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The Problem with Umbilical Cords…

March 11, 2014 9 comments

By Lindsey Wimmer, MSN, CPNP

Going through my email today, I had three notes from three different parents sharing their stories of umbilical cord issues.email

The first was a father wanting advice for helping his wife after she had recently delivered their stillborn child at 41 weeks.  The cause was determined to be a cord accident.

The second was a woman asking for prayers for a friend’s newborn child. During delivery, the umbilical cord was compressed and the child suffered hypoxia (lack of oxygen).  The baby is currently in the NICU undergoing body cooling in an attempt to reduce the swelling in his brain.

The third was a woman who recently delivered a baby in Japan.  Ultrasounds were a routine part of every prenatal visit during the third trimester.  At the 36 week visit, they noticed the baby had several umbilical cord wraps around the neck and arm.  Her OB showed her the concern, they did some extra tests to identify if the baby was in any distress, and then a cesarean section was scheduled at 38 weeks of gestation to avoid the baby having complications from the umbilical cord issues during a vaginal delivery.  She said it hadn’t occurred to her that her pregnancy might have been managed differently in the US.

A few major problems stand out to me with these stories.

bean scratching head

Families are told every day that umbilical cord issues don’t cause problems.  Yet, this is also the most common answer families are given when they ask why their child was stillborn.  This hypocritical approach is not acceptable.  If cord issues truly cause birth injuries and death, then that needs to be recognized, accepted, communicated, and addressed.  If they don’t, we need to stop attributing such a large number of poor outcomes to this cause.  It is true that many babies are born healthy despite umbilical cord issues, but this is not the same as saying the cord issues aren’t a cause for concern.

please don't say you cantProviders will often say cord problems are not concerning, but what they actually mean is that they don’t think they should alter the plan or don’t know what to do differently – so they simply offer false reassurance.  In the event of a poor outcome, a cord issue might really be the cause, but “cord accident” may also be the easy answer because it is accepted as something that “nothing” could be done about.

The woman from Japan proves that cord issues can be addressed.  It is impossible for us to guess if she would have had a poor outcome if they had chosen a different approach, but she and her providers chose not to gamble with her child’s health/life and took a route that they believed offered the least amount of risk.  This does not seem that radical to me.  I had similar thoughts and questions during my subsequent pregnancies.  My children all experienced different types of complications that were only identified because I was considered ‘high-risk’ (and that was only because of my previous stillbirth).  Each of these complications were managed and monitored closely.  They were delivered when the risks and benefits of their issues and prematurity flipped so that they had a greater likelihood of survival outside my womb than in it.  And they are all 3 happy, healthy beautiful children today.  Again – no way to know what the outcome would have been otherwise.  I’m eternally grateful for their health, I’m scared when I think about what other outcomes were possible, and I can’t help but wonder if their oldest brother would have survived if he had received the same level of care.

Likewise, we have no way of knowing if recognition of the cord issue could have prevented the stillbirth of the child in the first email.  But these are what-ifs that this family (and many of us) will live with for the rest of their lives.  The providers may be left with the same questions, How many babies MIGHT we be able to save or improve the outcome for if we identify potential problems before the mom or baby is symptomatic?Dr. Seuss don't give up

In the email from Japan, the cord issue was identified because she had a level of care that is not routine in the US and the provider was willing/able to offer a management plan that is not readily accepted in the US.  Americans have insurance companies wanting to reduce the number of tests and procedures, lawyers wanting to eliminate provider liability, and special interest groups pushing their agendas into the medical decision making process of families, providers, and hospitals. The baby in the NICU is a perfect example that everyone involved might have benefitted from knowing in advance about a potential cord issue and management beyond watching and waiting.  The stress, costs, and potential long-term effects for this child/family make some extra tests and a possible c-section seem pretty minor. The family who experienced a stillbirth didn’t know what cord issues could do or that they might be preventable until after their child had died.   The family in Japan was shown the potential issue and allowed to have a discussion with the provider about any risks and benefits of various options.  Together, they developed a plan that they felt comfortable would reduce the risk as much as possible.  Again, this seems rather simple to me.

I routinely hear stories of heath care professionals opting not to look for or to tell families (if they did look) about potential umbilical cord issues.  Their rationale is this – “Why scare the family when I can’t do anything about it?”  This is unbelievable. The family has a right to know regardless of the options.  Most people are understanding and realistic about what medicine is able to provide.  This would not be the first time that families are given information about a diagnosis that doesn’t have easy options.

But the next, obvious question is – why can’t we do anything?

I understand that we may not be able to unwrap a nuchal cord or undo a knot in the cord.  But we can manage the pregnancy differently from that point forward.  We do it every day with many other issues.  Why not this one?  When we see sensational stories on the news about significant anatomical abnormalities that are corrected in utero, it seems unreal that we throw our hands up when it comes to issues like cord and placenta issues.

Medicine is not black and white. 

What works for one person may not be the best solution for another. 

  • frustrated beanI am frustrated by recommendations and policies that assume all situations to be identical.
  • I am frustrated by providers choosing to keep their heads buried in the sand instead of looking for warning signs or risk factors because it makes their job easier or reduces their liability or because the odds are in their favor.
  • I am frustrated by health care professionals not involving families in health care decisions after an honest discussion of all information available.
  • I am frustrated by insurance companies or other parties influencing medical decision making more than the physicians and the families directly impacted.
  • I am frustrated by providers, organizations, and policies that ignore the fact that obstetrics is monitoring the health of TWO patients.

To me – these are some of the real problems with umbilical cords…and too many other causes of miscarriage, stillbirth, birth injury, and neonatal death.

We need more providers who are willing to do what makes sense

for their patients with their patients. 

We need more families to communicate their desires. 

We need more awareness of these issues so that every baby, mom, and family

get the absolute best that medicine can provide.

“What’s the truth about cord accidents?”

April 5, 2013 16 comments

by Lindsey Wimmer, MSN, CPNP

ribbon with footprintsI was asked this question earlier this week.  And it’s a very good question.  There are so many conflicting thoughts, ideas, and beliefs regarding the role of the umbilical cord in stillbirth.  So why is there so much confusion?  And, what is the truth?

The truth is that umbilical cord accidents CAN cause stillbirth.  There are numerous studies that have shown this to be the case.  The percentage of stillbirths caused by cord accident is not as clear.  Depending on the study, it can range from 5-30% of all stillbirths.  The Stillbirth Collaborative Research Network (SCRN) of the NICHD recently published well-respected results from their comprehensive, 5-site study.  In this paper, 11% of the stillbirths studied were attributed to cord issues.  This is a significant number, but it is also likely to be a conservative number because they required physical evidence of a cord accident to be present during autopsy for this diagnosis.

cord-around-neck-1aThere are many types of umbilical cord issues that can cause problems.  The more common issues include true knots, velamentous or marginal insertions, hyper or hypo coiling, lack of Wharton’s jelly, 2-vessel cords, and compression.  Characteristics like long cords, short cords, nuchal cords, or body loops may not directly cause interruption in the blood flow, but they present a situation where compression may be more likely.

Why do so many people insist that cords (especially nuchal cords) don’t cause problems?  I think it’s because most OBs and midwives have seen hundreds of healthy babies that are born with nuchal cords (the cords wrapped around the baby’s neck).  This leads many people to believe that it’s not a big deal.  The problem is that it CAN be a big deal for some babies.  Just because it isn’t a problem for ALL babies, doesn’t mean it isn’t a problem.  I know people who smoke and don’t have lung cancer.  That doesn’t mean that smoking is safe.  The second issue with this is that nuchal cords are just one type of cord issue that could be problematic.

Why are cord accidents difficult to diagnose?  There may be physical evidence of cord compression or other type of cord accident present after birth.  However, this is not always the case.  Plus, many stillbirths are not evaluated by someone trained in placenta and cord pathology to identify this evidence.  In fact specially trained placental pathologists are few and far between.

Another significant problem in diagnosis is that we lose possible evidence with delivery.  It is almost impossible to know (or even guess) where the cord and all other structures were when a problem occurred if we only look at the baby and cord AFTER they have been delivered.  I think all stillbirths should have a comprehensive ultrasound at the time of diagnosis to evaluate the umbilical cord, baby’s position, placental location, and amount of amniotic fluid.  This is information that is impossible to determine if we don’t look at the “scene of the crime” before it has been disrupted by the birth process.

With all of these issues, why are so many parents told that an umbilical cord accident was the cause of their child’s death?  This is a very good question.  Anecdotally, I hear much more than 11% of stillbirths being attributed to cord accidents.  Personally, I think this may be true in many of these cases.  I also think it feels like an ‘easy’ answer to give parents.  It is relatively simple to understand (as opposed to genetic alleles and complex medical conditions) and doesn’t appear to require a lot of explanation or proof for most families.  Plus, the term ‘accident’ gives the impression that is wasn’t anybody’s fault or that it was a freak occurrence – wrong place at the wrong time type of scenario.  I’ve heard people say the word accident makes it less likely the parents will blame their providers, and also that it brings a sense of closure if it’s “just one of those things”.   Regardless, it should not be a default diagnosis because it’s easy.  If that’s really the best educated guess of the provider, then this should be explained to the family.

I am also very irritated by the connotation that nothing can be done about issues called accidents.  In many cases, there are signs or symptoms that are not identified or addressed.  What these symptoms are and how they should be managed is not something I’ll get into here – but we need to start having frank discussions with expectant families and loss families about symptoms they have/had and if they could be signals of a baby in distress.

If it’s so simple, why is there so much confusion about cord accidents??  I think this is the result of the above issues in combination. During pregnancy, parents are told umbilical cords don’t cause problems.  But if a loss occurs, many of these same parents are told that a cord accident is the likely cause of their child’s death.  We can’t have it both ways.

How do we clear up the confusion?  In my opinion, several things should happen.

  • First, we need to STOP telling expectant parents that cord issues aren’t a cause for concern.
  • Second, we should be encouraging families to have the baby (or at least the umbilical cord and placenta) evaluated after a stillbirth to attempt to identify the cause of death without guessing.
  • Third, we need more information about how to identify these cord issues and how to manage them – this needs more research.

Until we have more research, we should be looking for signs of distress in pregnancies, and we should be looking at umbilical cord characteristics during any and all ultrasounds.  If cord issues or distress are identified, the parents deserve to be told and it needs to be addressed immediately.  Our OBs and midwives deserve more research and education to guide them in prevention of stillbirth from cord accidents.

With the highly sophisticated medical technology available today, I firmly believe this is a cause of stillbirth that is highly preventable!  We need to work together to make it happen!

stars_3-1-12v2-compressedHelp us learn more about umbilical cord accidents and all stillbirths – PLEASE participate in the STARS Study and encourage others to do the same.  We need women who have EVER had a stillbirth after 28 weeks gestation, women who have had a baby in the last 3 weeks, and women who are currently pregnant (28 weeks or more).

 Click on the logo on the left or go here to participate: http://starlegacyfoundation.org/stars1/

We can be part of the solution! 

The STARS Study is underway!

September 22, 2012 1 comment

By Lindsey Wimmer, MSN, CPNP

The STARS Study is underway!! We at the Star Legacy Foundation are incredibly excited to share this news with you!

One year ago at the Stillbirth Summit, a group of researchers, organizations, and stillbirth families began discussions about designing a research study. This group worked diligently over the last several months to create an online survey for this purpose. STARS (Study of Trends and Associated Risks for Stillbirth) was born and it is now open!

We have had great responses, a lot of interest, and also several questions. In case you have the same thoughts, here are the top 10 Frequently Asked Questions about the STARS Study.

1. What is the purpose of this study? – This study was designed to replicate portions of the Auckland Stillbirth Study to learn more about its findings. The other researchers at the Stillbirth Summit and stillbirth organizations provided input for additional questions to learn as much as we can.

2. What will be done with the data collected? – The researchers involved will use the information relative to their individual work. Their teams will analyze the information to determine if any conclusions can be made. If so, it may support their current/other research studies or it may spark a new concept for researchers to evaluate.

3. Who are the researchers? – The STARS Study team members are:

*  Jane Warland, RN, RM, PhD, University of South Australia; Adelaide, South Australia

*  Louise O’Brien, PhD, MS; University of Michigan; Ann Arbor, MI

* Jason Collins, MD, MCR; Pregnancy Institute; New Roads, LA

* Alex E P Heazell, MBChB, PhD; University of Manchester; Manchester, UK

* Jennifer L Huberty, PhD; University of Nebraska Medical Center; Omaha, NE

* Jamie A McGregor, MD, CM; University of Southern California; Los Angeles, CA

* Edwin A Mitchell, MBBS, FRSNZ, FRACP, DSc; University of Auckland; Auckland, New Zealand

* Mana Parast, MD, PhD; University of California San Diego; San Diego, CA

* Tomasina Stacey, RM, PhD; University of Auckland; Auckland, New Zealand

* Lindsey J Wimmer, MSN, CPNP; St. Catherine University; St. Paul, MN

The STARS Study Coordinators are:

* Shauna Libsack, Star Legacy Foundation

*  Sherokee Ilse, Babies Remembered

* Marti Perhach, Group B Strep International

* Candy McVicar, Missing GRACE Foundation

4. Is this study IRB approved? – This study was reviewed by the IRB at the University of Michigan and determined to be exempt. All IRB regulations regarding exempt studies have been met. IRB #HUM63655  If you’re wondering what an IRB is – an Institutional Review Board is a required function at any organization that conducts research with people.  The primary responsibility of the IRB is to be sure that research involving people is conducted with full informed disclosure and consent and is conducted ethically.

5. Who can participate? – We need women from the following three groups to complete the survey:

*  Women who are currently at least 28 weeks pregnant or who have given birth to a live-born baby in the last 3 weeks

* Women who have had a stillbirth after 28 weeks gestation in the last 3 weeks

* Women who have ever had a stillbirth after 28 weeks of gestation

Click here to participate in the study!

6. I live outside the US or did when my child was born. Can I participate? – Absolutely! This is an international survey. The more women who participate from around the world and around the US, the better our results will be.

7. Why are only stillbirths after 28 weeks being considered? – The study was designed to replicate portions of the Auckland Stillbirth Study. In this study, they evaluated late stillbirths (after 28 weeks). To make our results relevant to their findings, we needed to have similar criteria. In addition, this is an international study and there is not a clear definition between various countries about what gestation is considered a stillbirth. It does not change the importance of what can be learned from all types of pregnancy loss, but research rules require strict boundaries on some items.  Please know – that all babies are important to us and we have visions of additional research that would include earlier pregnancy & infant loss.

8. What about me? My stillbirth occurred before 28 weeks? – We appreciate your interest and willingness to help! We recognize the significance of earlier pregnancy losses and intend to have additional studies in the future that will be focused on those babies. I hope you’ll be willing to participate when we have more projects available!

9. How can I help?The best way to help with this study is to participate if you qualify, and to share the information with anyone else you know who may be interested, willing, and able to participate. The more women who complete the survey, the more we will learn. The faster we are able to get women to complete the survey, the sooner we will have information to share!

10. How can I learn about the findings? – The researchers will be writing papers regarding their analyses. We will definitely share any and all official findings on our website and on our facebook page. If you would like to receive an email when these findings are published, send an email to: info@starlegacyfoundation.org.

If you have other questions regarding this study, please contact me at lindsey@starlegacyfoundation.org .

THANK YOU for your help and support!

Copyright 2012 © Star Legacy Foundation

Thinking outside the box……

September 5, 2012 1 comment

Last October, Star Legacy Foundation hosted the Stillbirth Summit 2011.  After thinking about this type of an event for a while, we decided to pull the trigger and make it happen!

There are so many fantastic people working on stillbirth prevention around the world.  Looking through some of those efforts, we discovered some similarities and overlapping concepts that were very exciting.  Our minds wandered to ‘what if’ we could get these brilliant minds in the same room to share their findings.  The biggest winner of that type of event would be the babies!

The focus was on stillbirth topics that are emerging ideas and ‘outside the box’ thinkers.  We needed people who are open-minded and looking at all aspects of this considerable problem.  We got just that – and so much more!!  Fortunately, we had a great response from these researchers who were all very willing to participate.

The topics included infection, hypotension, thrombophilias, sleep, placenta, cord, and fetal movement.  Researchers included Dr. Harvey Kliman, Dr. Uma Reddy, Dr. Mana Parast, Dr. Moraji Peesay, Dr. Louise O’Brien, Dr. Jane Warland, Dr. Alex Heazell, Dr. Ed Mitchell, Dr. Tomasina Stacey, Dr. James McGregor, and Dr. Jason Collins.  The discussion was lively and very educational.  Even better, at the end of the presentations, everyone worked together to discuss ways to work together and identify new projects needed.

One of the outcomes discussed was the publication of the presentations from the Summit.  Dr. Mitchell and Dr. Heazell took a leadership role and each researcher wrote a summary of their presentation.  The combination of these efforts was a summary of the Proceedings of the Stillbirth Summit 2011.  We are thrilled to announce that this article was just published!

It is so important to have these topics and this information in the medical literature to help the cause of stillbirth prevention.  Please take a moment to read the article, share it with your friends, and share it with your health care providers.  Every little bit learned is one step closer to being able to prevent many, many stillbirths.

I am extremely grateful for the researchers who participated so eagerly and the many, many volunteers who helped make this event a reality.  We are looking forward to the next Stillbirth Summit – in 2014!  But for now, we take a moment to savor this accomplishment and say thank you to the researchers for sharing their findings with the world.

Click here to read the Proceedings of the Stillbirth Summit 2011

as published in

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About the author:

Lindsey Wimmer, a Pediatric Nurse Practitioner, is Mom to four children; Garrett, stillborn in 2004, Grant, Bennett and Austyn. Lindsey is an adjunct instructor of pediatrics at the St. Catherine University in St. Paul, MN and also teaches pediatric and obstetrical nursing  at Hennepin Technical College in Eden Prairie, MN.   Lindsey and her husband Trent founded the Star Legacy Foundation shortly after Garrett’s birth when realizing that the numbers of stillbirths in the US were staggering and that very little was being done to determine the causes or find prevention initiatives. Visit the Star Legacy Foundation to learn more.

A picture is worth a thousand words…and possibly your baby’s life too.

April 25, 2012 8 comments

by Lindsey Wimmer, MSN, CPNP

I LOVE pictures of my kids.  I mark the major milestone dates with pictures, I try to get pictures of the little faces I don’t want to forget, and I send pictures to family members assuming they want them as much as I do!  Those pictures tell us so much about them.  We can see their personalities, we watch them grow, we remember specific accidents or events, we evaluate genetics by figuring out who they look like, and so much more.  There are probably MANY reasons for this obsession (another blog topic in itself!) – but the bottom line is that I LOVE every picture I have of my kids.

That includes the ultrasound pictures I have of our son Garrett who was stillborn at 38 weeks.  Sadly, the last pictures I have of him while his heart was beating are from the 20 week ultrasound.  That is the only time in any of my kids lives that I have gone almost 5 months without taking their picture.  Yet that is the standard of care during pregnancy.  It seems crazy to me that we know so much is changing inside the uterus the last half of the pregnancy, yet we don’t utilize modern technology to watch and make sure mom and baby are healthy and growing as they should.

I believe at least one third-trimester (32 weeks to delivery) ultrasound should be a new standard for prenatal care. Some physicians and midwives have started this, but most have not.

First, ultrasound has been proven to be safe and is non-invasive.  There is essentially no physical risk to the mom or the baby.  What can we learn from a third trimester ultrasound?

1. How baby is growing and estimate current size

2. How much amniotic fluid is present

3. Where the placenta is, how large it is, and how mature it is

4. Where the umbilical cord is, how long it is, how twisted it is, if there are loops or knots in the cord

5. How the umbilical cord is inserted into the placenta

6. Blood flow through the placenta and umbilical cord to the baby

7. Signs of inflammation

8. Position of baby

Obstetricians know the end of pregnancy is critical – that’s why they start increasing the frequency of prenatal visits.  Yet, most of these visits include very little exam of the baby.  They will listen to the baby’s heartbeat and measure mom’s belly.  The heart beating for 15 seconds is hardly an accurate determinant of health.  Measuring mom’s belly with a tape measure does very little to tell us about what’s going on inside the uterus.  That measurement can be affected by the size of the baby, the size of the mother, the position of the baby, the amount of amniotic fluid, and the size of the placenta.  Once a baby is born, the pediatricians begin seeing that child on a regular basis.  First at birth, then at 4-5 days, then at 2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, and 24 months.  Not until a child is 2 years old does their growth and development slow down  enough that physicians feel comfortable letting them go more than 3 months between examinations.  We shouldn’t let a baby grow and develop that much before birth without watching more closely.

The major concern I hear is the cost.  I understand that this would add to the cost of prenatal care, but I believe the potential benefit is greater.  In most health care facilities, this ultrasound would cost the patient between $100 and $300 if their insurance did not cover it at all.  To some this is not a problem, and to others it is.  But I believe that physicians should offer it and let the patients decide if this is a cost they can incur.  We recommend vaccines, mammograms, blood tests, medicines, and more even though we know many patients won’t be able to afford them.  We leave the final decision to the patient.

 The other argument from health care professionals is that they can’t do anything about the umbilical cord or the other factors they could see.  But I disagree.  Pregnancies that have been deemed “high-risk” have these extras tests on a regular basis to monitor the situation.  The United States is actually very good at reducing prenatal and infant deaths among this population.  It’s the “low-risk” pregnancies that have a higher death rate.  Why??  Because the qualifications for high-risk are mostly characteristics of the mother.  Many high-risk babies are in danger because they have a low-risk mother.  The only way to find a high-risk baby is to LOOK at the baby with a third trimester ultrasound.  If a concern is found, the pregnancy can then utilize high-risk pregnancy protocols and be monitored more aggressively. 

If you are pregnant, ask your health care provider about a third trimester ultrasound.  Anytime you are concerned about the health of your baby, particularly any fluid leaking, weight loss, excessive weight gain, change in baby’s movements or behavior, pain, bleeding, fever, or past your due date – ask for an ultrasound and non-stress test for a full evaluation of your baby.  If you have concerns or symptoms, most insurance companies will cover the cost of these additional tests.  Don’t let cost be a roadblock if you or your baby are experiencing  concerning symptoms. Those extra pictures of your baby are not only precious keepsakes, but they might help save your baby’s life.  That’s a powerful picture.

P.S. We are taking an informal, unscientific survey of moms to see how often women are having a third trimester ultrasound.  If you have had a baby (alive or stillborn),  click here to take our survey.

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About the author:

Lindsey Wimmer, a Pediatric Nurse Practitioner, is Mom to four children; Garrett who was stillborn in 2004, Grant, Bennett and Austyn. Lindsey and her husband Trent founded the Star Legacy Foundation shortly after Garrett’s birth when realizing that the numbers of stillbirths in the US were staggering and that very little was being done to determine the causes or find prevention initiatives. Visit the Star Legacy Foundation to learn more.

Cord Accidents – Myth or Reality???

January 17, 2012 29 comments

by Lindsey Wimmer    

 

The Star Legacy Foundation is frequently contacted by couples that have been told their child was stillborn due to an umbilical cord accident. Yet, many obstetricians will also say that babies are born all the time with a nucal cord (cord around the neck) and dismiss that as a cause of a stillbirth. Cord issues aren’t just limited to nucal cords – simple compression, cord wraps around other body parts, torsion (twisting to the point of coiling back upon itself like a telephone cord does when twisted too many times), and true knots are also known to cause stillbirth.


Many of the same callers ask us what we know about Dr. Jason Collins and his work involving cord accidents. Dr. Collins, an obstetrician, has dedicated his career to stillbirth research and umbilical cord accidents specifically. The following is a brief summary of a presentation he recently gave at the Stillbirth Summit (October 4-6, 2011 in Minneapolis, MN, USA) which is a very high level overview of his research and conclusions.
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The presence of umbilical cord issues have been well documented in published literature since the 1700s. Yet, this remains an area of obstetrics that is greatly understudied and ignored. The umbilical cord, the insertion site, the placenta, and the baby should be evaluated and characterized with every pregnancy. With advancing imaging technology, it is becoming even easier to identify areas of concern on ultrasound as early as 10 weeks of gestation.

20 week fetus with clearly visible cord

Umbilical cord torsion occurs when the number of twists exceeds the ability of the cord to withstand the force generated. The cord compression generated causes fetal hypoxia (lack of oxygen). On placental exam, chorioangiosis (cellular changes) can be identified as a result of ischemia (restriction) due to cord compression. The length of the cord determines the amount of twisting that is harmful. The human umbilical cord will tolerate one twist per 5cm of cord length. Twists exceeding this ratio are associated with torsion and fetal death. The length of the umbilical cord and the number of twists present should be identified and documented at every delivery. Identification of torsion prenatally allows for altered management of the pregnancy with a better chance of a positive outcome.

There are two types of nuchal cords: type A and type B. Type A is a wrap that can possibly be undone with movement or delivery of the baby. Type B is a hitch that is impossible for the baby to release. If a type B loop around the neck, ankle, or other body part is pushed off the body, a true knot is formed.

With umbilical cord issues, the factor that determines the risk is the amount of slack available. For this to be determined, the cord location, cord structure, placenta, placental position, cord length, insertion site, and position of the baby must all be evaluated and considered. Short cords have been associated with an increased risk of neurologic insults and long cords have been associated with an increased risk of fetal death.

Double Nucal Cord

Work at the Pregnancy Institute has indicated that hyperactivity, hypoactivity, and hiccups may be clinical indicators of fetal distress. Women presenting with these symptoms should be evaluated for sources of cord compression. Fetal heart rate can provide information on this compression as well. Frequent decelerations, W signs, lambda signs, and spikes should be taken as indicators of fetal distress and managed accordingly. The exact amount of time that it takes for fetal chemistry to return to normal after cord compression has not been studied, but we estimate that more than three compressions in ten minutes would create increasing blood chemistry concerns and should be dealt with immediately.

Interviews at the Pregnancy Institute have also revealed that a vast number of fetal deaths occur during maternal sleep between the hours of midnight and 6am. Maternal low blood pressure may play a significant role in this finding as a reduction in blood pressure may alter the fetal response to underlying cord issues. Melatonin is produced during sleep and is known to affect the uterus. During these overnight hours, the melatonin produced stresses the uterus and the baby is challenged. Babies with cord compression may not tolerate this stressor.

Finally, work at the Pregnancy Institute has identified that umbilical cord accidents are not random or rare. Women who have had umbilical cord issues with previous pregnancies, have as much as a ten-fold increased risk of umbilical cord issues in future pregnancies. These women need additional monitoring for these concerns.
Management of umbilical cord issues is possible with proper diagnosis and fetal monitoring.

It is true that not all cord issues lead to stillbirth. However, it is also true that cord issues are a significant risk factor and cause many stillbirths. The evaluation of the umbilical cord and placenta should be included in a new standard of care for obstetrics in the 21st century.

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About the author:

Lindsey Wimmer, a Pediatric Nurse Practitioner, is Mom to four children; Garrett who was stillborn in 2004, Grant, Bennett and Austyn. Lindsey and her husband Trent founded the Star Legacy Foundation shortly after Garrett’s birth when realizing that the numbers of stillbirths in the US were staggering and that very little was being done to determine the causes or find prevention initiatives. Visit the Star Legacy Foundation to learn more.

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