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PERINATAL OUTCOME OF NUCHAL CORD.

Byline: Farnaz Zahoor, Zakia Minhas and Adil Zaki

ABSTRACT

Objective: To find out the perinatal outcome in cases of vaginal delivery with nuchal cord versus babies delivered by elective ceaserian section with nuchal cord.

Methodology: A retrospective, cross-sectional, comparative study done between January to December 2011 at Kalsoom Maternity Hospital where 1776 patients were analyzed for presence of nuchal cord prior to and at the time of delivery and perinatal outcome. The cases with nuchal cord undergoing vaginal delivery were 205 (study group) versus 85 elective ceaserian section with nuchal cord served as control group. Outcome variables between the two groups were compared.

Results: Incidence of nuchal cord was 16.3 Percent . Incidence of single nuchal cord was highest in normal delivery (73.9 Percent). No significant difference was found between the mean of both 1- and 5-minute Apgar scores (8 and 10, respectively) between the two groups, but infants born with nuchal cords vaginally, tended to have lower scores at 1 minute (p=0.008). This trend was not evident in the 5-minute Apgar test.

Two neonatal admission were done (in vaginal delivery group) for 24 hour and then discharged for babies with apgar score 3/10, 5/10 and 4/10, 6/10 respectively. Elective ceaserian section cause an additional morbidity and does not justify in case of nuchal cord as outcome is almost same in both condition. Conclusion: Nuchal cord is not associated with adverse perinatal outcome therefore do not influence clinical management. Doing elective section is not justified as there is no difference in perinatal outcome. Key Words: Nuchal cord, Perinatal oucome, Apgar score, ceaserian section

INTRODUCTION

In condition of nuchal cord, umbilical cord is wound around fetal neck of fetus. The prevalence of nuchal cord at delivery is extremely high with a single loop reported in around the 30 Percent of neonates1 It is believed by most obstetricians to be the cause of unexplained fetal distress or perinatal death but this is not true and such effects may have been attributed to other conditions.

However, whether or not nuchal cords are associated with significantly increased adverse perinatal outcome is debated. Studies of outcomes after nuchal cord in singleton pregnancies delivering term have reached conflicting conclusions.

Some authors 2-4 reported that the nuchal cord is associated with an increased risk of fetal distress, meconium- stained amniotic fluid and lower Apgar score whereas others did not 5,6 find an increased frequency of non reassuring fetal heart rate patterns, operative vaginal delivery and low Apgar score in cases with nuchal cord. Ogueh et al reported umbilical cord nuchal loops are associated with induction of labor, slow progress of labor, and shoulder dystocia 7.

Sheiner et al 8 reported a higher rate of labour induction and not reassuring fetal heart pattern, but no significant association with perinatal mortality or caesarean section. Does the nuchal cord really affect the outcome of delivery?.This retrospective study investigated the actual frequency of nuchal cord encountered and determined the effect, if any of a nuchal cord on an infant as it passes through the birth canal and immediately after delivery.

METHODOLOGY

A retrospective comparative study done at Kalsoom Maternity Hospital between January to December 2011. A review of the labor records showed that 1776 infants were born at Kalsoom Maternity Hospital during the mentioned period. Demographic data on the mother were collected from a review of the prenatal record, and included age, parity, previous personal and obstetric history. The maternal delivery record provided the data for gestational age, method of delivery, presence of meconium in the amniotic fluid, fetal heart rate monitoring that was done routinely, presence of nuchal cord, number of cords, instrumental delivery and any other complications that may have occurred at the time of delivery. The newborn's record was used to collect data for sex, birthweight, Apgar scores, congenital anomalies, any admission to neonatal unit and perinatal course.

Of the 1776 vaginal deliveries, 205 were selected as study group.The iclusion criteria was pregnancies with singleton normal cephalic pregnancy between 37 and 41 completed weeks with cord around neck at time of delivery. The remaining were excluded from the study after following exclusion criteria which included preterm,congenital abnormalities and noncephalic presentation and postdate pregnancies. Eighty five patients were in control group included patients diagnosed at term to have cord around neck opted to under go elective c/section without any additional risk factor Statistical analysis were performed using chi-square with Yates' correction factor or Fisher's exact test on nominal data, and Student's t test for independent samples on interval data.

RESULTS

Incidence of nuchal cord in this study was 16.3 Percent . Incidence of single nuchal cord was highest in normal delivery (73.9 Percent). There was no significant difference found between the mean of both the 1- and 5-minute Apgar scores (8 and 10, respectively) between the two groups, but infants born with nuchal cords undergoing vaginal trial tended to have lower scores at 1 minute (p=0.008) Table 1. This trend was not evident in the 5minute Apgar test.

Two neonatal admission were done for 24 hour in vaginal delivery group and then discharged for babies with apgar score 3/10, 5/10 and 4/10, 6/10 respectively. Six patients had meconium stained liquor which was managed by intrauterine wash with normal saline and all these babies had Greater than 7 apgar at 1 minute. An observation made, which was although not objective of study that, as the number of cords around neck increased the apgar score Less than 7 at 5min increased progressively Table 2. There is no significant association

Table 1: Apgar score in cases of Normal Vaginal Delivery and Caesarian Section

###Mode of Delivery

###Normal Vaginal###Caesarian

###Delivery###Section

Apgar Score Less than###7###Count###33###4

at 1 minute Greater than 7###Percent within Mode of Delivery###16.1 Percent###4.7 Percent###

###Count###172###81

###Percent within Mode of Delivery###83.9 Percent###95.3 Percent

Total###Count###205###85

###Percent within Mode of Delivery###100.0 Percent###100.0 Percent

Table 2: Relationship of number of cord around neck in Normal Vaginal Delivery and Apgar score

###Apgar Score###Total

###Less than 7###Greater than 7

###Single###Count Percent within Number of Cord around Neck###25 15.2 Percent###139 84.8 Percent###164 100.0 Percent

Number of###Double###Count Percent within Number of Cord around Neck###7 18.9 Percent###30 81.1 Percent###37 100.0 Percent

Cord around Multiple###Count Percent within Number of Cord around Neck###1 25.0 Percent###3 75.0 Percent###4 100.0 Percent

Neck###Total###Count Percent within Number of Cord around Neck###33 16.1 Percent###172 83.9 Percent###205 100.0 Percent

Table 3: Relationship of various maternal and fetal parameters on different mode of delivery

###Mode of

###Delivery###n###Mean###Standard Deviation###p-value

Gestational Age###Normal###205###38.1171###1.17821###.465

###Caesarian###85###38.2235###.99255

Weight of Baby###Normal###205###7.2059###1.03463###.520

###Caesarian###85###7.1235###.87078

Apgar score###Normal###205###7.6293###1.09773###.019

###Caesarian###85###7.9176###.38458

Number of Cord around Neck###Normal###205###1.2195###.45976###.016

###Caesarian###85###1.3765###.59715

Parity###Normal###205###1.4878###1.63482###.938

###Caesarian###85###1.4706###1.86182

Normal = Normal Vaginal Dilvery

Table 4: Comparison of fetal outcome in both the groups

###Mode of Delivery###p-value

###Normal Vaginal Delivery###Caesarian Section

###n###Percent###n###Percent

###No meconium###199###97.1 Percent###85###100.0 Percent

###msl 1###4###2.0 Percent###0###.0 Percent

Meconium###msl 2###2###1.0 Percent###0###.0 Percent 0.281

###msl 3###0###.0 Percent###0###.0 Percent

NICU###No###202###98.5 Percent###85###100.0 Percent

Admission###Yes###3###1.5 Percent###0###.0 Percent 0.262

Apgar score Less than 7.00###33###16.1 Percent###4###4.7 Percent

###Greater than 7.00###172###83.9 Percent###81###95.3 Percent 0.008

between number of cord and parity, gestational age and weight of baby Table 3. Elective section cause an additional morbidity and does not justify in case of nuchal cord as outcome is almost same in both condition. Comparison between the different fetal outcome measures in two group is showed in Table 4. Since vaginal delivery has no significant morbidity on fetus so elective section is not justified.

DISCUSSION

The frequency of nuchal cords found in this study is 16.3 Percent, which is similar to findings in prior studies, the incidence varies from 12.6 Percent to 33.3 Percent, with an overall average of 20.4 Percent 9.

Thus, nuchal cords commonly occur. During the study, various observations were made, although it was not the objective of study, that there was no association between nuchal cords and maternal age and parity. There was no indication that the presence of a nuchal cord influences the length of the pregnancy, a finding that agrees with other reports 10-13.

Nuchal cord was seen in boys more (55.2 Percent in boys vs. 44.8 Percent in girls) similar to another study 10 but there was no significant association with nuchal cords. The presence of a nuchal cord in this study was not associated with an increased frequency of vacuum or forceps deliveries. About 9 Percent had vacuum delivery and 2 Percent forcep delivery for case group. Thus, operative deliveries were not more common in those pregnancies involving nuchal cords, although this is controversial in the literature 10,12,14.

The presence of a nuchal cord is often cited as a major cause of fetal distress, as evidenced by meconium stained amniotic fluid and/or fetal bradycardia or tachycardia 10,13,15.

In a study by Fisher 16, fetal distress was twice as common in births complicated by nuchal cords which is reverse of Spellacy et al 13 stated that the incidence of meconium is not increased by nuchal cords In this study only 4.3 Percent had meconium and none of them had bradycardia or tachycardia. The meconium staining of liquor in this study was managed by intrauterine wash with normal saline with 5 minute apgar score at birth Greater than 7.

The present study was unable to demonstrate a significant difference in the mean 1minute Apgar score between the two groups, although the nuchal cord group did tend to have a larger percentage of infants (16.1 Percent) born with a score of less than 7. This difference was absent at 5 minutes after birth when the second Apgar score was given, suggesting that any possible effect is only transient. Similar findings by other suggest that nuchal cords are not a major cause of fetal asphyxia 12-14.

Studies in the past have implicated nuchal cords as a cause of fetal death 17.

but several authors agree with the present study that nuchal cords do not increase fetal mortality 10,12, 13,16.

Shui and Eastman 11 found a higher fetal death rate in those deliveries not involving nuchal cords, and concluded that coiling of the umbilical cord around the infant's neck was a rare cause of perinatal death.

Doing ceaserian section for solely nuchal cord when perinatal outcome is not affected, will only add additional morbidity to mothers health and increasing rate of section.IThe maternal mortality is higher than that associated with vaginal birth (5.9 for elective cesarean delivery v. 2.1 for vaginal birth, per 100 000 completed pregnancies 18.

Cesarean section also requires a longer recovery time, operative complications such as lacerations and bleeding 19, 20, future reproductive morbidity such as risk of placenta previa (5.2 per 1000 live births) and placental abruption (11.5 per 1000 live births) 21.

Although elective caesarian may be opted by patients to avoid intrapartum complication of nuchal cord ,what they don't realize is they are exposing babies to neonatal complications like the risk of neonatal respiratory distress necessitating oxygen therapy is higher if delivery is by cesarean (35.5 with a pre labour cesarean v. 5.3 with vaginal delivery, per 1000 live births) 22.

In this study there were 4.7 Percent babies delivered by c section with 1 minute apgar score Less than 7 (table 1).Thus one cannot be certain that elective c section is going to give good apgar score at 1min every time.

Also, a recent study has reported that the risk of unexplained stillbirth in a second pregnancy is somewhat increased if the first birth was by cesarean rather than by vaginal delivery (1.2 per 1000 vs. 0.5 per 1000) 23.

WHO indicated that a caesarean section rate greater than 10-15 Percent is not justified in any region of the world. In this study rate of elective section for nuchal cord is 4.7 Percent, by reducing this rate we can reduce total incidence of c section.

CONCLUSION

This study suggests that nuchal cords occur commonly, but are rarely associated with significant neonatal morbidity or mortality. Doing elective cesarean section in such cases only increases maternal morbidity without significant difference in neonatal outcome.

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CONTRIBUTORS

FZ conceived the idea and planned the study. ZM supervised the study. AZ helped in write up of the manuscript. All the authors contributed significantly to the research that resulted in the submitted manuscript.

This article may be cited as: Zahoor F, Minhas Z, Zaki A. Perinatal outcome of nuchal cord. J Postgrad Med Inst 2013; 27(2):174-8.

Department of Obstetrics and Gynaecology Kalsoom Maternity Hospital Peshawar Pakistan

Address for Correspondence: Dr. Farnaz Zahoor, Department of Obstetrics and Gynaecology Kalsoom Maternity Hospital Peshawar Pakistan E-mail: farnaz_1410@hotmail.com
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Publication:Journal of Postgraduate Medical Institute
Article Type:Report
Date:Jun 30, 2013
Words:2867
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