Question: Is caesarean section at 35 weeks justified in the presence of umbilical cord around the fetal neck?
Answer: No studies were identified of the effectiveness of caesarean section in the presence of umbilical cord around the fetal neck.
Gonzalez-Quintero et al evaluated the outcomes of pregnancies with sonographically detected nuchal cords remote from delivery during the second and third trimesters of gestation. A total of 233 patients were included in this study, of which 118 had sonographically detected nuchal cords identified during the study period. There were no statistically significant differences between patients with sonographically detected nuchal cords and control patients with respect to maternal age, estimated gestational age at sonography, method of delivery, meconium-stained fluid, birth weight, intrapartum fetal heart abnormalities, 5-minute Apgar scores of less than 7, and neonatal intensive care unit admissions. Patients with nuchal cords detected by sonography were more likely to give birth before 37 weeks' gestation than control patients (21% versus 11%; P = .040).
Studies of outcomes after nuchal cord in singleton pregnancies delivering at term or delivery have reached conflicting conclusions, with no adverse perinatal outcome reported by Mastrobattista, Sheiner or Shrestha; rare adverse outcomes reported by Miser et al., yet adverse outcomes reported elsewhere for example by Jauniaux, Ogueh or Rhodes:
- Jauniaux et al reported “a significantly higher incidence of Apgar score less than 7 at 1 minute, meconium-stained amniotic fluid, emergency cesarean section, need for neonatal resuscitation, and of admission to the neonatal intensive care unit in the nuchal cord group compared with the controls. Multiple looping of the umbilical cord around the fetal neck was the main factor accounting for the higher incidence of these complications and the only explanation put forward for the three perinatal deaths that occurred in this group, all of whom presented in the preceding week with decreased fetal movements.”
- Ogueh et al reported “Umbilical cord nuchal loops are associated with induction of labor, slow progress of labor, and shoulder dystocia”
- Rhoades et al found that “Nuchal cord was associated with increased risks of fetal distress (OR 2.7, 95% CI 2.1-3.4), meconium staining (OR 2.1, 95% CI 1.7-2.6), five-minute Apgar score < 7 (OR 1.6, 95% CI 1.1-2.4) and assisted ventilation < 30 minutes (OR 1.9, 95% CI 1.4-2.6).”
A prospective study of 200 singleton pregnancies (Lal) found that 26.6% of nuchal cords detected by ultrasound at 30-32 weeks were seen to persist at 36-38 weeks.
(Evidence level III)
References:
- Gonzalez-Quintero VH. Tolaymat L. Muller AC. Izquierdo L. O'Sullivan MJ. Martin D. Outcomes of pregnancies with sonographically detected nuchal cords remote from delivery. Journal of Ultrasound in Medicine. 23(1):43-7, 2004 Jan. Abstract
- Jauniaux E. Ramsay B. Peellaerts C. Scholler Y. Perinatal features of pregnancies complicated by nuchal cord. American Journal of Perinatology. 12(4):255-8, 1995 Jul. Abstract
- Lal N. Deka D. Mittal S. Does the nuchal cord persist? An ultrasound and color-Doppler-based prospective study. Journal of Obstetrics & Gynaecology Research. 34(3):314-7, 2008 Jun. Abstract
- Mastrobattista JM. Hollier LM. Yeomans ER. Ramin SM. Day MC. Sosa A. Gilstrap LC 3rd. Effects of nuchal cord on birthweight and immediate neonatal outcomes. American Journal of Perinatology. 22(2):83-5, 2005 Feb. Abstract
- Miser WF. Outcome of infants born with nuchal cords. Journal of Family Practice. 34(4):441-5, 1992 Apr. Abstract
- Ogueh O. Al-Tarkait A. Vallerand D. Rouah F. Morin L. Benjamin A. Usher RH. Obstetrical factors related to nuchal cord. Acta Obstetricia et Gynecologica Scandinavica. 85(7):810-4, 2006. Abstract
- Rhoades DA. Latza U. Mueller BA. Risk factors and outcomes associated with nuchal cord. A population-based study. Journal of Reproductive Medicine. 44(1):39-45, 1999 Jan. Abstract
- Sheiner E. Abramowicz JS. Levy A. Silberstein T. Mazor M. Hershkovitz R. Nuchal cord is not associated with adverse perinatal outcome. Archives of Gynecology & Obstetrics. 274(2):81-3, 2006 May. Abstract
- Shrestha NS. Singh N. Nuchal cord and perinatal outcome. Kathmandu University Medical Journal. 5(3):360-3, 2007 Jul-Sep. Abstract
Search date: May 2009
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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