Nuchal cord; how to optimise neonatal outcomes!

Nuchal cord - the umbilical cord round the baby's neck at birth is a common scenario which occurs in approximately 20-30% of births (Hutchon, 2013).

So, it's unsurprising that this is a subject I am regularly asked about; particularly in relation to optimal and delayed cord clamping.

Indeed it seems that management of a nuchal cord varies from practitioner to practitioner. Student midwives often describe their concern when births with a nuchal cord are mismanaged without evidence.

I am therefore going to give you a very brief run down of the evidence and look at the physiology of what's occurring at birth including placental, umbilical cord and neonatal physiology.

This topic is something I regularly discuss at midwifery conferences and one that will be covered in a module in the upcoming BloodtoBaby course 'Bedside stabilisation with and intact placental circulation'.

Quick fire physiology

Compression of the umbilical cord through nuchal cord and various other birth scenarios can cause reduction of blood (oxygen/nutrients) to baby.

This is due to the structural physiology of the soft walled umbilical vein which can be easily compressed due to the low venous pressure. The harder, muscular umbilical arteries are not affected in the same way as the baby’s heart is pumping 40% of its combined output through the umbilical arteries at high pressure (Mercer, Skovgaard, Peareara-Eaves & Bowman, 2005). The umbilical arteries continue to move carbon dioxide and waste products from the fetus. In simple terms, when the umbilical vein is regularly occluded, there is a net transfer of blood from the fetus to the placenta.

Dependant on the severity of cord compression babies tolerance to labour may be reduced. In acute cases chemical adaptations of the fetal blood may cause degrees of acidaemia which could in chronic cases lead to acidosis and a hypoxic baby. During this time before birth the baby makes adaptations, fetal movements are reduced as non essential components are sacrificed - the reduced blood volume is used to protect the babies central circulation - the heart and brain.

During the second stage of labour the vaginal wall pressure also acts to ensure the central circulation is perfused, just as antishock garments help in the management of maternal haemorrhage in low income countries (Mercer & Erickson-Owens, 2014). However, once baby is born, the peripheral circulation opens up and because baby only has a limited supply of blood due to the cord compression, it’s usually born flat with lack of tone and respiratory effort.

The baby is hypovolemic - there is not enough blood to perfuse the lungs and brain.

Image credit unknown. Contact for authorship

Protective management

It is vital that these babies are allowed placental transfusion; this supports an increase in blood volume (oxygenated) which can then provide and supply the brain and lungs. The baby won’t breathe and cry until the respiratory centre in the brain is activated; perfused with oxygenated blood.

In an ideal world, all compromised babies would be resuscitated on an intact cord. So, whilst initiating the Newborn Life Support resuscitation algorithm - starting with stimulation, thermoregulation and if needed inflation breaths to aerate the fetal lungs, the placental circulation can ensure the redistribution of blood to the baby.

It's worth noting that the opened vascular system of the lungs in connection with aeration, requires a considerable amount of blood (Niermeyer & Velaphi, 2013).

Nucal cord relief

Hutchon (2015) states that a nuchal cord rarely impedes the descent and delivery of the body, usually bringing the loose loop of over the baby’s head is the simplest solution.

However when the cord is short and tight, or there are several loops around the neck, further descent of the body may be limited and another approach is necessary. The Somersault manoeuvre as detailed by Mercer (2005) and Reed (2015) involves placing the palm of the hand over the occiput and gently pushing the baby’s head towards the mother’s thigh.

The Somersault Manoeuver (Coggins & Mercer, 2009)

The baby’s neck remains close to the mother's perineum and flexion of the head encourages flexion of the rest of the baby, resulting in flexion of the baby’s body and delivery of the body by maternal effort.

Once delivered the cord can be unwrapped and left intact to allow the trapped blood and the placental transfusion to return to the baby.

Future thoughts

These are real challenges when practitioners are conditioned and required to perform immediate cord clamping in order to get the baby to the resuscitaire. In fact immediate cord clamping causes adverse effects on the circulatory and respiratory stability of the neonate.

Yigit, Tutsak, Yıldırım, Hutchon & Pekkan (2019) found that cardiovascular effects including hypovolemia accompanied with a reduction in cardiac output, cerebral and organ blood flow, and hypoxia due to clamping prior to the establishment of ventilation are major factors of morbidity and mortality in neonates of all gestations.

The sooner we can transition practice towards bedside stabilisation with an intact placental circulation the better. Dedicated members of the BloodtoBaby team will soon be bringing you a new course designed to improve knowledge of this subject which will hopefully help future practice change.

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References

Bendon, R. (2019). Umbilical cord accident: Part 2. Retrieved 17 July 2019, from https://obstetricalpathology.com/umbilical-cord-accident-part-2/

Coggins, M., & Mercer, J. (2009). Delayed Cord Clamping: Advantages for Infants. Nursing For Women's Health, 13(2), 132-139. doi: 10.1111/j.1751-486x.2009.01404.x

Hutchon, D. (2013). Management of the Nuchal Cord at Birth. Journal Of Midwifery And Reproductive Health, 1(1): 4- 6.. Retrieved from http://jmrh.mums.ac.ir/article_1249_2a5fb052678741c0cbded4ceb07abf1f.pdf

Mercer, J., & Erickson-Owens, D. (2007). MANAGEMENT OF NUCHAL CORD. Journal Of Midwifery & Women's Health, 52(5), 524-525. doi: 10.1016/j.jmwh.2007.06.015

Mercer, J., & Erickson-Owens, D. (2014). Is It Time to Rethink Cord Management When Resuscitation Is Needed?. Journal Of Midwifery & Women's Health, 59(6), 635-644. doi: 10.1111/jmwh.12206

Mercer, J., Skovgaard, R., Peareara-Eaves, J., & Bowman, T. (2005). Nuchal Cord Management and Nurse-Midwifery Practice. Journal Of Midwifery & Women's Health, 50(5), 373-379. doi: 10.1016/j.jmwh.2005.04.023

Niermeyer, S., & Velaphi, S. (2013). Promoting physiologic transition at birth: Re-examining resuscitation and the timing of cord clamping. Seminars In Fetal And Neonatal Medicine, 18(6), 385-392. doi: 10.1016/j.siny.2013.08.008

Pleș, L., Beliș, V., Rîcu, A., & Sima, R. (2016). Medico-legal issues of the nuchal cord at birth. Romanian Journal Of Legal Medicine, 24(4), 289-293. doi: 10.4323/rjlm.2016.289

Reed, R. (2015). Nuchal Cords: the perfect scapegoat. Retrieved 17 July 2019, from https://midwifethinking.com/2015/05/13/nuchal-cords/

Yigit, B., Tutsak, E., Yıldırım, C., Hutchon, D., & Pekkan, K. (2019). Transitional fetal hemodynamics and gas exchange in premature postpartum adaptation: immediate vs. delayed cord clamping. Maternal Health, Neonatology And Perinatology, 5(1). doi: 10.1186/s40748-019-0100-1