Why Does an Unborn Baby With a Short Umbilical Cord Die

J Obstet Gynaecol India. 2012 Oct; 62(5): 520–525.

Original Article

Written report of Length of Umbilical String and Fetal Issue: A Study of 1,000 Deliveries

Nilesh Unmesh Balkawade

Dr. 5. M. Govt. Medical College, Solapur, Maharashtra Bharat

502, Krishnashanti Residency, 139, Bhelkenagar, Kothrud, Pune, 411038 Maharashtra Bharat

Mangala Ashok Shinde

Dr. V. M. Govt. Medical College, Solapur, Maharashtra Bharat

Received 2011 Jul six; Accepted 2012 Apr 23.

Abstract

Objective

To study the correlation of umbilical string length with fetal parameters similar Apgar score, sexual activity, weight, and length, and its outcome on labor event.

Blueprint

Prospective study of 1,000 cases.

Setting

Government Hospital

Textile and Method

Examination of umbilical string was washed for whatever loop around neck, trunk, etc; no. of loops of cord and positions; Knots of cord (Truthful or fake), any cord abnormalities. Fetal parameters recorded were sex, weight, and length of the newborn. Fetal outcome studied by Apgar score at i and 5 min.

Results

In our written report, the cord length varied from 24 to 124 cm. The hateful cord length was 63.86 cm (±15.69 cm). Maximum cases seen were in the grouping of string length betwixt 51 and 60 cm. Lower fifth percentile was considered equally curt cord and upper fifth percentile was considered as long string. Short-cord group was associated with significantly higher (p < 0.05) incidence of LSCS cases. Cord length did non vary co-ordinate to the weight, length, and sexual practice of the infant. The incidence of all types of string complications increases as the string length increases (p < 0.001*). Nuchal cords had higher mean cord length than in cases without nuchal cords (p < 0.001). Every bit the number of loops in a nuchal string increases to more than two loops, the operative interference increases. The significance was tested past using a Chi-square exam, and it was found to be statistically significant (p < 0.05). Nuchal cords were seen to be associated with more cases of fetal heart abnormalities (p < 0.001). There is higher incidence of variability in fetal heart rate with extremes of cord length (p < 0.001). The incidence of birth asphyxia was significantly more in long and brusk cords equally compared to cords with normal cord length (p < 0.001).

Conclusion

The present study showed that the length of umbilical cord is variable; all the same, maximum number of cases had normal cord length. Cases which had short and long cords constituted abnormal cord length. These cases had higher incidence of string complications, increased incidence of operative interference, intrapartum complications, increased fetal heart rate abnormalities, and more chances of birth asphyxia. Simply cord length did non vary co-ordinate to the weight, length, and sex of the babe.

Introduction

The umbilical cord is the lifeline of the fetus: "The infant'south life hangs by a cord", as said past Ian Donald [1] aptly tells the importance of the umbilical cord. Viviparity ways that the embryo develops inside the body of the mother. The all-time example is placental mammals. One of the most important parts of the fetoplacental unit is the umbilical cord. Consummate cord occlusion frequently leads to fetal demise while intermittent obstacle has been associated with intrauterine brain damage. Compression and vasospasm in utero are important factors in fetal distress. Conscientious umbilical cord examination often reveals meaning lesions which may be associated with these processes. As obstetricians, we realize this when a heavy price of fetal life is due to cord complications.

Suspected fetal distress or a failure of the fetus to descend properly during labor is not uncommon. Frequently no explanation for such intrapartum complications is apparent. Complications associated with long or short umbilical cord may explicate this enigma. Excessively short cords have been associated with a delay in second stage of labor, irregular fetal heart rate, placental abruption, rupture of umbilical string, inversion of uterus, nativity asphyxia, and cord herniation. Excessively long umbilical cords are associated with cord prolapse, torsion, true knot entanglement around the fetus, and delivery complications. In that location are more cases of fetal distress, fetal anomalies, and respiratory distress.

Cord length at term has appreciable variation, with extremes ranging from no cord (achordia) to lengths up to 300 cm. At nascence, the mature cord is about l–lx cm in length and 12 mm in diameter. A long cord is divers equally >100 cm and a curt cord as <30 cm. There may be equally many every bit 40 spiral twists in the cord, likewise as false knots and true knots. Short umbilical cords may be associated with adverse perinatal outcomes such equally fetal growth restriction, congenital malformations, intrapartum distress, and a twofold risk of death (Krakowiak and associates, 2004) [2].

Though the pathogenesis of variability of umbilical string length remains unclear, this study would provide information well-nigh the length of umbilical cord and its clan with adverse fetal outcome.

Methods

This is a prospective written report conducted in the Department of Obstetrics and Gynecology of Authorities Medical College set-up, from December 2007 to October 2009. The present study included 1,000 cases at random. The patients admitted to labor room with menstruation of gestation >37 weeks were included in nowadays study. Cases excluded from the study are

• preterm deliveries;

• multifetal gestation; and

• babies with major congential anomalies.

• Fetal eye charge per unit was monitored clinically during labor. Way of commitment, vaginal or cesarean, was noted.

• Test of umbilical string: it was beingness washed at the fourth dimension of delivery and afterwards commitment for the post-obit:

  • the presence of any loop around cervix, trunk, shoulder, etc.;

  • cord loops tight or loose in LSCS cases;

  • number of loops of cord and positions;

  • knots of cord (truthful or false); and

  • any cord abnormalities (cyst, hematoma, velamentous insertion, etc.).

• After the delivery of fetus, cord was clamped at two places and cut in between. From the cut end up to fetal umbilicus and placental attachment umbilical string, length was measured and added. Information technology was measured with flexible tape in cm.

  Number of umbilical arteries was not studied in nowadays series. Blazon of insertion on the placenta was too noted. Adherent blood clots were removed from the maternal surface of the placenta. Placental weight was recorded in grams.

  • Following parameters were recorded after the time of delivery.

    1. Sexual practice of the newborn.

    2. Weight of the newborn: newborn was weighed afterward cutting the cord inside one-half an hour of delivery.

    3. Length of newborn—past keeping two hard plates, one at crown and one at the heel and distance between two plates measured and length of newborn measured (CHL).

    4. Fetal outcome was studied past Apgar score at 1 and 5 min.

Results

In our study, the string length varied from 24 to 124 cm. The mean cord length was 63.86 cm (±15.69 cm) i.e., 25.xiv". Maximum cases seen were in the group of cord length betwixt 51 and 60 cm (27.4 %) (Fig.1).

Distribution of cases according to length of umbilical string

Lower 5th percentile of the nowadays series is 45 cm = short cord. Upper 5th percentile of the present series, 95 cm = long cord. Rest are considered as normal (Tabular arrayone).

Table 1

Distribution of cases in groups according to length of umbilical cord

Length of string	No. of cases	Percentage (%)	Mean umbilical cord length in cm
Brusque	59	5.9	37.06 ± 6.34
Normal	888	88.eight	63.44 ± 11.93
Long	53	five.3	100.86 ± 6.51
Total	1000	100

The commonest type of string attachment in this report grouping is ane of eccentric type (67.2 %), followed by cardinal type (32.4 %) both of which are normal cord attachments. In that location were very few cases of aberrant cord attachment including marginal and velamentous insertion, 0.3 and 0.1 %, respectively.

Cases of short-cord grouping had maximum cases of LSCS (40.7 %), than cases with long (24.five %) or normal (23.six %) cord length. Normal-cord grouping cases had maximum no. of vaginal delivery cases (76.4 %) more than 75.5 % for long-cord group and 59.3 % for short-cord grouping. Short-cord group was associated with significantly college (p < 0.05) incidence of LSCS cases.

Of the full, nuchal coiling was seen in 20.vii % (207 cases). In cases with a long cord the incidence of nuchal coiling is 67.9 % (36 cases), while in cases with a short cord information technology was ane.seven and 19.one % in cases with a normal string length. 1 instance had v tight loops of cord around neck. The cord length was 110 cm in this case with central string insertion, the duration of 2nd stage of labor was increased, and LSCS had to be done for fetal distress. After delivery, Apgar score of the baby was low [Apgar = 4 (ane min) and 6 (5 min)]. NICU admission of the baby had to exist done. In long-string group, vii.5 % cases had true knots, whereas in normal-string grouping 1.3 % cases were having true knots. There were eight cases of string prolapse of which 2 cases had a long cord, and half dozen cases had a normal string length (Table2).

Table two

Umbilical cord length and incidence of cord complications

Umbilical cord length	Cord complexity
	No. of cases	Nuchal cords (north = 207) (%)	True knot (northward = xvi) (%)	Cord prolapse (n = viii) (%)	Cord hematoma (n = 1)	Total (n = 232)
Short string	59	one (1.7)	0	0	0	ane
Normal	888	170 (19.1)	12 (i.3)	half-dozen (0.67)	one	189
Long* cord	53	36 (67.9)	4 (7.5)	2 (three.8)	0	42

The incidence of operative interference increases in cases with cord complications. For all the cases of cord prolapse, LSCS was done. The per centum of total LSCS cases in the present study was 24.7 % (247 per 1,000 cases). Thus, cord complications were associated with more incidences of LSCS [nuchal string 35.7 %, true knot 25 %, and 100 % for cord prolapse and cord hematoma].

As the number of loops in a nuchal cord increases to more than two loops, the operative interference increases. The significance was tested by using a Chi-square test, and it was found to be statistically significant (p < 0.05) (Table3) .

Tabular array 3

No. of nuchal cords and manner of delivery

No. of coils	No. of cases (%)	Hateful string length (in cm ± SD)	Mode of delivery
			Vaginal (%)	LSCS (%)
1 loop	124 (12.4)	68.55 ± 15.69	88 (71)	36 (29)
Two loops	67 (6.7)	88.47 ± 15.78	31 (46.three)	36 (53.seven)
Iii loops	13 (1.3)	96.15 ± 15.87	13 (100)	0
Four loops	02 (0.2)	100 ± sixteen.05	01 (fifty)	01 (50)
Five loops	01 (0.1)	110	0	01 (100)

Mean string length in cases with nuchal cords was 77.24 ± 15.71 and that in cases without nuchal cords was 60.37 ± 15.69. Umbilical cords with nuchal cords had higher mean cord length than in cases without nuchal cords. Significance was tested by using Z test and was found to be highly significant (p < 0.001).

True knots were associated with a higher hateful string length of 77.56 cm for cases with true knots than those cords without this abnormality. The divergence is statistically significant (p < 0.001).

There is no significant difference (p > 0.05) in the mean cord length with respect to the sex and length of the babe.

Fetal heart rate was monitored by intermittent auscultation as continuous fetal monitoring was not possible. Bradycardia was seen in 32.seven % of short-cord grouping and 41.five % in long-cord group. There is college incidence of variability in fetal heart rate with extremes of cord length: bradycardia and tachycardia are seen more than with short and long cords than with normal cords. It was highly significant (p < 0.001) statistically using the Chi-square exam.

The incidence of birth asphyxia was significantly more in long and short cords as compared to cords with normal cord length. When studied in comparing to cords with normal length, short cords and long cords were associated more commonly with birth asphyxia: Apgar score of ≤6. Birth asphyxia was seen maximum (56.6 %) in cases with long cord length. The difference was measured by using Chi-foursquare test. It was statistically highly meaning (p < 0.001).

Maximum still births (thirteen.2 %) in long-cord group and maximum early neonatal deaths (11.86 %) in short-cord group. Nevertheless births and early neonatal deaths are more with short- and long-string groups than those in normal string groups. It was found that perinatal mortality was more with brusk and long cords than that in normal ones, and the departure was highly significant (p < 0.001).

Give-and-take

Umbilical String Length

Mean umbilical cord length in the nowadays series is comparable to mean umbilical string length of other authors. The length of the umbilical string varies widely. Cord length varies betwixt 0 [3] to 300 cm [4]. The average length of the umbilical cord is usually between 50 and threescore cm [v]. This study is comparable with the findings of Mishra et al. [half-dozen], where the average cord length was 50–sixty cm and Malpas [4] where the maximum cord length was between 46 and 79 cm.

Eccentric insertion of the cord is the commonest finding. In Flim-flam's [vii] series of one,000 cases, it was seen in 62 % cases, and in our study it was plant in 67.2 % cases.

In the study of Mishra et al. [6] criteria for brusk cord was <20 cm, long cord >100 cm, and command group between l and sixty cm. They also included the same set up of patients, i.e., full term from 38 to 40 weeks of gestation, and cases with maternal and fetal complications were excluded from the written report. In present written report, normal-cord grouping includes 36–84 cm, and so percentage of LSCS in both studies are comparable, and there are increased incidence of LSCS in short- (45.45 %) and long-cord (56.66 %) groups.

In that location was no deviation in the overall mode of delivery for the string, entangled, or non-entangled and all twins, although string entanglement was more prevalent in spontaneous vertex vaginal deliveries [8].

This increased incidence of operative interference may be due to string abnormalities (coiling around neck, trunk string abnormalities, and true knot) in long-cord grouping (Table4). The percentage of total LSCS cases in the present study was 24.vii % (247 per 1,000 cases). The cord complications were associated with more incidences of LSCS [nuchal cord 35.7 %, truthful knot 25 %, and 100 % for cord prolapse and cord hematoma].

Table four

Distribution of cases according to changes in fetal heart charge per unit (FHR)

Length of string	Normal	Bradycardia	Tachycardia
Short	33 (56.8 %)	19 (32.seven %)	06 (x.3 %)
Normal	731 (82.nine %)	135 (15.iii %)	15 (i.7 %)
Long	27 (50.9 %)	22 (41.v %)	04 (7.v %)
Full	791	175	25

Lamonica et al. [9] in their study of "minimum string length to allow spontaneous vaginal delivery" stated that the uterine axis and birth canal are not so long as to impede spontaneous vaginal delivery in the presence of a curt umbilical cord. They also reported that placental location makes no divergence except perhaps when the cord is excessively short.

In the nowadays series, at that place is significant increased incidence of LSCS in curt-string group. In that location is an increased incidence of normal delivery (74.82 %) in normal-cord group compared with short- and long-cord group.

The incidences of all types of cord complications increase as the cord length increases. The present study is comparable with the study by Rayburn et al. [10] and Greenhill [11]. Both the studies have shown statistically pregnant (p < 0.001) association of cord complications with increase in the cord length (i.east., long cords).

In the present study, long cords were associated more with loops around neck and likewise with increased fetal centre rate changes. The exact cause of a slow neonatal eye is not known: information technology is probably due to vagotonia rather than true hypoxia [12].

In the present report, out of the 1,000 cases studied, 207 had nuchal cords (i.due east., 20.7 %). The incidence of multiple nuchal cords was slightly more than than those given in other study groups. In our report, as the number of loops of cord around neck increased, the hateful cord length was constitute to be more: 68.55 cm for one loop, 88.47 cm for two loops, and 96.15 cm for iii loops. Longer cords tend to become looped around cervix. Nuchal coiling tin occur in shorter cords, in which the cord tends to be more tightly wrapped effectually the infant's neck. This was also shown by Rogers et al. [13].

In our study, the hateful cord length in cases with a true knot was 56.25 cm (±iv.23) which was longer than the mean cord length (p < 0.05).

In our study, there were eight cases of cord prolapse (0.viii %). The mean cord length in cases with string prolapse was 71.87 cm (±fifteen.8) which was more than than cases without cord prolapse. However, it was statistically insignificant (p > 0.05) as the number of cases was less. Thus, we confirm the findings of Sarwano et al. [14] who showed that the run a risk of complications increased lineraly with the cord length. The reported incidence of prolapse of the umbilical cord varies betwixt 0.2 and 0.6 % of births.

In the present serial, out of the 1,000 cases, babies having nascency asphyxia (Apgar ≤6) were 234 (i.eastward., 23.4 %). Out of these incidences of severe birth, asphyxia was maximum in long-cord groups (56.6 %). In short-cord grouping, it was 37.3 % compared to normal-string group (xx.5 %). Higher percentage of nascence asphyxia in long-cord grouping may exist additionally due to more incidences of cord abnormalities (nuchal string, true knot, and cord prolapse). In instance of short cord, excessive traction will cause spasm of umbilical vessels; premature separation of placenta will pb to increase in nativity asphyxia.

The incidence of fetal center rate abnormalities was more in cases with brusque and long cords in our study. The study is comparable in its percentage of fetal heart abnormality in relation to variable cord length with the study by Rayburn [x].

At that place were more cases of birth asphyxia in short- and long-string groups as compared to cords with normal length.

On the other mitt, Atalla et al. [15] establish no relation betwixt umbilical string indices and intrapartum FHR decelerations, meconium staining of the amniotic fluid, or mode of delivery. Spellacy et al. [12] showed that all string complications showed significantly low Apgar scores at 1 min.

Shrestha [16] studied Nuchal cord and perinatal outcome. Neonatal outcome was analyzed by Apgar score at 1 and v min and the demand for neonatal unit access. Apgar score <seven at 1 min was present in 24.78 % (n = 29) of newborns in study group and 14.68 % (n = 58) of newborns in control group, which was statistically significant (p = 0.01).

Determination

The present written report showed that the length of umbilical string is variable; nevertheless, maximum number of cases had normal string length. Cases which had short and long cords constituted abnormal cord length. These cases had higher incidence of cord complications, increased incidence of operative interference, intrapartum complications, increased fetal heart rate abnormalities and more chances of birth asphyxia.

Thus, this report shows the importance of the knowledge of cord length.

The findings of a worrisome fetal heart rate tracing, or failure of fetal descent during labor is not uncommon. A keen obstetrician would not only be interested in proper management of such complications, but besides in documenting these important findings for further enquiry.

There is a huge arena for research in this field as what we are seeing is but the tip of an iceberg. The challenge should exist taken up, and newer equipment and strategies should be adult to analyze and avoid cord complications. This would decrease the incidences of the perinatal morbidity and bloodshed due to cord complications in the future and help in realizing the expections for the commitment of a healthy baby.

Acknowledgments

Our sincere thanks go to Dr Vasanti Munot, Ex-Hon. Ass.Prof.; my Ex-PG Guide, Dr Kurdukar, Asso. Prof.; Dr Vidya Tirankar, Asso. Prof., Department of Obstetrics and Gynecology, Dr Five. M. Govt. Medical College, Solapur for guiding us through the study.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3526711/

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