Nuchal Cord Complications*

A nuchal cord is a complication that occurs when the umbilical cord wraps around the foetus’ neck. These are common and can occur at any time. In some cases, they do not impact the pregnancy’s outcomes, but in others, they pose a significant risk for lowered blood flow, hypoxia (low oxygen levels), and delivery complications. They can interrupt normal blood, nutrient and oxygen exchange, resulting in the baby sustaining serious injuries. They are often detected via ultrasound with a precision of up to 83-97 percent with color Doppler.

Doctors manage nuchal cords by preventing umbilical cord compression during the labor/delivery process or in the weeks leading up to the delivery. In some cases, immediate C-sections are necessary. If they are 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 these. It is medical negligence if doctors do not monitor and treat the mother and baby properly, or do not follow standard practices. This is medical negligence if the baby is injured.

Medical Explanations

What Is a Nuchal Cord?

A nuchal cord is a dangerous pregnancy, labour and delivery complication in which the umbilical cord wraps around the foetus’ neck. Nuchal cords disrupt the normal flow of blood, gases and nutrients from the mother to the foetus and can cause severe injuries including birth asphyxia (hypoxic ischemic encephalopathy or HIE) and cerebral palsy.

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.

Depending on the nature of the knot, nuchal cords are classified into two types:

  • Type A Nuchal Cord: When the umbilical cord wraps around a baby’s neck 360 degrees, it is called a nuchal cord, or type A nuchal cord.
  • Type B Nuchal Cord: A type B nuchal cord pattern occurs 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 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
Nuchal Cord and Hypoxic Ischemic Encephalopathy (HIE)

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:

  • Umbilical cord prolapse: This is a complication in which the umbilical cord slips into the vagina ahead of the baby.
  • Vasa previa: This complication occurs when an umbilical cord blood vessel crosses the cervix under the baby and is torn.
  • 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, intellectual and developmental disabilities (I/DD) and learning disabilities. Nuchal cords can cause HIE.
  • Foetal death
  • Intrauterine growth restriction (IUGR): IUGR is a condition in which compromised and abnormal intrauterine growth results in a smaller than average fetus. IUGR babies are at high risk for intrapartum hypoxic ischemic encephalopathy (HIE) and are delivered before 40 weeks gestation. IUGR is commonly caused by nuchal cords.
  • Meconium aspiration syndrome: A serious medical condition in which the foetus breathes a mixture of meconium (the baby’s stool) and amniotic fluid into its 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 foetal movement, or 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.

Monoiamniotic 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 a nuchal cord include:

  • Long umbilical cord length
  • The baby is large for gestational age (LGA)
  • Multiple gestation pregnancies
  • Nutritional deficiencies affecting the structure and protective barrier of the umbilical cord
  • Too much amniotic fluid surrounding the baby (hydramnios)
  • Abnormal fetal presentation during delivery, such as breech or shoulder presentation

Diagnosing a Nuchal Cord

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.Fetal Ultrasound - Preventing Birth Injuries

Signs and Symptoms of a Nuchal Cord

The most common sign of a nuchal cord is decreased fetal activity after week 37.  If the knot occurs during labor, the foetal monitor will detect an abnormal heart rate.

Treatment for 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 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 negligence.

Your Legal Options

Legal Help

If you are seeking the help of an solicitor 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 solicitors at Medical Law have over a century of joint legal experience handling cases involving dozens of different complications, injuries and instances of medical negligence related to obstetrics and neonatal care.

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