onset of labour. An experienced midwife would suspect these in a post Caesarian woman and would ensure a precautionary ultrasound was done.
This woman also had disproportion of size – very tall and very small feet. which may lead to reduced pelvimetry and disproportion which sometimes results in difficulty for the baby to enter the pelvis head down. This woman also researched breech looked at the options and chose to stay close to home with friends and relatives rather than go a long distance for the ECV. This outcome may have produced a surgical birth isolated from family and friends – not everyone has public transport or finds it economical to travel long petrol eating distances to visit hospitals. I am a believer in the woman leading her care and that is I believe the happy outcome in this instance. Had I not alerted the hospital I believe this breech may have been missed.
LOVE LOVE LOVE that you wrote an article about this. I’ve been singing this song for years (8) to anyone who cared to listen – was thinking of writing an article myself but it looks like you’ve pretty much covered almost every point.
One thing I find myself doing most often when the cord is tight-ish in an obstructive way (seldom) is slip my 10 fingers through the loops, sort of holding the single/double/triple cord necklace at the perineal level and let the baby squeeze through as s/he comes out. Cord always stretches, and still pulsates after birth, no probs.
In hundreds of births, I’ve never cut and clamped on the perineum, and would feel SUPER nervous doing so. I saw it done by provider once early in my training, and the baby didn’t make it.
In my book:
Nuchal cords = no big deal … cutting the cord before baby born & stable = watch out.
Thanks for writing this article, I’m spreading it around to, well everyone I know : )
Of my 8 births (all at home) I have had 2 babies with cord issues,
First- baby #4 had 2 complete figure eights, the cord went from umbilicus up around the neck-down around his waist twice. As his head was born my midwife told me “there is a cord stop pushing” I instantly knew not to stop pushing, I pushed his shoulders, then his hips and he finally released, the cord was never an issue as it was the longest cord we had ever heard of, we measured it and it was 44 inches. Placenta delivered and then cord was cut.
Second- baby #6 during labor baby was presenting with the side of his head above his ear. My midwife was able to reposition his head, I began pushing and started feeling an extreme pain in my abdomen just below my navel that was not normal. As his head was born my midwife discovered a nuchal cord (it was around his neck once and went up over his ear on one side) that was extremely tight, his head then pulled back and started turning purple, he had severe shoulder dystocia, my midwife cut the cord and was able to maneuver him out. Baby had an apgar of 3 but was resuscitated successfully. When the placenta came we first noticed the extremely short cord (we also measured this cord total length was 12.25 inches) and 1/3 of the placenta was clotted, we feel that as he descended the cord put traction on the placenta and it was peeling off, for some reason he had a very strong cord. We discovered some interesting things during the newborn exam, 1- the cord being above my baby’s ear had caused it to form incorrectly, 2- he had “noose marks” from the tension the cord placed on him around approx 2/3 of his neck, 3- his head had been tipped to his left side for so long he had developed Torticollis (from the cord being up over one ear).
I truly believe that most nuchal cords are a variation of normal, just as breech born babies are (I can speak from experience as baby #5 was born frank breech at home).
Thank you for advocating for all babies with nuchal cords!
To clarify my above post, these births were attended by different midwives. The midwife with #4 was trained that nuchal cords are always a problem and I could see the concern on her face as I continued pushing but I “knew” that all was fine and to keep pushing With baby #6 cutting the cord on the perineum was the first time in over 6 years since she had felt a need to do so, she had learned through her 15+ years as a midwife that cords are not usually a problem. Baby #6 has had no other problems other than the Torticollis and is now almost 5.
I learnt, somewhere, and it seems to make sense, that if a baby is conceived, at the optimum time, i.e mid cycle, it imbeds at the fundus (where the blood supply is best). Hanging off it’s cord, like a light bulb off a flex from the ceiling, it is IMPOSSIBLE to get entangled in the cord. Conversely if the placenta is on the side wall of the uterus all manner of shenanigans can take place. Good pre conceptual care, and natural family planning would help this objective……..
Great article – I’ve done two lotus births and left the cord till it fell off of its own accord. Great results. I happen to give birth to babies with extremely short cords. Not sure why. Midwife says it would have been impossible for the cord to wrap round the neck. It does make giving birth in water (my preferred way to reduce pain) a little funny as I have to stand up immediately and exit the water as I have no distance on the cord to lift baby up to me. My placenta has taken approx 30 – 45 mins to birth after the baby.
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i have attended 6 births on my own now and had both my babies at home. because mine were both posterior and rotated in labor, my son’s cord was around his neck twice and my daughter’s once… i simply unwrapped them after they came out. both were born without any problems and breathed immediately. of the births i have attended, only one was born without some sort of cord wrap. 2 were very tangled (around the body, under the shoulder, etc) and both were just fine and breathed very quickly after they were unwrapped (though it did take all three of us
). the rest had simple neck wraps again with no problems. thank you so much for offering a place to share this information!!!
I have found this blog very interesting. I gave birth to my son in June last year. I was in the birthing pool for the first part where they monitored his heart rate every 15 minutes when I wasn’t contracting. I opted for an epidural in the end and was taken to the labour ward where they strapped a heart monitor to me to listen to the baby’s heart continuously. Very quickly they could see that at every contraction, his heart rate was dropping to almost nothing. I presume this had been happening for quite some time but that the periodic monitoring in the pool had failed to pick up on it. The mw pressed the alarm and the doctors rushed in. I was told the baby needed delivering straight away, which they did using forceps. It was all rather traumatic and he came out with the cord wrapped around his neck and body which I always thought was the reason his heart rate was dropping so dramatically. I am wondering if this is correct now, although I see Melanie had the same experience.
When cord is around the neck it is protected from compression therefore it is more likely that the cord was being compressed between baby and uterus or pelvis (especially if the waters were no longer protecting it). However if you baby’s head was moving into your vagina it is normal for the heart rate to dip with contractions due to head compression. This is normal and not a complication – although some practitioners panic.
I agree that nuchal cord is a very common occurrence, up to 70% of births. It is not always a cause of fetal distress, however significant cord compression resulting in fetal hypoxia is the most common cause of fetal distress and can be due to many causes including nuchal cord. I don’t agree with your labeling – scapegoat. If intervention is needed for fetal distress it should be done. Waiting longer or delayed cord clamping isnt always the answer and can result in a fetal demise.
This post was based on an extensive literature review of all the available research evidence on nuchal cords. A nuchal cord is very rarely the cause of cord compression especially in first stage. In fact the cord is more protected from compression physiologically when around then neck than when draped over a shoulder or back. However the nuchal cord gets the blame = scapegoat even when it was most likely pitocin to blame. If there is fetal distress present in labour intervention is indicated. Not sure where I have said otherwise. C-sections can save lives. However some interventions such as cutting cords actually cause complications. If a practitioner chooses to do this they are open to legal action because it is acknowledged that it is bad practice (5 US cases so far). I would urge you to reconsider cutting cords and to read my post on the importance of placental circulation during resus. Cutting cords can result in fetal demise.
My own son was born almost two years ago now. While I was induced for pre-e, I was luckily able to ahve a vaginal birth. What I do remember is that after they gave me pitocin the baby went into distress. They were ready to cut me open, had shaved me and everything, but I remember telling myself that I didn’t want a c/s and I just needed to open up and get the baby out. From the time they checked and prepped me to the time they were going to put me under (about 15 minutes and after they had given me the meds to stop the contractions) I went from a 6 and 75% effaced to 10cm and fully effaced with the baby engaged. I pushed without contractions and a vacuum assist. When our son was born the cord was wrapped around his neck twice and he was very blue. They cut the cord as soon as he was clear and it took a few minutes before we heard him cry. I have always believed it was the pitocin that caused his distress and cutting the cord so quickly that kept him from recovering as quickly as he could have. It’s beyond reassuring to read your post and the numbers and know that the feeling I had that I could have had a natural birth in spite of the wrapped cord was not just wishful thinking.
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Thanks for the last entry from Robyn Heud. Strong woman strong baby. This site is just wonderful. I can count the number of times I cut a cord on my hand once for three times around the neck. The second stage was slow in coming but the fetal heart beat did not waver except to be what I call a hard and slowing beat. I prefer to listen rather than read graphs which I was forced to do many times when teaching. Love the diagrams and the whole damn thing. What a great asset Facebook has become for educators like me. We just love to teach and share.
I need to elaborate on my previous comment. The fetal heart beat slows in second stage as part of the process sometimes novices panic about that, experienced people would not.
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Great article!
Just met with a couple where the dad’s greatest concern was how we would deal with a nuchal cord. He had been told his entire life how he was very distressed at birth due to the cord being wrapped around his neck. He would have died if the doctor had not gone up inside and unwrapped the cord from around his neck which was preventing his birth. When I told him this was just impossible he was surprised but insisted the doctor had done something to save his life. These type of stories perpetuate the dangers of birth and the need for management.
Great article Rachel.
As a Doula I always wondered how I would deal with a nuchal cord in a BBA situation, but now I feel confident I would know what to do – or should I say what NOT to do! I was also surprised to read about the frequency of nuchal cords.
Luckily the midwives in our area adopt a very hands off approach, and will only loop a cord if it’s absolutely necessary. We also encourage our clients to think about delayed cord clamping.
Keep up the good work.
Caroline
Great article! I look forward to reading more!
I was born with the cord looped around my neck three times. I was also born sunny side up, although my Mom had tried many, many times to flip me (hands & knees, butt in the air rocking). The midwife stated that I was so snug in the cord that she couldn’t have flipped me. My midwife did cut the cord because it was around my neck so many times/so tightly. I (thankfully) suffered no ill-effects!
I delivered my daughter by midwives in October of 2009. She had the cord looped one time, and we managed to do delayed cord clamping. I don’t know for sure if they looped or not, but I will definitely show this to my midwives for the next one (due March 2012)!
This post was extremely helpful! I will admit I teach natural childbirth classes and didn’t realize I had the wrong information for my clients. I will be sharing this information with future clients. This topic comes up in a great deal of classes as well, and I know they will learn a lot from this blog.
Just thought I’d share this link with you. It has pictures of a baby who had a nuchal cord x4 at her midwife assisted homebirth! Absolutely amazing pics! http://birthwithoutfearblog.com/2011/10/10/cord-around-the-neck-isnt-an-emergency-birth-pi/comment-page-1/#comment-4368
Thank you! I’ve added a link to this at the bottom of the post.
I am 37 weeks and 5 days pregnant, and my baby who was head down at 35 weeks is now breech. I went in for an external version, but after ultrasound doctor said I am not a candidate due to nuchal cord. This is my 2nd pregnancy and had previous vaginal delivery. Doctor said my only option is a c section. Wondering if there are any resources/optons for me.
C-section is not your only option although it might be the only option your doctor supports and is prepared to be involved with (if you are private). Attempting a vaginal breech birth without the support of your care provider will be difficult and if you do this it might help to get yourself a doula or advocate to deal with hospital staff while you labour (I am assuming you are hospital birthing due to seeing a doctor). I think a previous comment relates to breech with a nuchal cord. Some resources for breech birth:
http://www.breechbirth.org.uk/index.html (UK) and http://www.breechbirth.org.uk/index.html are a good start with links and information. Good luck and let us know what happens.
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This is by far the most understandable and comprehensive article that I have come across on the normalcy of nuchal cords. Thank you for this!
Makes so much sense. I wear a woollen scarf and wrap it round my neck several times but I never worry about strangulation because it is stretchy. Well done mother nature.
Ad me to the list of “somersault births” My babe had a very tight nucal cord x3 times around. We have the most amzing pictures of him under the water, being born this way. My midwife said she had heard of it happening, but this was the first time she had seen it. He took about 30 secs to take his first breath… and cord was cut about 2.5 hours later.
Fantastic article, glad I stayed home and allowed nature to take it’s course.