The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

The Effects of umbilical cord entanglement upon

labor management and fetal health: retrospective
case control study

Nuriye Buyukkayaci duman, Senay Topuz, Mehmet Omer Bostanci, Umit

Gorkem, DeryaYuksel Kocak, Cihan Togrul & Tayfun Gungor

To cite this article: Nuriye Buyukkayaci duman, Senay Topuz, Mehmet Omer Bostanci, Umit
Gorkem, DeryaYuksel Kocak, Cihan Togrul & Tayfun Gungor (2017): The Effects of umbilical cord
entanglement upon labor management and fetal health: retrospective case control study, The
Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2017.1293033

To link to this article: http://dx.doi.org/10.1080/14767058.2017.1293033

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The Effects of umbilical cord entanglement upon labor management and fetal health:

retrospective case control study

Nuriye BUYUKKAYACI DUMAN – Department of Obstetric and Gynecology Nursing, Hitit

University School of Health, Corum, TURKEY

Senay TOPUZ – Department of Midwifery, Ankara University Faculty of Health Sciences,

Ankara, TURKEY

Mehmet Omer BOSTANCI, Corresponding author, Department of Physiology, Hitit University

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Faculty of Medicine, Corum, TURKEY

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Umit GORKEM – Department of Obstetric and Gynecology, Hitit University Faculty of

Medicine, Corum, TURKEY

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Derya YUKSEL KOCAK – Department of Obstetric and Gynecology Nursing, Hitit University
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School of Health, Corum, TURKEY

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Cihan TOGRUL –Department of Obstetric and Gynecology, Hitit University Faculty of

Medicine, Corum, TURKEY

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Tayfun GUNGOR –Department of Obstetric and Gynecology, Hitit University Faculty of

Medicine, Corum, TURKEY

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Correspondence
Email: mobostanci@hotmail.com
Phone, +90 364 2221100-5002
Fax, +90 364 2221102

Short title: The Effects of Umbilical Cord Entanglement

Keywords: Umbilical Cord Entanglement, labor Management, Fetal Health

Abstract

Objective: This retrospective study aimed at determining prognostic factors that paved the way

for Umbilical Cord Entanglement (UCE) and the effects of UCE upon labor management and

fetal health.

Methods: 60 women who gave term birth with head presentation and received UCE diagnosis

following birth composed the case group while another 60 women with the same characteristics

who were selected with randomized sampling method and who did not develop UCE comprised

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the control group. The data obtained were processed with SPSS 22.0 statistical program. T test

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was used for comparing demographic and obstetric data and mean birth weight of babies in the

case group and control group. For comparing data on active labor management and fetal health,
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numbers, percentages and chi-square test were used. Also for comparing values <5, fisher’s chi-

square test was employed.

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Results: Emergent cesarean delivery (case: 58.3.0%; control: 21.7%), vacuum assisted vaginal
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delivery (case: 20.0%; control: 3.3%), forceps assisted vaginal delivery (case: 8.3%; control:

1.7%), fetal distress (case: 60.0%; control: 25.0%), amniotic fluid meconium (case: 58.3%;
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control: 21.7%), APGAR score less than 7 at the 1st minute (case: 58.3%; control: 21.7%) and

APGAR score less than 7 at the 5th minute were higher in the women in the case group than the
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women in the control group (p<0.05).

Conclusion: UCE increased rates of interventional birth, emergent cesarean delivery, vacuum

assisted vaginal delivery, forceps assisted vaginal delivery, amniotic fluid meconium and fetal

distress.
Introduction

Umbilical cord entanglement (UCE) is defined as a 360 degree wrapped cord around the fetus’

neck, body, and extremities [1-3]. Clinically, UCE is most commonly seen as nuchal cord

entanglement [4,5] and its prevalence generally ranges from 15.0% to 30.0% at term pregnancies

[6-8]. Basic reasoning for UCE is the fetus’ movements for cephalic presentation at third

trimester. UCE mostly resolves on its own as time for birth nears [5,7,9]. However in some cases,

it cannot resolve because it is entangled [10]. The effect of UCE upon active labor management

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and fetal health is disputable. In some studies, it is reported that cases with UCE do not present

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any complications against fetal health during labor and have vaginal delivery without any

problem [7,9]. In contrast, other studies reported that UCE delays second stage of labor because
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it prevents engagement of fetal head [1-3]. In these studies, UCE is associated with interventional

birth risks, acute fetal distress (AFD), amniotic fluid meconium, high incidence of emergent
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cesarean delivery, neonatal asphyxia, and neonatal death risk [1-3]. As the number of the loops
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increases or umbilical cord tightens, it is reported that risk for AFD increases during labor [10].

Therefore, it is thought that to explore the effect of UCE upon labor process and fetal health will
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guide practices of health care personnel who work at obstetric clinics. This was the determinant

factor in undertaking the current study. The aim of the present study is to determine the
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prognostic factors that paved the way for UCE and effects of UCE upon labor management and

fetal health.

Methods

The current study was a retrospectively designed case-control study to determine the effect of

umbilical cord entanglement upon active labor management. The population of the study was

composed of women who gave birth at obstetric clinics of Hitit University Research and Training
Hospital between April 2011 and October 2012. During the same period 60 women who gave

term birth with head presentation and received UCE diagnosis following birth composed the case

group, while another 60 women with the same characteristics who were selected with randomized

sampling method and who did not develop UCE comprised the control group. Sample size was

calculated by using Altman nomogram (80 % power). Accordingly, in the study of Dundar et al.

(2006) previously done on the same subject it was found that incidence of cord entanglement

around fetal neck was 16.5 % which was taken as a reference to calculate the size of the sample

of the current study [1]. UCE diagnoses were made by the obstetrician or midwives/nurses who

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delivered the baby in cases that presented at least one umbilical cord entanglement around the

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fetus’ neck, body, and extremities following birth. Cases with chronic systemic diseases

(diabetes, hypertension, renal diseases), multiple pregnancies, preterm labor, premature rupture of
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membranes, abnormal fetal presentation (breech presentation, face presentation, transverse

presentation), and amniotic fluid anomalies (oligo-polyhydramnios) were not included in the
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study. Fetal heart rate was routinely and regularly monitored with fetal monitorization during
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active, latent, and transitional phases. Fetal bradycardia, late deceleration, and variable

deceleration were identified as fetal distress. Accordingly, cases whose fetal heart rate (FHR) was
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under 100 beats per minute were assessed as having fetal bradycardia, cases whose FHR lasted at

least for 30 seconds and 40 beats per minute were assessed as having late deceleration, and cases
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whose FHR lasted shorter than 2 minutes and under 15 beats per minute were assessed as having

variable deceleration [11]. Term pregnancies were those between 37th and 42nd weeks. For the

collection of the data, a data collection form designed by the researchers in line with the literature

and containing 20 questions about labor management and fetal health was employed. The

APGAR scoring system was used in order to assess post-natal physical conditions of babies in

the case group and control group [12]. According to APGAR system, scoring is made between 0-
2 in terms of heart rate, respiratory effort, muscle tone, response to stimulus, and skin color.

Accordingly babies whose APGAR score was between 8 and 10 were referred to as healthy.

Cases whose APGAR score was below 7 was referred to as neonatal asphyxia. This assessment

was performed at the 1st postnatal minute and 5th postnatal minute. The data obtained were

processed with SPSS 22.0 statistical program. T test was used for comparing demographic and

obstetric data and mean birth weight of babies in the case group and control group. Chi-square

test was used for comparing data on active labor management and fetal health. Also for

comparing values below 5, fisher’s chi-square test was employed.

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Ethical Considerations

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The ethical suitability of the research was approved by Ethical Council of the Medicine Faculty

of Medipol University (590). For the pre-test of the research instruments and the administration
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of the research, the necessary permissions were obtained from the hospital.

Results
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In the present study, the difference between the case group and control group was statistically
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insignificant in terms of mean age (case: 30.89±2.42; control: 29.34±2.46), gestational week

(case: 40.00±0.41 week; control: 39.46±0.60 week), gravidy number (case: 1.45±0.44; control:
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1.42±0.45), parity number (case: 1.55±0.40; control: 1.58±0.47), birth weight (case:

3345.06±1.01 g; control: 3296.08±1.43 g) and male fetus rate (case: % 55.0; control: % 43.0)
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(p>0.05, Table 1). Besides both groups, neither presented intrauterine growth retardation (IUGR)

nor had babies with low (LBW).

In the present study, the type of UCE of nearly all the women in the case group was nuchal cord

entanglement (96.7%). It was observed that the umbilical cord was wrapped around the body of

fetus in only two women. As for the case group, when the number of umbilical cord

entanglement of women was examined it was noted that 41.7% of women had umbilical cord
entanglement once (n=25) while 48.3% of them had umbilical cord entanglement twice (n=35).

When case and control groups were compared in terms of some characteristics related to active

labor management and fetal health second phase of 80.0% of the women in the case group and

33.3% of the women in the control group prolonged. Similarly 80.0% of the case group had

interventional labor while 25.0% of the control group had interventional labor. When the groups

were examined in terms of mode of interventional labor, the rate of emergent cesarean delivery

was higher in the case group (81.2%) than the control group (67.3%). The difference between the

groups was statistically found to be significant (p<0.05). Also, rates of vacuum assisted vaginal

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delivery (case: 20.0%; control: 3.3%), forceps assisted vaginal delivery (case: 9.7%; control:

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6.3%) were higher in the case group than the control group. The difference between case and

control groups was statistically found to be significant in terms of vacuum assisted vaginal
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delivery and emergent cesarean delivery (p<0.05) but the difference between the groups was

statistically found to be insignificant in terms of forceps assisted vaginal delivery (p>0.05, Table
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2). In addition rates of fetal distress (case: 60.0%; control: 25.0%), amniotic fluid meconium
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(case: 58.3%; control: 21.7%), APGAR score less than 7 at the 1st minute (case: 58.3%; control:

21.7%) and APGAR score less than 7 at the 5th minute were higher in the women in the case
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group than the women in the control group. This difference between the groups was statistically

found to be significant (p<0.05, Table 3.).

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Discussion

In some studies, it is reported that umbilical cord entanglement (UCE) defined as cord that is

wrapped around the fetus’ neck, body and extremities 360 degrees causes operative vaginal

delivery, cesarean delivery and fetal asphyxia [1-3] whereas in others it does not affect labor

management and fetal health directly [7,9]. Clinically the most commonly encountered UCE is

nuchal entanglement. [4,5]. Similar to the literature, in our study it was detected that the
umbilical cord was wrapped around the neck of the fetus in among nearly all the women in the

case group (96.7% ).

It was reported that UCE occurred independently of maternal age, gravidy number, and

gestational week. (2,7,8,13). In the study of Zahoor et al. where 1176 cases were examined, it

was reported that maternal age and gestational week are not effective on UCE development [13].

When the literature was examined, different findings were discovered related to the role of parity

number on UCE development. In the study of Onderoglu et al. (2008) it was reported that there

was a positive correlation between multiparity and UCE [7]. In the study of Zahoor et al. in

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which primiparous and multiparous women were compared in terms of UCE, it was concluded

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that there was no correlation between parity and UCE [13]. Similarly, in our study it was

observed that the number of gravida and parity did not affect UCE (p>0.05).
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According to the literature, although umbilical cord entanglement may occur at any

trimester of pregnancy entanglement, it can be easily resolved in the first trimester. However,
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during the last weeks of pregnancy, UCE risk increases due to movements of the fetus engaged
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with the cord. [1,3]. In a review study of Martinez-Aspas et al. on UCE, it was emphasized that

UCE is frequently seen during the last weeks of pregnancy [5]. In the current study, UCE
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diagnoses were made by obstetricians and midwives/nurses during birth. According to the

literature however, it is thought that UCE may have occurred among the women in the case group
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during the last weeks of pregnancy. The fact that we did not have ultrasound images for the last

trimester of pregnancy was a limitation of the study.

In some of the relevant studies it was stated that UCE risk may increase in the case of a

male fetus [1,13]. Likewise, the rate of a male fetus among the women in the case group was

higher than the control group but the difference was statistically insignificant (p>0.05).
 Outcomes of the some studies show that UCE may lead to IUGR or risk for low birth

weight rarely [3,14]. In some cases UCE may occur with normal perinatal outcomes

[1,7,13,15,16]. This situation is associated with such factors as the amount of amniotic fluid

meconium, number of cord entanglements, and cord pressure [3]. In the present study, there were

no IUGR or neonates with low birth weight. Hence it may be argued that UCE did not affect

intrauterine fetus growth and this finding aligned with literature.

Because UCE prevents fetal head from being engaged with pelvis, it may retard labor

process, which as a result, may lead to increased rate of interventional birth and emergent

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cesarean delivery. Relevant studies show that the need for interventional birth, mainly vacuum

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and cesarean delivery, increased in UCE cases [1, 17]. Similarly in our study, it was seen that

second stage of labor was longer in women in the case group than the control group. Rates of
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interventional vaginal delivery and emergent cesarean delivery among the women in the case

group were higher than the control group. Additionally, rates of vacuum assisted vaginal delivery
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and forceps assisted vaginal delivery were higher in case group as compared to control group
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(p<0.05). As far as this finding was concerned, it may be suggested that UCE increased duration

of second stage labor and the need for interventional delivery and emergent cesarean delivery.
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According to a recent study, UCE is associated with cord knots, pressure and umbilical

cord prolapses, as well as neonatal asphyxia and mortality [16]. UCE manifested with fetal
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bradycardia, variable deceleration, and late deceleration may be seen during antepartum and

intrapartum period. As the number of cord entanglement increases, so do these signs and they

may lead to intrapartum fetal distress [3,13,15,16]. Some studies conducted with cases with

oligohydramnios stated that prevalence of fetal distress augmented due to increasing umbilical

cord pressure during uterus contractions [1, 3]. In the present study, it was found that rates of

fetal distress and amniotic fluid meconium of women in the case group who do not have
oligohydramnios were higher than the control group (p<0.05). Concurrently, the mean APGAR

score less than 7 at the 5th minute was higher among neonates of the women in the case group

than neonates of the women in the control group (p<0.05). According to our findings, it may be

suggested that UCE increased fetal distress, amniotic fluid meconium, and neonatal asphyxia risk

alone.

In the study of Kobayashi et al. (2015), it was identified that fetuses of the cases with

UCE were under high risk for low APGAR score. In another study, Assimakopoulos et al. (2005)

was also reported that UCE resulted in low APGAR score. The study of Onderoğlu et al. (2008)

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indicated that cases with more than one cord entanglements had abnormal fetal heart rate and

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high risk for amniotic fluid meconium. These results are consisted with the present study.

The relevant studies pointed out that fetal mortality was rarely seen in cases with UCE
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[13,15,16]. Such factors as oligohydramnios, high number of entanglement, and umbilical cord

compression augment fetal mortality risks [3, 13,15,16]. In our study, although cases with UCE
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presented increased levels of fetal distress and amniotic fluid meconium, no fetal mortality
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occurred which may be explained by the possibility that the umbilical cord was wrapped once or

twice at most and cases had normal amount of amniotic fluid among the case group with UCE.
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Conclusion

Outcomes of the present study pointed out that UCE increased rates of interventional birth,
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emergent cesarean delivery, vacuum assisted vaginal delivery, forceps assisted vaginal delivery,

and amniotic fluid meconium. Additionally, among babies in the case group with UCE, rates of

mean APGAR score less than 7 at the 1st minute and mean APGAR score less than 7 at the 5th

minute were higher than the women in the control group. Based on the results of the study, it can

be said that the knowledge of the UCE, type of entanglement, and number of entanglement by

color doppler ultrasonography especially in the third trimester of pregnancy is important in terms
of fetal health and management of labor. New studies should be done to determine the effects of

UCE upon labor and fetal health amongst cases with oligohydramnios.

Declaration of Interest

The authors report no conflicts of interest.

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Table 1. Distribution of the women in case and control groups in terms of some

demographic and obstetric characteristics

Fetal Health Status Groups Mean±SD t Value

Case 30.89 ±2.42

Maternal age (year) 3.4793
Control 29.34 ± 2.46

Case 40.00 ± 0.41

Gestational age (week) 5.7559
Control 39.46 ±0.60

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Case 1.45±0.44
Gravida number 0.3692

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Control 1.42±0.45

Case 1.55±0.40
Parity number 0.3765
Control
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Case 3345.06 ±1.01

Birth weight (g) 216.711
Control 3296.08 ± 1.43
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Table 2. Distribution of the women in case and control groups in terms of labor management

according to some characteristics

Groups
Case Control
Characteristics (N=60) (N=60) Chi-Square p

Prolongation of second stage of labor % 80.0 % 33.3 26.606 0.000

Interventional birth % 80.0 % 25.0 36.391 0.000
Type of interventional birth

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Cesarean delivery % 67.3 % 81.2 15.313 0.000
Vacuum assisted vaginal delivery % 23.0 % 12.5 - 0.001

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Forceps assisted vaginal delivery % 9.7 % 6.3 - 0.207
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Table 3. Distribution of fetuses in case and control groups in terms of fetal health status

Groups
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Case Control
Fetal Health Status (N=60) (N=60) Chi-Square p
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Amniotic fluid meconium % 58.3 % 21.7 15.313 0.000

Fetal Distress % 80.0 % 25.0 13.642 0.000
APGAR Score at the 1st minute < 7 % 58.3 % 21.7 15.313 0.000
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APGAR Score at the 5th minute < 7 % 20.0 % 3.3 - 0.001

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