Nuchal Cord: Umbilical Cord Wrapped Around Baby’s Neck

A nuchal cord is a complication that occurs when the umbilical cord wraps around the baby’s neck one or more times. This is common and occurs in about 15 to 35 percent of pregnancies. 

Often, nuchal cords do not impact pregnancy outcomes. However, certain types of nuchal cords can  pose a significant risk to the baby. 

Nuchal cords can interrupt normal blood, nutrients, and oxygen exchange. This can lead to a variety of birth injuries, including hypoxic-ischemic encephalopathy (HIE), a form of brain damage caused by oxygen deprivation around the time of birth (1).

If a nuchal cord is present, doctors should carefully monitor and manage this condition. In some cases, babies with a nuchal cord may still be delivered vaginally (there are specific maneuvers that can help to prevent complications). However, there are circumstances under which a C-section or emergency C-section is necessary (2).


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What is a nuchal cord?

A nuchal cord is a common but potentially dangerous complication in which the umbilical cord wraps around the fetus’ neck.

What is a double nuchal cord?

A double nuchal cord, or nuchal cord x 2,  occurs when the umbilical cord wraps around the baby’s neck two times. This is also relatively common, occurring in about two-seven percent of births. It is also possible for a nuchal cord to be wrapped more than twice.

Even when the cord is wrapped multiple times, the baby may still be born healthy. However, babies with multiple nuchal cords may be at a slightly higher risk of complications such as impaired fetal growth and fetal heart rate abnormalities (1).

Can the umbilical cord strangle the baby?

Although rare, the umbilical cord can ‘strangle’ a baby by cutting off oxygen flow through the neck to the brain. This may involve compression of the carotid artery. Additionally, the umbilical cord may become compressed against itself or the fetal neck, which reduces the flow of oxygenated blood through the umbilical cord. This can also be very dangerous to the baby (1).


Umbilical cord asphyxia

The umbilical cord is responsible for supplying the baby with oxygenated, nutrient-rich blood, and carrying deoxygenated, nutrient depleted blood back to the placenta. If a nuchal cord interferes with these processes by compressing the umbilical cord, or restricts arteries and veins in the fetal neck, this can lead to birth asphyxia (fetal oxygen deprivation).

Types of nuchal cord

The likelihood of birth asphyxia and other birth injuries is influenced by the type of nuchal cord.

Nuchal cords are classified into two main types:

Type A Nuchal Cord: “Unlocked”

When the end of the umbilical cord connected to the placenta crosses over the end connected to the baby. This may be called an “unlocked” nuchal cord, and is likely to spontaneously disentangle when the baby moves in-utero.

Type B Nuchal Cord: “Locked”

When the end of the umbilical cord connected to the placenta crosses under the end connected to the baby. This may be called a “locked” nuchal cord, and it is less likely to spontaneously disentangle.

When the cord is wrapped around the baby’s neck, either in a type A or type B true knot pattern, the baby can be deprived of oxygen by the following mechanisms:

  1. The cord is compressed, which means the vessels in the cord are impinged upon or occluded, thereby halting the flow of blood to the baby;
  2. The cord is so tight it restricts flow in major blood vessels in the baby’s neck;
  3. The nuchal cord causes venous blood to be congested, or backed up, which decreases circulation in the baby.

As previously mentioned, a nuchal cord may also contain single or multiple loops; multiple loops may pose a greater risk of fetal complications.

Additionally, the risk of birth asphyxia depends on how tight or loose a nuchal cord is. If the cord is wound tighter, the risk of asphyxia may be greater. It is important to note that fetal movement can sometimes cause an initially loose nuchal cord to tighten (1).

 

Nuchal Cord and Hypoxic Ischemic Encephalopathy (HIE)

A nuchal cord with resultant fetal hypoxia


Birth injuries caused by a nuchal cord

Potential complications and birth injuries resulting from a nuchal cord include the following (1):

  • Hypoxic-ischemic encephalopathy (HIE): HIE 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 (i.e. birth asphyxia). Some children with HIE develop disorders such as cerebral palsy, epilepsy, and intellectual/developmental disabilities.
  • Fetal death
  • Intrauterine growth restriction (IUGR): Babies who are abnormally small are at higher risk for brain damage during the birthing process, and must be managed very carefully.
  • Meconium in the amniotic fluid: If the baby takes their first bowel movement while still in utero, the meconium (stool) can pose a serious threat to their health. Unborn babies swallow amniotic fluid, and if this fluid contains meconium, it can cause a dangerous complication called meconium aspiration syndrome (MAS).
  • Fetal heart rate abnormalities, which can increase the risk of operative delivery (use of tools like forceps and vacuum extractors).
  • Umbilical artery acidemia
  • Neurodevelopmental abnormalities

Risk factors for a nuchal cord

A nuchal cord may be more likely to form under the following circumstances (1, 2, 3):

  • The fetus is very active/moves around a lot
  • There is a long umbilical cord
  • The umbilical cord has insufficient Wharton’s jelly
  • The umbilical cord is poorly structured
  • The pregnancy involves twins/multiples
  • There is too much amniotic fluid surrounding the baby (polyhydramnios)

As the baby’s gestational age increases, so does the likelihood of a nuchal cord.


Signs and symptoms of a nuchal cord

Usually, pregnant women do not experience any symptoms from a nuchal cord. If the nuchal cord is affecting the baby’s oxygenation, then the baby may begin to show signs of fetal distress such as an abnormal heart rate on the fetal monitor (1).

Diagnosing a nuchal cord
Fetal Ultrasound - Preventing Birth Injuries

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. At term, the sensitivity of ultrasound for detecting nuchal cords is about 70% for gray-scale imaging, and 83% – 97% with color Doppler (1).


What happens when medical professionals detect a nuchal cord?

Nuchal cords are very common. The can form at any time, disentangle and reform. During prenatal testing, a nuchal loop may be recognized with an ultrasound or it may be suspected if the baby is showing signs of distress during a nonstress test or biophysical profile

During labor and delivery, the fetal heart rate monitor will pick of oxygen deprivation in the baby, which manifests as nonreassuring heart tracings. Once these tracings occur, the baby should be promptly delivered, usually by emergency C-section

Sometimes during delivery, the physician will try to slip the cord over the baby’s head to decrease compression while attempting to deliver the shoulders or body. 

Or the physician may try to use a technique that involves slipping the cord over the baby’s shoulders or another maneuver that allows the baby to be born in a somersault. Whatever the approach, the medical team should start making preparations for an emergency C-section in case the baby cannot be quickly and safely delivered via the vaginal route. A nuchal cord is an obstetrical emergency that requires close monitoring of the baby’s heart rate and prompt delivery at the first signs of distress.

Failure to diagnose nuchal cord

Failure to recognize birth asphyxia and nonreassuring heart tracings during prenatal testing or labor and delivery is negligence. Failure to quickly deliver a baby who is experiencing birth asphyxia is also negligence. If this negligence causes permanent injury in the baby, it is medical malpractice. Birth asphyxia often causes neonatal encephalopathy and hypoxic-ischemic encephalopathy, which can cause permanent brain damage and cerebral palsy.


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 and deliver the baby through the loop. 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.

In rare cases, other interventions, such as an emergency C-section, must be performed (1, 3). A delay in performing a necessary 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

If you are seeking the help of an attorney after a nuchal cord was mismanaged, it is very important to choose a lawyer and firm that focus solely on birth injury cases. The attorneys at ABC Law Centers 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.

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. Please reach out today to learn more. You pay nothing throughout the entire legal process unless we win your case.

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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?


Related reading

Nuchal Cords and Birth Injury


Sources:

  • UpToDate, www.uptodate.com/contents/nuchal-cord.
  • “Nuchal Cord: What You Should Know.” Healthline, Healthline Media, www.healthline.com/health/pregnancy/nuchal-cord.
  • Barhum, Lana. “Nuchal Chord: Causes, Complications, and Management.” Medical News Today, MediLexicon International, www.medicalnewstoday.com/articles/319762.php.