Download PDF
CC BY-NC-ND 4.0 · Geburtshilfe Frauenheilkd
DOI: 10.1055/a-2561-6555
GebFra Science
Original Article

Detection of Nuchal Cord Based on Specific CTG Patterns Intrapartum – A Myth?

Article in several languages: English | deutsch
Lars Brodowski 
1   Klinik für Gynäkologie und Geburtshilfe, Medizinische Hochschule Hannover, Hannover, Germany (Ringgold ID: RIN9177)
,
Roza Röchte-Christoforatou
2   Zentrum für Pränatalmedizin, Hannover, Germany
,
Ismini Staboulidou
2   Zentrum für Pränatalmedizin, Hannover, Germany
,
Constantin Sylvius von Kaisenberg
1   Klinik für Gynäkologie und Geburtshilfe, Medizinische Hochschule Hannover, Hannover, Germany (Ringgold ID: RIN9177)
,
Elna Kühnle
1   Klinik für Gynäkologie und Geburtshilfe, Medizinische Hochschule Hannover, Hannover, Germany (Ringgold ID: RIN9177)
› Author Affiliations
› Further Information
Also available at
  Permissions and Reprints

Abstract

Background

Nuchal cord, the situation when the umbilical cord is wrapped around the neck of the fetus, is a common occurrence during pregnancy and intrapartum. Abnormal cardiotocography patterns (CTG patterns) during nuchal cord are usually not associated with increased perinatal morbidity. This retrospective data analysis aimed to investigate the occurrence of specific CTG patterns with nuchal cord.

Methods

150 CTGs with and 150 CTGs without nuchal cord at 60 and 30 minutes prior to delivery were randomly selected from the obstetric database of Hanover Medical School out of a total cohort of 7573 births (spontaneous delivery, vaginal-operative delivery, secondary caesarean section) between 2014 and 2017. After anonymization in accordance with the 2015 FIGO criteria, CTG patterns were interpreted by three physicians with varying levels of professional experience. The physicians were also asked to assess whether nuchal cord was present or not. The interrater variability between investigators regarding the interpretation of the CTG patterns was also investigated using proportion of agreement and kappa statistics.

Results

Nuchal cord was present in 11% of the total cohort. The study cohort and the total cohort were equivalent in terms of patient characteristics. No significant differences were found in the assessments of the three physicians with regard to CTGs with and without nuchal cord. Likewise, logistic regression analysis was unable to identify a specific CTG pattern in cases with nuchal cord intrapartum. High interpretation variability between physicians was found regarding CTG interpretations (PoA > 0.5).

Conclusion

CTG interpretation just before delivery of the infant is not useful to detect nuchal cord. Moreover, despite the existence of defined criteria, the variability between the CTG interpretations of the three physicians was high.

Keywords

nuchal cord - CTG interpretation - quality indicators

Supplementary Material



Publication History

Received: 05 January 2025

Accepted after revision: 15 March 2025

Article published online:
22 May 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References/Literatur

  • 1 Bernad ES, Craina M, Tudor A. et al. Perinatal outcome associated with nuchal umbilical cord. Clin Exp Obstet Gynecol 2012; 39: 494-497
    PubMedSearch in Google Scholar
  • 2 Carter EB, Chu CS, Thompson Z. et al. Electronic Fetal Monitoring and Neonatal Outcomes when a Nuchal Cord Is Present at Delivery. Am J Perinatol 2020; 37: 378-383
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Peesay M. Nuchal cord and its implications. Matern Health Neonatol Perinatol 2017; 3: 28
    CrossrefPubMedSearch in Google Scholar
  • 4 Henry E, Andres RL, Christensen RD. Neonatal outcomes following a tight nuchal cord. J Perinatol 2013; 33: 231-234
    CrossrefPubMedSearch in Google Scholar
  • 5 Clapp 3rd JF, Stepanchak W, Hashimoto K. et al. The natural history of antenatal nuchal cords. Am J Obstet Gynecol 2003; 189: 488-493
    CrossrefPubMedSearch in Google Scholar
  • 6 Sheiner E, Abramowicz JS, Levy A. et al. Nuchal cord is not associated with adverse perinatal outcome. Arch Gynecol Obstet 2006; 274: 81-83
    CrossrefPubMedSearch in Google Scholar
  • 7 Cohain JS. Nuchal cords are necklaces, not nooses. Midwifery Today Int Midwife 2010; (93) 46–8, 67–8
    PubMedSearch in Google Scholar
  • 8 Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor. Cochrane Database Syst Rev 2001; (02) CD000063
    CrossrefPubMedSearch in Google Scholar
  • 9 Ayres-de-Campos D, Bernardes J, Costa-Pereira A. et al. Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision. Br J Obstet Gynaecol 1999; 106: 1307-1310
    CrossrefPubMedSearch in Google Scholar
  • 10 Schaffer L, Burkhardt T, Zimmermann R. et al. Nuchal cords in term and postterm deliveries--do we need to know?. Obstet Gynecol 2005; 106: 23-28
    CrossrefPubMedSearch in Google Scholar
  • 11 Larson JD, Rayburn WF, Crosby S. et al. Multiple nuchal cord entanglements and intrapartum complications. Am J Obstet Gynecol 1995; 173: 1228-1231
    CrossrefPubMedSearch in Google Scholar
  • 12 Mastrobattista JM, Hollier LM, Yeomans ER. et al. Effects of nuchal cord on birthweight and immediate neonatal outcomes. Am J Perinatol 2005; 22: 83-85
    Thieme ConnectPubMedSearch in Google Scholar
  • 13 Wang L, Kuromaki K, Kawabe A. et al. Nuchal cord complication in male small for gestational age increases fetal distress risk during labor. Taiwan J Obstet Gynecol 2016; 55: 568-574
    CrossrefPubMedSearch in Google Scholar
  • 14 Ayres-de-Campos D, Arulkumaran S. FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Physiology of fetal oxygenation and the main goals of intrapartum fetal monitoring. Int J Gynaecol Obstet 2015; 131: 5-8
    CrossrefPubMedSearch in Google Scholar
  • 15 Blix E, Sviggum O, Koss KS. et al. Inter-observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts. BJOG 2003; 110: 1-5
    PubMedSearch in Google Scholar
  • 16 Kottner J, Audige L, Brorson S. et al. Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed. Int J Nurs Stud 2011; 48: 661-671
    CrossrefPubMedSearch in Google Scholar
  • 17 Kesrouani A, Daher A, Maoula A. et al. Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population. J Matern Fetal Neonatal Med 2017; 30: 434-436
    CrossrefPubMedSearch in Google Scholar
  • 18 Kong CW, Chan LW, To WW. Neonatal outcome and mode of delivery in the presence of nuchal cord loops: implications on patient counselling and the mode of delivery. Arch Gynecol Obstet 2015; 292: 283-289
    CrossrefPubMedSearch in Google Scholar
  • 19 Tagliaferri S, Esposito FG, Esposito G. et al. Impact of nuchal cord on antenatal and intrapartum foetal heart rate surveillance and perinatal outcome. J Obstet Gynaecol 2020; 40: 316-323
    CrossrefPubMedSearch in Google Scholar
  • 20 Hankins GD, Snyder RR, Hauth JC. et al. Nuchal cords and neonatal outcome. Obstet Gynecol 1987; 70: 687-691
    PubMedSearch in Google Scholar
  • 21 Miser WF. Outcome of infants born with nuchal cords. J Fam Pract 1992; 34: 441-445
    PubMedSearch in Google Scholar
  • 22 Nageotte MP. Fetal heart rate monitoring. Semin Fetal Neonatal Med 2015; 20: 144-148
    CrossrefPubMedSearch in Google Scholar
  • 23 Ekengard F, Cardell M, Herbst A. Impaired validity of the new FIGO and Swedish CTG classification templates to identify fetal acidosis in the first stage of labor. J Matern Fetal Neonatal Med 2022; 35: 4853-4860
    CrossrefPubMedSearch in Google Scholar
  • 24 Ekengard F, Cardell M, Herbst A. Low sensitivity of the new FIGO classification system for electronic fetal monitoring to identify fetal acidosis in the second stage of labor. Eur J Obstet Gynecol Reprod Biol X 2021; 9: 100120
    CrossrefPubMedSearch in Google Scholar
  • 25 Schneider KT. [Comments on the Guideline: Use of CTG during pregnancy and childbirth]. Z Geburtshilfe Neonatol 2006; 210: 36-37
    Thieme ConnectPubMedSearch in Google Scholar
  • 26 Palomaki O, Luukkaala T, Luoto R. et al. Intrapartum cardiotocography -- the dilemma of interpretational variation. J Perinat Med 2006; 34: 298-302
    CrossrefPubMedSearch in Google Scholar
  • 27 Rei M, Tavares S, Pinto P. et al. Interobserver agreement in CTG interpretation using the 2015 FIGO guidelines for intrapartum fetal monitoring. Eur J Obstet Gynecol Reprod Biol 2016; 205: 27-31
    CrossrefPubMedSearch in Google Scholar