Nuchal Cord & Birth Asphyxia
A nuchal cord is a complication that occurs when the umbilical cord wraps around the baby’s neck. This is common and occurs in about 20-30% of pregnancies. In some cases, nuchal cords do not impact pregnancy outcomes, but in others, they pose a significant risk of lowered blood flow, hypoxia (low oxygen levels), and delivery complications. Nuchal cords can interrupt normal blood, nutrient, and oxygen exchange, resulting in serious injuries to the baby. Nuchal cords are often detected via ultrasound with a precision of up to 83-97% with color Doppler. Doctors manage nuchal cords by preventing umbilical cord compression during labor/delivery or in the weeks leading up to delivery. Because nuchal cords can cause hypoxia, they may be managed with immediate delivery, and in some cases by emergency C-section. If C-section is not performed quickly enough, this can make the effects of hypoxia and ischemia significantly worse. It is paramount that the medical team handling a pregnancy be skilled in handling complications like nuchal cords. It is medical negligence if doctors do not monitor and treat the mother and baby properly, or do not follow standard practices. If the baby is injured, this is medical malpractice.
What Is a Nuchal Cord?
A nuchal cord is a dangerous pregnancy, labor, and delivery complication in which the umbilical cord wraps around the fetus’ neck. Nuchal cords disrupt the normal flow of blood, gases, and nutrients from the mother to the fetus and can cause severe injuries, such as birth asphyxia (hypoxic-ischemic encephalopathy or HIE) and cerebral palsy.
What is a Double Nuchal Cord?
A double nuchal cord is a birth complication that occurs when the baby’s umbilical cord wraps around his or her neck two times. These occur less frequently than single nuchal cords but have similar outcomes. Sometimes, a double nuchal cord does not cause any complications during the pregnancy, while other times it can put the child at risk for hypoxia, decreased blood flow, and other delivery complications that may result in serious birth injuries.
Can the Umbilical Cord Strangle the Baby?
The umbilical cord can ‘strangle’ a baby by cutting off oxygen flow. If the cord is compressed, knotted, or prolapsed, the baby’s oxygen supply is reduced, which means asphyxiation may occur. If the umbilical cord is around the baby’s neck, there is the additional risk that the cord will tighten around the neck during labor and delivery, reducing blood flow to the baby’s brain.
Nuchal Cord and Birth Asphyxia
In most cases, the umbilical cord is about 20 inches long and almost one inch in diameter. It usually appears loosely coiled. Inside the cord are two arteries and one vein—the vein supplies the baby with oxygenated, nutrient-rich blood, and the arteries carry de-oxygenated, nutrient-depleted blood back to the placenta. On occasion, the umbilical cord will only have two vessels—one artery and one vein.
Nuchal cords are classified into two main types:
- Type A Nuchal Cord: When the umbilical cord wraps around a baby’s neck 360 degrees.
- Type B Nuchal Cord: When the cord cannot be undone and ends up as a true knot.
Nuchal cords are very common, with prevalence rates of 15 to 34 percent at term. A nuchal cord may form at any time. Nuchal cords may form, disentangle, and reform or they may persist. In some cases, a nuchal cord may not affect pregnancy outcome significantly. In others, the nuchal cord may lead to restricted fetal blood flow (ischemia), decreased oxygen (hypoxia), decreased fetal development, diminished fetal movement, and complicated delivery. All of these complications significantly increase a baby’s risk for birth asphyxia. Mechanisms that cause ischemia and hypoxia/ asphyxia include:
- Restriction of the carotid artery (neck artery) blood flow from tight nuchal cord entanglement around the neck
- Severe congestion of venous blood flow
- Compression of the umbilical cord vessels themselves when the nuchal cord becomes tightly compressed against itself or the baby’s neck
Complications and Birth Injuries Caused by a Nuchal Cord
While some babies are born without injury despite developing with a nuchal cord, a nuchal cord can cause severe harm to the baby. Nuchal cords are particularly dangerous if the following conditions are present:
- The nuchal cord is tight around the neck
- The nuchal cord is wrapped around the neck more than once
- Low amniotic fluid permits umbilical cord compression
Potential complications and birth injuries resulting from a nuchal cord include the following:
- Hypoxic-ischemic encephalopathy (HIE)/birth asphyxia: HIE (also known as birth asphyxia) is a neonatal brain injury caused by oxygen deprivation and limited blood flow to the baby’s brain at or near the time of birth. Cell death and subsequent brain damage occur when the brain does not receive adequate oxygenation. HIE is the most common type of neonatal encephalopathy (NE). HIE can cause disabilities and injuries including cerebral palsy, seizures, developmental disabilities, and learning disabilities. Nuchal cords can cause HIE.
- Fetal death
- Intrauterine growth restriction (IUGR): IUGR is a condition in which compromised and abnormal intrauterine growth results in a smaller than average fetus. Babies with IUGR are at high risk for intrapartum hypoxic-ischemic encephalopathy (HIE) and are delivered before 40 weeks of gestation. IUGR is commonly caused by nuchal cords.
- Meconium aspiration syndrome: A serious medical condition in which the fetus breathes a mixture of meconium (the baby’s stool) and amniotic fluid into the lungs around the time of delivery.
- Increased rate of intrapartum fetal heart rate abnormalities leading to an increased rate of operative delivery and umbilical artery acidemia.
- Neurodevelopmental abnormalities
Causes and Risk Factors for a Nuchal Cord
The formation of a nuchal cord may be:
- A random event
- Related to excessive fetal movement
- Caused by a long umbilical cord
As the baby’s gestational age increases, so does the likelihood of a nuchal cord. One study found the presence of a nuchal cord in 5.8 percent of deliveries at 20 weeks gestation, and 29 percent of deliveries at 42 weeks gestation.
Monoamniotic twins (twins that share the same amniotic sac) always have cord entanglement, to some degree. One twin’s own cord can become wrapped around his or her neck or that of the other twin.
Risk Factors for Nuchal Cord Include:
- Long umbilical cord length
- A baby that is large for gestational age (LGA)
- Multiple gestation pregnancies (twins, triplets, etc.)
- Nutritional deficiencies affecting the umbilical cord
- Too much amniotic fluid surrounding the baby (polyhydramnios)
- Abnormal fetal presentation during delivery (breech, shoulder presentation, etc.)
Nuchal cords are often identified during an obstetrical ultrasound. To identify a nuchal cord, physicians look at multiple views of the fetal neck. A nuchal cord is diagnosed when the umbilical cord is seen encircling at least three-quarters of the fetal neck. If the cord encircles at least half of the neck, it may be classified as suspicious for the presence of a nuchal cord. The sensitivity of ultrasound for detecting nuchal cords at term has been reported to be about 70% for gray-scale imaging, and 83% – 97% with color Doppler.
Signs and Symptoms of a Nuchal Cord
One of the possible warning signs of a nuchal cord is the baby beginning to move less after 37 weeks of gestation. If a nuchal cord occurs during labor, the fetal monitor may detect abnormal heart rate.
Treatment of a Nuchal Cord
The main goal in managing a nuchal cord is to prevent umbilical cord compression during delivery. Preserving an intact nuchal cord will depend on how tightly it is wrapped around the baby’s neck. A loose nuchal cord can usually be easily slipped over the baby’s head to decrease traction during delivery of the shoulders or body. If this is not possible due to tightness, there is a technique wherein the physician may be able to slip the cord over the infant’s shoulders. If this is also not possible, the physician may use the somersault technique, which allows the shoulders and body to be born in a somersault, with the cord being unwrapped after the baby is delivered.
Sometimes, if there is more than one nuchal loop or the loop is too tight and cannot be removed easily, the cord must be clamped and cut before the delivery of the shoulders to ensure adequate oxygen supply to the baby.
If a vaginal delivery is prolonged and threatens the health, safety or life of the baby, an emergency C-section must be performed. A delay in performing a C-section can severely exacerbate the detrimental effects of hypoxia and ischemia and can lead to serious brain injury.
The physician and medical team must be very knowledgeable and skilled at handling issues that arise during labor and delivery that can deprive the baby of blood and oxygen. The team must be able to act quickly. Failure to properly monitor and treat the mother and baby during pregnancy, labor, and delivery is medical negligence. Failure to follow standards of care and guidelines, and to act skillfully and quickly, also constitutes negligence. If this negligence leads to injury of the baby, it is medical malpractice.
Birth Injury and Nuchal Cord Attorneys Helping Victims of Medical Malpractice
If you are seeking the help of an attorney for your nuchal cord, birth asphyxia, or birth injury case, it is very important to choose a lawyer and firm that focus solely on birth injury cases. The attorneys at Reiter & Walsh, P.C. have over a century of joint legal experience handling cases involving dozens of different complications, injuries, and instances of medical malpractice related to obstetrics and neonatal care.
The Reiter & Walsh, P.C. team has helped victims of medical malpractice with nuchal cord injuries and birth injuries all over the country. Our attorneys and in-house medical staff determine the causes of our clients’ injuries, the prognoses of birth injured children and areas of medical negligence. We consult closely with leading medical experts, forensic specialists and life care-planning professionals to secure our clients’ future care and their parents’ peace of mind, knowing their child will be cared for, no matter what. Our specific focus on birth injury allows our attorneys to provide unparalleled legal service to our clients.
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Video: Nuchal Cords and Birth Asphyxia
Watch nuchal cord attorneys Jesse Reiter and Rebecca Walsh discuss nuchal cords, hypoxic-ischemic encephalopathy (HIE), and birth asphyxia in this video.
How Do You Pronounce Nuchal Cord?
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- Zahoor, Farnaz, Zakia Minhas, and Adil Zaki. “PERINATAL OUTCOME OF NUCHAL CORD.” Journal of Postgraduate Medical Institute (Peshawar-Pakistan) 27.2 (2013).