Multiple Nuchal Cord Loops

Multiple nuchal cord loops are two or more coils of umbilical cord around the fetal neck, with double loops less common than a single loop and triple or more rare. They result from a long cord and active fetus. They matter because they carry a higher chance of fetal heart rate abnormalities, operative delivery, low Apgar scores and, if tight, fetal hypoxia.

• Risk factors: long cord, polyhydramnios, male fetus, multiparity, fetal hyperactivity.
• A tight cord around the neck with multiple loops is the main danger.
• Most babies are born healthy.

Women are usually well. The baby shows repeated variable decelerations in labour, slow descent or a delivery with several coils around the neck and sometimes the body.

• Variable decelerations that become deeper and longer.
• Cord felt tight at the neck at birth.
• Differential diagnosis: single nuchal cord, true knot, cord prolapse, short cord, abruption, cephalopelvic disproportion.
• Complications: fetal hypoxia, low Apgar score, hypoxic ischaemic encephalopathy, emergency caesarean section, assisted vaginal delivery, shoulder dystocia delay, stillbirth, neonatal death.

The approach is ultrasound with colour Doppler, with cardiotocography in late pregnancy and labour.

• Ultrasound with colour Doppler: two or more rings of cord vessels around the neck, confirmed in two planes.
• Cardiotocography: variable decelerations with slow recovery, reduced variability.
• Estimated fetal weight, amniotic fluid index, umbilical artery Doppler.
• At birth: count the loops and test tightness once the head is delivered; umbilical cord blood gas.

The principle is monitoring, prompt recognition of pathological tracing and a safe technique to free the cord.

• Supportive: no intervention for normal tracings; daily fetal movement counts; continuous cardiotocography in labour; left lateral position; birth in a facility with caesarean section and neonatal care.
• Pharmacological: oxytocin 10 IU IM at birth; terbutaline 0.25 mg subcutaneous once for uterine hyperstimulation with decelerations; Ringer's lactate 500 to 1000 mL IV over 15 to 30 minutes for intrauterine resuscitation; cefazolin 2 g IV before caesarean section; neonatal adrenaline 0.01 to 0.03 mg/kg IV (0.1 to 0.3 mL/kg of 1 in 10,000) if heart rate stays below 60 per minute after 30 seconds of effective ventilation and compressions.
• Procedures: slip loose loops over the head or shoulders one at a time; for tight loops use the somersault manoeuvre or clamp with two clamps and cut between them, then deliver the shoulders at once; do not pull the cord; assisted vaginal delivery when fully dilated with a pathological tracing; caesarean section aiming for birth within 30 minutes of the decision for persistent pathological tracing; neonatal bag and mask ventilation at 30 to 60 breaths per minute with chest compressions in a ratio of 3 to 1 if the heart rate stays below 60 per minute.
• Red flags: prolonged decelerations, bradycardia, absent variability, reduced fetal movements, floppy or pale baby at birth.
• Follow-up: umbilical cord blood gas; newborn Apgar score and neurological examination; observation for 24 hours with feeding and temperature checks; monitor for neonatal encephalopathy over 72 hours if depressed.