Multiple part umbilical cord entanglement and neonatal outcomes.

OBJECTIVE: Umbilical cord entanglement is known to be a major cause of fetal hypoxia and to be correlated with several neonatal complications, but almost all of the previous reports were restricted to nuchal cord. In this study, we retrospectively examined the correlation between multiple part cord entanglement and pregnancy outcomes. MATERIALS AND METHODS: A total of 2156 cases were recruited from term deliveries in our hospital from 2008 to 2012. We counted umbilical cord loop numbers not only for nuchal cord but also for trunk and limb cord entanglement. We classified the cases into three groups: no loop, single loop and multiple loops group. We statistically analyzed pregnancy outcomes statistically in the three groups. RESULTS: One thousand, four hundred and fifty-eight cases had no cord entanglement, 594 cases had single loop entanglement and 104 cases had multiple loops entanglement. Values of umbilical artery blood, pH (p = 0.002) and base excess (p < 0.001) showed significantly unfavorable status in entanglement cases, especially in the multiple loops group. A significantly larger percentage of neonates in the multiple loops group needed for oxygen (p < 0.001). CONCLUSION: Multiple umbilical cord entanglement is highly correlated with early neonatal unfavorable status and need for resuscitation.

Impact of cord entanglement on perinatal outcome of monoamniotic twins: a systematic review of the literature.

OBJECTIVE: To review the current literature concerning perinatal outcome of monoamniotic pregnancies with cord entanglement. METHODS: A search in PubMed, EMBASE and MEDLINE for articles published between January 2000 and December 2011 was performed, using the following keywords: monoamniotic/monochorionic pregnancy(ies); twins; cord entanglement; fetal ultrasound/surveillance. Inclusion criteria for the study were: monoamniotic twins with documented cord entanglement at delivery, and perinatal outcome reported as proportional rates. Exclusion criteria were: higher-order multiple pregnancy; selective feticide; presence of twin reversed arterial perfusion sequence; conjoined twins; fewer than four cases in the series; and non-English language publication. Survival rates were stratified for method of prenatal management, sonographic diagnosis of cord entanglement and delivery mode. A meta-analysis was also performed using data from articles that stratified outcome according to the presence or absence of cord entanglement at birth. Comparison between neonates with cord entanglement and controls was deemed significant if the 95% CI of the pooled odds ratios did not encompass 1. MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines were followed. RESULTS: Nine articles met the inclusion criteria for this review, including a total of 114 monoamniotic twin sets (228 fetuses) with cord entanglement. The overall survival rate was 202/228 (88.6%). Perinatal mortality occurred in 26 (11.4%) fetuses; of these, 17 (65%) died in utero and nine (35%) died at birth. Five neonatal deaths occurred as a result of prematurity, two were related to structural abnormalities and two were caused by cord entanglement. Sonographic visualization of cord entanglement did not improve outcome. Four articles were included in the meta-analysis, with no significant difference in mortality between controls (n = 66 fetuses) and twins with cord entanglement (n = 82 fetuses), and higher morbidity in controls. CONCLUSIONS: Cord entanglement does not contribute to prenatal morbidity and mortality in monoamniotic twin pregnancies.

Neonatal outcomes following a tight nuchal cord.

OBJECTIVE: The best practices for the care of a neonate born after a tight nuchal cord have not been defined. As a step toward this, we compared the outcomes of neonates born after a tight nuchal cord vs those born after a loose nuchal cord vs those born after no nuchal cord. STUDY DESIGN: This was a retrospective comparison using electronic data of all deliveries during a 6-year period (2005 to 2010) in a multihospital healthcare system in the western United States. At the time of delivery, each birth was recorded as having a tight nuchal cord, a loose nuchal cord or no nuchal cord. Nuchal cord was defined as a loop of umbilical cord ≥360° around the fetal neck. 'Tight' was defined as the inability to manually reduce the loop over the fetal head, and 'loose' as the ability to manually reduce the loop over the head. RESULT: Of 219,337 live births in this period, 6.6% had a tight nuchal cord and 21.6% had a loose nuchal cord. Owing to the very large number of subjects, several intergroup differences were statistically significant but all were judged as too small for clinical significance. For instance, those with a tight nuchal cord had a very slightly older gestational age, a very slightly lower birth weight, a preponderance of male fetuses, primagravid women, singleton pregnancies and shoulder dystocia (all P<0.001). Term neonates with a tight nuchal cord were slightly more likely to be admitted to a Neonatal Intensive Care Unit (6.6% vs 5.9% admission rate, P=0.000). Those with a tight nuchal cord were not more likely to have dopamine administered or blood hemoglobin measured on the first day, nor were they more likely to receive a transfusion or to die. The subset of very low birth weight neonates with a tight nuchal cord, compared with those with no nuchal cord, were of the same gestational age and birth weight, with the same Apgar scores, and were not more likely to have severe intraventrucular hemorrhage, retinopathy of prematurity or periventricular leukomalacia, or to die. CONCLUSION: The presence of a tight nuchal cord is not uncommon, occurring in 6.6% of over 200,000 consecutive live births in a multihospital health system. No differences in demographics or outcomes, judged as clinically significant, were associated with a tight nuchal cord. Thus, we speculate that the best practices for neonatal care after a tight nuchal cord do not involve an obligation to conduct extra laboratory studies or extra monitoring solely on the basis of the report of a tight nuchal cord.

Unanticipated difficult airway in obstetric patients: development of a new algorithm for formative assessment in high-fidelity simulation.

BACKGROUND: The objective of this study was to develop a consensus-based algorithm for the management of the unanticipated difficult airway in obstetrics, and to use this algorithm for the assessment of anesthesia residents' performance during high-fidelity simulation. METHODS: An algorithm for unanticipated difficult airway in obstetrics, outlining the management of six generic clinical situations of "can and cannot ventilate" possibilities in three clinical contexts: elective cesarean section, emergency cesarean section for fetal distress, and emergency cesarean section for maternal distress, was used to create a critical skills checklist. The authors used four of these scenarios for high-fidelity simulation for residents. Their critical and crisis resource management skills were assessed independently by three raters using their checklist and the Ottawa Global rating scale. RESULTS: Sixteen residents participated. The checklist scores ranged from 64-80% and improved from scenario 1 to 4. Overall Global rating scale scores were marginal and not significantly different between scenarios. The intraclass correlation coefficient of 0.69 (95% CI: 0.58, 0.78) represents a good interrater reliability for the checklist. Multiple critical errors were identified, the most common being not calling for help or a difficult airway cart. CONCLUSIONS: Aside from identifying common critical errors, the authors noted that the residents' performance was poorest in two of our scenarios: "fetal distress and cannot intubate, cannot ventilate" and "maternal distress and cannot intubate, but can ventilate." More teaching emphasis may be warranted to avoid commonly identified critical errors and to improve overall management. Our study also suggests a potential for experiential learning with successive simulations.

Ultrasound diagnosis and management of umbilical cord abnormalities.

The incidence of placenta and umbilical cord abnormalities is high in abnormal course of the delivery. Although the detection rate of umbilical cord abnormalities is steadily increasing with the improvement of ultrasound technology, and the fact that ultrasound scanning can distinguish umbilical cord conditions, this information has not exerted much impact on the management of labor to date. We believe prenatal detection of umbilical cord abnormalities must reduce the number of emergent cesarean sections and intrauterine fetal death. In this review, we describe the ultrasound diagnosis and management of major umbilical cord abnormalities, including abnormalities of cord insertion site (velamentous and marginal cord insertion), hypercoiled cord and nuchal cord, considering the current knowledge on physiologic and pathologic aspects of each umbilical cord abnormality.