Hong Kong Med J 2015 Apr;21(2):143–8 | Epub 10 Mar 2015
DOI: 10.12809/hkmj144349
ORIGINAL ARTICLE
Impact of nuchal cord on fetal outcomes, mode of delivery, and management: a questionnaire survey of pregnant women
CW Kong, FHKAM (Obstetrics and Gynaecology); Diana HY Lee, MB, BS; LW Chan, FRCOG; William WK To, MD, FRCOG
Department of Obstetrics and Gynaecology, United Christian Hospital, Kwun Tong, Hong Kong
Corresponding author: Dr CW Kong (melizakong@gmail.com)
 Full paper in PDF
Abstract
Objectives: To explore pregnant women’s views on the impact of nuchal cord on fetal outcomes, mode of delivery, and management.
 
Design: Questionnaire survey.
 
Setting: Antenatal clinic of two regional hospitals in Hong Kong.
 
Participants: A questionnaire survey of all pregnant women at their first visit to the antenatal clinic of United Christian Hospital and Tseung Kwan O Hospital in Hong Kong was conducted between August and October 2012.
 
Results: Most participants (71.8%) were worried about nuchal cord, and 78.3% and 87.7% of them thought that nuchal cord could cause intrauterine death and fetal death during labour, respectively. Approximately 87.5% of participants thought that nuchal cord would reduce the chance of successful vaginal delivery and 56.4% thought that it would increase the chance of assisted vaginal delivery. Most (94.1%) participants thought that it was necessary to have an ultrasound scan at term to detect nuchal cord. In addition, 68.8% thought that it was necessary to deliver the fetus early and 72.8% thought that caesarean section must be performed in the presence of nuchal cord. Participants born in Mainland China were significantly more worried about the presence of nuchal cord than those born in Hong Kong. However, there was no difference between participants with different levels of education.
 
Conclusion: Most participants were worried about the presence of nuchal cord. Many thought that nuchal cord would lead to adverse fetal outcomes, affect the mode of delivery, and require special management. These misconceptions should be addressed and proper education of women is needed.
 
 
New knowledge added by this study
  •  Most women were worried about the presence of nuchal cord.
  •  Many women thought that nuchal cord would lead to adverse fetal outcomes, affect the mode of delivery, and require special management.
Implications for clinical practice or policy
  •  Avoiding routine ultrasound scans for nuchal cord in order to reduce needless maternal anxiety and unnecessary caesarean sections on women’s request is warranted.
  •  The correct concept that nuchal cord would not normally lead to adverse fetal outcomes and that its presence should not affect the mode of delivery should be publicised widely in Hong Kong.
 
 
Introduction
In daily clinical practice, pregnant women regularly request antenatal ultrasound scans to look for nuchal cord around the time of delivery or request that the presence of nuchal cord is specifically checked for when they undergo ultrasound scans for other obstetric reasons. Many women have requested elective caesarean sections because nuchal cord has been detected on ultrasound scan. In order to explore women’s views on the impact of nuchal cord on fetal outcomes, mode of delivery and management, we conducted a questionnaire survey to evaluate their true concerns and beliefs.
 
Methods
A questionnaire evaluating the impact of nuchal cord on fetal outcomes and mode of delivery were distributed to all pregnant women at their first antenatal visit to the out-patient clinic of United Christian Hospital and Tseung Kwan O Hospital from August to October 2012. The questionnaire was in three versions: traditional Chinese, simplified Chinese, and English according to the participant’s preference (Appendices 1 to 3). Participants who were not able to understand Chinese or English were excluded from the study. The questionnaires were collected by the nursing staff immediately after completion. Assuming that 50% of the women would express concern about the presence of nuchal cord, a sample size of 357 women would allow for random errors of up to 5%. Assuming the response rate to the questionnaire to be around 80%, distribution of around 450 questionnaires would be sufficient.
 
The Statistical Package for the Social Sciences (Windows version 20.0; SPSS Inc, Chicago [IL], US) was used for statistical analysis. Chi squared test and Fisher’s exact test were used when appropriate. All the differences were defined as being statistically significant at P<0.05.
 
Results
Of 950 questionnaires distributed, a total of 869 (91.5%) questionnaires were received. The demographic data of the participants are shown in Table 1. Around 72% of participants expressed worries about nuchal cord. The different demographic parameters among the participants who expressed worries about nuchal cord were analysed (Table 2). Participants born in Mainland China were more worried about nuchal cord than those born in Hong Kong. Advanced maternal age, nulliparity, and lower education level were not associated with higher maternal anxiety for nuchal cord.
 

Table 1. Demographic data of the participants (n=869)
 

Table 2. Comparison of the demographic data of participants who were concerned about nuchal cord
 
The perceived incidence of nuchal cord was assessed by a linear scale from 0% to 100%. Excluding the 50 participants who did not reply to this question, 37.9% thought that the incidence of nuchal cord was less than 20%. The perceived sonographic accuracy for nuchal cord was similarly assessed. Around one third (31.2%) of participants thought that the accuracy was less than 70% while 35 participants did not answer this question.
 
The perceived impact of nuchal cord on fetal outcomes, mode of delivery, and management are shown in Table 3. Around 78.3% and 87.7% thought that nuchal cord could cause intrauterine death and fetal death during labour, respectively, while 87.5% of participants thought that it would reduce the chance of successful vaginal delivery and 56.4% thought that it would increase the chance of assisted vaginal delivery. In addition, 94.1% of participants thought that it was necessary to have ultrasound scan to detect nuchal cord at term, while 68.8% thought that it was necessary to deliver the fetus early and 72.8% thought that caesarean section must be performed in the presence of nuchal cord.
 

Table 3. Participants’ views of nuchal cord on fetal outcomes, mode of delivery, and management of nuchal cord (n=869)
 
Women’s experience of nuchal cord from their previous pregnancies or from their relatives’ or friends’ deliveries were explored. We asked questions on the mode of delivery for nuchal cord pregnancies and whether or not the babies were healthy. Only 32 (8.8%) participants had nuchal cord in their previous pregnancies; one participant had nuchal cord in both her previous two pregnancies. Among those nuchal cord pregnancies, 48.5% of them had normal vaginal deliveries, 15.2% had instrumental deliveries, and 36.4% had caesarean sections. None of these babies were remarked to be unhealthy. A total of 142 (16.6%) participants had relatives or friends who had nuchal cord in their previous pregnancies, and some of them had more than one relative or friend who had nuchal cord in their previous pregnancies. The total number of their relatives’ or friends’ deliveries with nuchal cord was 155. Among those nuchal cord pregnancies, 31.6% of them had normal vaginal deliveries, 9.0% had instrumental deliveries, and 59.4% had caesarean sections. Approximately 6.5% of the babies were claimed to be unhealthy by the participants and such replies were evenly distributed in the normal vaginal delivery group, instrumental delivery group, and caesarean section group (Table 4).
 

Table 4. Participants’ experiences of nuchal cord
 
Table 5 shows the comparison of the views between participants with different places of birth and education levels. Those born in Mainland China were more likely to believe that nuchal cord led to assisted instrumental deliveries when compared with those born in Hong Kong (63.2% vs 50.7%). In contrast, they were less likely to believe that nuchal cord led to intrapartum death in labour (84.1% vs 90.9%) and the need for earlier delivery (64.9% vs 71.8%). There were no significant differences between the two groups in their views on the impact on intrauterine death, chance of successful vaginal delivery, and whether or not caesarean section was needed.
 

Table 5. Comparison of the participants’ views of nuchal cord on foetal outcomes, mode of delivery, and management of nuchal cord between participants born in Hong Kong and those born in Mainland China and between participants with non-tertiary education and those with tertiary education
 
For the education level, there was no significant difference for worry about the presence of nuchal cord. Those who had received tertiary education were less likely to believe that nuchal cord led to intrauterine death (71.9% vs 81.8%). However, more of this group thought that nuchal cord decreased the chance of successful normal vaginal delivery (91.8% vs 85.0%).
 
Discussion
This questionnaire survey revealed that many of our participants were worried about nuchal cord. The percentage (71.8%) was much higher than anticipated, implying that this issue should be given greater attention in the antenatal education of pregnant women. Our local audit showed that the incidence of nuchal cord was 27% among all singleton deliveries (n=5166) in 2010 (not published). Therefore, about one third of the participants underestimated the incidence of nuchal cord.
 
It is common for nuchal cord to be the indication for caesarean section in China, which accounted for 16.1% to 25.4% of the indications in a teaching hospital and some regional hospitals there.1 2 As many participants are immigrants from Mainland China, their views on nuchal cord were compared with those born in Hong Kong. Although this survey showed that participants born in Mainland China were more worried about nuchal cord than those born in Hong Kong, most participants in both groups also believed that nuchal cord could cause intrauterine death (>77%) and would reduce the chance of successful vaginal delivery (>85%). Moreover, despite variable levels of education, most participants also believed that nuchal cord would cause fetal death during labour (>87%) and more than 70% thought that caesarean section was needed in the presence of nuchal cord. Therefore, it was apparent that misconceptions about the clinical implications of nuchal cord were widespread among all groups.
 
In our survey, only 8.8% of the participants claimed to have nuchal cord in their previous pregnancies and none of them reported adverse fetal outcomes. However, a significant proportion of the participants’ experiences and impressions on nuchal cord were from their relatives and friends. From this survey, the caesarean section rate in participants’ relatives or friends with nuchal cord was high. This may be one of the reasons why so many participants thought that caesarean section must be performed for nuchal cord.
 
Women were worried about nuchal cord due to the concept that nuchal cord could lead to adverse fetal outcomes. Although some studies showed nuchal cord was associated with increased prevalence of variable fetal heart rate decelerations during labour and increased incidence of umbilical artery acidaemia, higher incidences of lower 1-minute Apgar score and meconium-stained liquor,3 4 these findings may not reflect clinically on fetal wellbeing. Furthermore, most available studies showed nuchal cord was not associated with lower Apgar scores in 5 minutes and was not associated with increase in caesarean sections, neonatal intensive care unit admissions, and perinatal mortalities.5 6 7 8 9 Such reassuring evidence supporting the benign nature of nuchal cord and the absence of true adverse impact clinically on the fetal outcomes should be publicised widely to the general population to reduce their misconceptions and anxiety.
 
Although 94.1% of participants thought that it is necessary to have an ultrasound scan to detect nuchal cord at term, this is not usually necessary. As almost all participants now have continuous fetal heart rate monitoring during labour in Hong Kong, even if there is presence of nuchal cord causing variable fetal heart rate decelerations during labour, this will be detected on cardiotocogram and appropriate actions such as fetal blood sampling or assisted delivery can be performed when needed. Avoiding routine ultrasound scans for nuchal cord should reduce needless maternal anxiety and unnecessary caesarean sections on participants’ request, as 68.8% thought that it was necessary to deliver the fetus early and 72.8% thought that caesarean section must be performed for nuchal cord.
 
Conclusion
Many pregnant women are worried about nuchal cord due to misconceptions on its effect on fetal outcomes and mode of delivery. Proper education is necessary to reduce maternal anxiety. The correct concept that nuchal cord would not normally lead to adverse fetal outcomes and that its presence should not affect the mode of delivery should be publicised widely in Hong Kong.
 
Appendices

Additional material related to this article can be found on the HKMJ website. Please go to , and search for the article.
 
References
1. Gao Y, Xue Q, Chen G, Stone P, Zhao M, Chen Q. An analysis of the indications for cesarean section in a teaching hospital in China. Eur J Obstet Gynecol Reprod Biol 2013;170:414-8. CrossRef
2. Qin C, Zhou M, Callaghan WM, et al. Clinical indications and determinants of the rise of cesarean section in three hospitals in rural China. Matern Child Health J 2012;16:1484-90. CrossRef
3. Hankins GD, Snyder RR, Hauth JC, Gilstrap LC 3rd, Hammond T. Nuchal cords and neonatal outcome. Obstet Gynecol 1987;70:687-91.
4. Singh G, Sidhu K. Nuchal cord: a retrospective analysis. Medical Journal Armed Forces India 2008;64:237-40. CrossRef
5. Sheiner E, Abramowicz JS, Levy A, Silberstein T, Mazor M, Hershkovitz R. Nuchal cord is not associated with adverse perinatal outcome. Arch Gynecol Obstet 2006;274:81-3. CrossRef
6. Shrestha NS, Singh N. Nuchal cord and perinatal outcome. Kathmandu Univ Med J (KUMJ) 2007;5:360-3.
7. Schäffer L, Burkhardt T, Zimmermann R, Kurmanavicius J. Nuchal cords in term and postterm deliveries—do we need to know? Obstet Gynecol 2005;106:23-8. CrossRef
8. González-Quintero VH, Tolaymat L, Muller AC, Izquierdo L, O’Sullivan MJ, Martin D. Outcomes of pregnancies with sonographically detected nuchal cords remote from delivery. J Ultrasound Med 2004;23:43-7.
9. Peregrine E, O’Brien P, Jauniaux E. Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section. Ultrasound Obstet Gynecol 2005;25:160-4. CrossRef