Extra long cord with true knots: unlikely to happen again, right??

[Qbear'smama]

I will ask my MW about this but since I am not seeing her until late August, I thought I would see if anyone here has an opinion or insight. DD was born with an umbilical cord that was 1/3 longer than average (it was way long!) and a tangle of true knots in it. Essentially, the extra length kept it from tightening but it was nonetheless a miracle that she was alive and healthy with a knotted cord like that. Now when I feel the one I am pregnant with flipping around, it worries me like, "is he tying knots right now??" I am really hoping it was just a weird occurrence with DD, any thoughts?

[MsBlack]

Cord wraps and even 'true knots' (even more than one) seldom present a risk to otherwise healthy babies. It might seem like a miracle that your baby was not compromised, but really, it's a pretty ordinary part of the process!

Here is a good analogy: take a garden hose; when it is empty and warmed by the sun, you might be able to tie a knot in it tight enough that the knot actually prevents flow--or at least greatly constricts normal flow--once you turn the water on.

Now take a hose that is already turned on. Imagine trying to tie a tight knot in that hose--or even go do this experiment--you will find that it is very difficult to make the knot tight enough to reduce the water supply at all. The water inside the hose is able to hold the hose walls open, the water pressure and density are strong enough forces to prevent a tight knot from being tied, prevent any real kinking in the hose that might reduce water flow. You can also take a full hose that is stopped by a valve at the far end of the water supply (with no knots, just a straight hose)--and step on it. You'll find that it's pretty hard to fully compress the hose to shut off the flow. Same goes for cord.

An umbilical cord is live thing, not a hose, but the same general physics principles apply. The cord is never empty, but always full of blood under pressure. Further, in a healthy cord and baby, there are other factors of the cord's design that help it to maintain good strong bloodflow in the presence of various stressors--not just knots. For instance, because of the jelly-like substance inside the cord, surrounding the blood vessels of the cord, and because of the wet conditions inside the womb itself, it is pretty hard for a baby to compress the cord during pregnancy. The cord is going to tend to slip/slide out of the way if baby's shifting starts to trap it between baby and the mom's body. Cord compression can occur, of course--but given the closer and closer quarters of baby and cord within the womb as pregnancy advances, along with baby's increasing weight and strength, the cord's normal construction does very well to prevent mishaps along the way.

Also, if the cord does get trapped and thus compressed, leading to a failure of sufficient blood flow and oxygen to baby, this will set off alarms in the baby--who will wiggle, squirm, kick, thus shifting it's position and most always freeing the cord from entrapment. During labor, with the pressure of contrax, the ever-shrinking uterus, cord compression is not always preventable no matter the health of the cord or baby's attempts to wiggle things free--the cord can get trapped between baby and mom's pelvis (hidden or obvious cord prolapse), but this is unusual.

Finally--it is with those extra long cords that you are most likely to see knots and wraps. Knots can occur more easily in a longer cord, just from baby swimming around in there with so much slack in the cord. But think of the knots and wraps as nature's way of preventing cord prolapse--when the cord is shortened by being wrapped around the neck or body, it is just less likely to slip down ahead of baby!

We can trust that the design is quite efficient in many ways, including the eventual labor-pattern where mom and baby make needed adjustments to accomodate baby's survival as indicated. Remember that there is continuous biochemical feedback between mom and baby, that helps labor adjust itself just as needed for best outcome. With one of the multi-wraps I've seen (the worst one), for instance, 1st stage of labor was stop-start, and seemed fairly mild for the most part and baby stayed high for longer than mom's cervical dilation seemed to indicate. Then suddenly, 'all hell broke loose': mom got to complete, and pushing lasted only a few minutes--a very rapid, intense few minutes. That cord did indeed tighten enough during baby's descent to reduce bloodflow through the baby's neck--but only for a brief time. Just as soon as baby was out, cord slackened enough to be able to unwrap it, and circulation resumed immediately.

Cord wraps/'nuchal cord' is fairly common--knots less common but also not 'rare'--but problems from this are relatively UNcommon. I've never seen one that actually prevented safe birth, tho it can happen on rare occasion. So again...your birth wasn't any more miraculous than any other birth; you just got to witness a highly efficient design work well in the normal course of things

[GuildJenn]

My first baby died (after four days of seizures and pain) from a 2x nuchal cord and researching it is a dark hobby of mine.

It's a very poorly understood issue and it tends to polarize the medical birth/natural birth debate because the natural community sees nuchal cord issues as mostly-safe and the medical community sometimes points out loops around the neck etc. as justification for a c-section even though it's true it might never have led to an issue. Regardless, there isn't good research anyway.

Here's the latest round-up of research which may or may not be useful. http://docs.google.com/viewer?a=v&q=...ctDnujATT-C6Pw If you take that as the best info available right now...

Yes, you are marginally more likely to have a cord issue than people who have never had one, statistically. No one knows why, and the difference is not that great. The chances are still very low.

What you may want to discuss with your provider is that there has been some recent research that there are some minor signs of cord distress. They are: LOTS of hiccuping and also, frantic motion in the night when the mother is sleeping (probably enough to wake you up). The theory is that as the cord is becoming more compromised the baby compensates with more of each of those things.

However, a lot of providers are concerned about this because they don't want pregnant women to worry about what is ALSO normal behaviour. That's fine, but I don't like people paternalistically keeping info from me so I don't worry.

[GuildJenn]

Oh and P.S. - my son was born with no cord issue whatsoever even though my daughter's wrap was one of the worst.

[MsBlack]

Originally Posted by GuildJenn

My first baby died (after four days of seizures and pain) from a 2x nuchal cord and researching it is a dark hobby of mine.

It's a very poorly understood issue and it tends to polarize the medical birth/natural birth debate because the natural community sees nuchal cord issues as mostly-safe and the medical community sometimes points out loops around the neck etc. as justification for a c-section even though it's true it might never have led to an issue. Regardless, there isn't good research anyway.

Here's the latest round-up of research which may or may not be useful. http://docs.google.com/viewer?a=v&q=...ctDnujATT-C6Pw If you take that as the best info available right now...

Yes, you are marginally more likely to have a cord issue than people who have never had one, statistically. No one knows why, and the difference is not that great. The chances are still very low.

What you may want to discuss with your provider is that there has been some recent research that there are some minor signs of cord distress. They are: LOTS of hiccuping and also, frantic motion in the night when the mother is sleeping (probably enough to wake you up). The theory is that as the cord is becoming more compromised the baby compensates with more of each of those things.

However, a lot of providers are concerned about this because they don't want pregnant women to worry about what is ALSO normal behaviour. That's fine, but I don't like people paternalistically keeping info from me so I don't worry.

Great--I really appreciate your posting this info and your own history, GuildJenn.

I haven't yet looked into the link, so perhaps this stuff is covered there--but I wanted to mention a couple things you reminded me of.

1. When true knots, or otherwise 'ordinary' cord wraps (not excessive) end up causing problems or even death for a baby, one possible reason for this is that for that baby, the cord did not form 'perfectly right' Deficiency of the jelly between the umbilical vessels, for instance, can leave the cord with inadequate mechanism for resisting ordinary stressors of baby movement in utero, or allow true knots to draw tight enough to compromise circulation (when ordinarily they don't draw that tight). In that kind of case, it's not so much the cord knots or wraps that are the problem...it's the construction of the cord itself. Wraps and knots are far more common than are cords which develop too poorly to their job well enough.

2. My last baby was born by csec that I knew was needed from heart tones and other labor signs, tho it wasn't clear why until delivery. That's when it was discovered that he had major, excessive cord wrapping around his neck, body and limbs. This explained why, in transition when he tried repeatedly to descend, he would jerk back up again within several seconds (I felt this very clearly). His heart rate would plummet, and remain scary-low for many seconds before resolving to normal once he'd moved back up. It seems 2 things were in play with that: one, when he tried to enter the pelvis, his cord was compressed badly, in several places. 2, when he tried to descend, all those wraps left him with no slack in the line--he was pulling on the cord and placenta (which started to separate some during labor). However, his apgars were great, the csec did prevent those cord issues from harming him in any way--it was a fine cord, fed him into a 9lb 9oz baby, it was just unusually well-wrapped, too much for normal birth.

But I want to add that until advanced labor, he never showed the signs you mentioned as to hiccups or wild movement. His movement sure got wild once I was 7-8cms, tho, every time he started to descend in response to the force of contrax. Prior to that tho, he behaved normally in every way during pregnancy. And he was the only 1 of 6 to have any cord wrapping at all.

Also--one of my other babes did demonstrate a lot of hiccups, and way wild movement during most of my pregnancy. No cord issues tho--and a rough but normal birth (rough due to malpositioning). He was just always and remained a highly active child.

For myself, I never hope to dismiss anyone's concerns out of hand. No, worrying is not helpful in any case--but a persistent concern, one that is not adequately laid to rest with information/understanding, can be a sign that mama knows something that monitoring by any means cannot fully show. That is something to respect IMO. Yet, when I hear someone like the OP saying that it was a 'miracle my baby survived', it's right, IMO, to speak of the evidence and the usual trends with respect to cord wraps. I wasn't at her birth--I can't say whether or not it was actually a close call--but I do know that knots, even multiple knots, are rarely a cause of real problems or even 'close calls'.

But yes--knots and cordwraps CAN be a problem, as we are both in a position to know from experience...your experience even more compelling than mine.

Now to go look at that link...thanks again, I'm rebuilding my database after a computer crash last year swallowed all my links--I appreciate your sharing

[2xand2y]

My first born had an extremely short (and thin) cord, she had hiccups ALL the time. Now she is a perfectly healthy 9 year old. My subsequent 3 kids all had average cords. I just wanted to mention it because, your body/and your babies won't always grow the same kind of cord.

[GuildJenn]

Originally Posted by MsBlack

Great--I really appreciate your posting this info and your own history, GuildJenn.

1. When true knots, or otherwise 'ordinary' cord wraps (not excessive) end up causing problems or even death for a baby, one possible reason for this is that for that baby, the cord did not form 'perfectly right' Deficiency of the jelly between the umbilical vessels, for instance, can leave the cord with inadequate mechanism for resisting ordinary stressors of baby movement in utero, or allow true knots to draw tight enough to compromise circulation (when ordinarily they don't draw that tight). In that kind of case, it's not so much the cord knots or wraps that are the problem...it's the construction of the cord itself. Wraps and knots are far more common than are cords which develop too poorly to their job well enough.

True, but in my case the pathology report showed that the cord was normal. It was an issue of lack of slack - and if you read the info, that often is the determining factor (not that the ones you cited aren't), and that's really just a positioning issue - where is the cord.

Bottom line: No one really knows why some situations are dire and many are not, because it hasn't been studied adequately and the numbers are low in any case.

Originally Posted by MsBlack

2. My last baby was born by csec that I knew was needed from heart tones and other labor signs, tho it wasn't clear why until delivery. That's when it was discovered that he had major, excessive cord wrapping around his neck, body and limbs. This explained why, in transition when he tried repeatedly to descend, he would jerk back up again within several seconds (I felt this very clearly). His heart rate would plummet, and remain scary-low for many seconds before resolving to normal once he'd moved back up. It seems 2 things were in play with that: one, when he tried to enter the pelvis, his cord was compressed badly, in several places. 2, when he tried to descend, all those wraps left him with no slack in the line--he was pulling on the cord and placenta (which started to separate some during labor). However, his apgars were great, the csec did prevent those cord issues from harming him in any way--it was a fine cord, fed him into a 9lb 9oz baby, it was just unusually well-wrapped, too much for normal birth.

That's similar to my daughter (the monitoring was misread by the hospital staff), but of course her Apgars were terrible (she was born flat and revived).

Originally Posted by MsBlack

But I want to add that until advanced labor, he never showed the signs you mentioned as to hiccups or wild movement. His movement sure got wild once I was 7-8cms, tho, every time he started to descend in response to the force of contrax. Prior to that tho, he behaved normally in every way during pregnancy. And he was the only 1 of 6 to have any cord wrapping at all.

Yes... if you read the research you'll see it's not a hundred percent relationship. What the research asked was "could there be ANY indication prior to labour" and there is a correlation with those behaviours. It doesn't mean it's a clear exact sign. But so far it's the only one they've been able to correlate with besides cord anomalies spotted on an ultrasound.

If you're a mother who wants to know what she could look for, personally, I'd like to know if there is a possibility there could be advanced warning. Some people don't, but I assume they're not on the Internet asking & looking.

Originally Posted by MsBlack

For myself, I never hope to dismiss anyone's concerns out of hand. No, worrying is not helpful in any case--but a persistent concern, one that is not adequately laid to rest with information/understanding, can be a sign that mama knows something that monitoring by any means cannot fully show. That is something to respect IMO. Yet, when I hear someone like the OP saying that it was a 'miracle my baby survived', it's right, IMO, to speak of the evidence and the usual trends with respect to cord wraps. I wasn't at her birth--I can't say whether or not it was actually a close call--but I do know that knots, even multiple knots, are rarely a cause of real problems or even 'close calls'.

But yes--knots and cordwraps CAN be a problem, as we are both in a position to know from experience...your experience even more compelling than mine.

Now to go look at that link...thanks again, I'm rebuilding my database after a computer crash last year swallowed all my links--I appreciate your sharing

Slight rant ahead:

You know...I don't like how the natural birth community continually negates women's narratives when they come away with an understanding from their deliveries that there was a serious risk of problems.

I mean yes on the one hand I get that it's part of the "battle" about delivery=emergency and all that. But on the other hand, this is exactly the behaviour that white male doctors have been accused of in dealing with women clients forever - that they negate that woman's fears and experience.

"Oh no that won't happen" isn't the same as "999 times in 1000 that won't happen."

The truth is that sort of like a funny mole on your skin, a baby with wraps and knots in the cord is at higher risk of a poor outcome than one that doesn't have any. Like having a funny mole doesn't mean you have cancer, having cord issues doesn't mean your baby will die. But it also doesn't mean it never happens, and each person+provider has to make the decisions at the time that make the most sense.

[Qbear'smama]

Originally Posted by GuildJenn

Slight rant ahead:

You know...I don't like how the natural birth community continually negates women's narratives when they come away with an understanding from their deliveries that there was a serious risk of problems.

I mean yes on the one hand I get that it's part of the "battle" about delivery=emergency and all that. But on the other hand, this is exactly the behaviour that white male doctors have been accused of in dealing with women clients forever - that they negate that woman's fears and experience.

"Oh no that won't happen" isn't the same as "999 times in 1000 that won't happen."

The truth is that sort of like a funny mole on your skin, a baby with wraps and knots in the cord is at higher risk of a poor outcome than one that doesn't have any. Like having a funny mole doesn't mean you have cancer, having cord issues doesn't mean your baby will die. But it also doesn't mean it never happens, and each person+provider has to make the decisions at the time that make the most sense.

While I appreciate the reassurance of MsBlack's information (very well explained, thank you) I do agree with the above. The fact is, even though statistically the chances of a bad outcome were not enormous, the research I found on true knots certainly seemed to indicate that their presence raises the odds for a bad outcome and the reality is it definitely could have happened. I am grateful that my daughter was born healthy, perhaps using the word "miracle" was a little hyperbole on my part, but even the most minute chance of disaster that was averted is a miracle to me...I consider it a miracle that we all make it back home safe and sound every day Thank you for your perspectives.

[MsBlack]

Hmmm, I guess I'll assume for the moment that you're lumping me in with that group which 'continually negates women's narratives', etc...at least, I can see where a person might perceive my posts in that way.

Anyhoo--the last thing I want to do is negate anyone's feelings or story. I don't intend to do that....I fully honor Qbear's feelings and sense of things, no judgement or correction intended there. It's more a matter of hoping to introduce another perspective, which may speak to her (and to others, as the audience we address generally includes more than the people we hear from). But maybe not--I really DON'T know if it truly was a near-miss kind of thing, only the stats as 'probably not, but sure coulda been'. Still, sometimes learning more about something shifts my own feelings and perceptions of an experience...heck, it took me years to come to peace with my csec, seemed there was no one I respected who could say whether or not I made the right call. As a mw, I just couldn't feel really clear about it (had never seen it before), and as a homebirth fanatic I felt I'd probably just let myself and baby down somehow.

Til finally one day I was telling a new mw-friend about his labor, the awful heart tones, descent-then-jerking-up-again...and she says "Oh, was he all wrapped up in his cord? I've seen that a few times" Bingo! a shift arrived, it changed everything for me.

So--that is all I hope to contribute to, for the OP or anyone else reading. IF that works for her/them--IF that fits.

[Qbear'smama]

You did provide a different perspective, your explanation of the design of the cord, why it is unlikely to be disasterous makes total sense to me and is much more reassuring than someone just saying "eh, not likely to cause a problem" and I thank you for sharing this knowledge with me. I mean, when I looked at reasearch on true knots and fetal demise, there was nothing giving me a good sense of how the cord works to avoid most problems in these cases. But of course it's the "coulda been" that gets me, KWIM? My MWs would have done what they needed to do if DD's state had indicated a problem, of that I have no doubt, and indeed everything went well. So no, not a "close call," but looking at that knotted up cord, reading studies on intrauterine fetal demise, it does leave you with a "Thank God!" kind of perception. Thanks again.

[MsBlack]

Oh goodie! Just what I was hoping to hear

I have found, for myself and with most of my clients, knowing more and being able to understand things really does help.

[MyFullHouse]

Originally Posted by Qbear'smama

You did provide a different perspective, your explanation of the design of the cord, why it is unlikely to be disasterous makes total sense to me and is much more reassuring than someone just saying "eh, not likely to cause a problem" and I thank you for sharing this knowledge with me. I mean, when I looked at reasearch on true knots and fetal demise, there was nothing giving me a good sense of how the cord works to avoid most problems in these cases. But of course it's the "coulda been" that gets me, KWIM? My MWs would have done what they needed to do if DD's state had indicated a problem, of that I have no doubt, and indeed everything went well. So no, not a "close call," but looking at that knotted up cord, reading studies on intrauterine fetal demise, it does leave you with a "Thank God!" kind of perception. Thanks again.

I'm there with you, Qbear'smama!
My last delivery was w/ a true knot and 2x nuchal cord, and distress (heart rate as low as 40) was detected via hand held doppler. OF COURSE it gives me a "Thank God!" perspective (and I'm not even religious, lol), and makes me nervous about cord issues with this baby!

This has been a very informative thread.

[GuildJenn]

Originally Posted by MsBlack

Hmmm, I guess I'll assume for the moment that you're lumping me in with that group which 'continually negates women's narratives', etc...at least, I can see where a person might perceive my posts in that way.

Anyhoo--the last thing I want to do is negate anyone's feelings or story. I don't intend to do that....I fully honor Qbear's feelings and sense of things, no judgement or correction intended there. It's more a matter of hoping to introduce another perspective, which may speak to her (and to others, as the audience we address generally includes more than the people we hear from). But maybe not--I really DON'T know if it truly was a near-miss kind of thing, only the stats as 'probably not, but sure coulda been'. Still, sometimes learning more about something shifts my own feelings and perceptions of an experience...heck, it took me years to come to peace with my csec, seemed there was no one I respected who could say whether or not I made the right call. As a mw, I just couldn't feel really clear about it (had never seen it before), and as a homebirth fanatic I felt I'd probably just let myself and baby down somehow.

Til finally one day I was telling a new mw-friend about his labor, the awful heart tones, descent-then-jerking-up-again...and she says "Oh, was he all wrapped up in his cord? I've seen that a few times" Bingo! a shift arrived, it changed everything for me.

So--that is all I hope to contribute to, for the OP or anyone else reading. IF that works for her/them--IF that fits.

It makes sense - I didn't really mean you in particular as I think your perspective is balanced as you've been there, and you were mostly providing information.

I've just heard a lot of people really negate the dangers of cord accidents and of course it's true on the one hand - the stats are in everyone's favour.

[mwherbs]

When I have read the bigger studies that are out of country the percent of babies that have true knots usually with long cords it is 1.2% ,the numbers are even smaller if you exclude twins,also the numbers of associated problems if the babies are not twins is less

So there are some repeating risk factors
Moms who had polyhydramnious, caring a baby boy and had an amnio, moms who had gestational diabetes,or chronic hypertension,or were anemic.
There is some consideration that babies with longer cords have longer cords because the baby is more active the extra movement supposedly causes the cord to be longer. And I never know what to make of the placental pathology reports because from studies on lab results even in the same lab there is no consistency when analyzing the info, in any case there are some studies that show alterations in blood flow even on the placental bed level of babies who have true knots and have longer cords.
I read an OZ study where they tested how much pressure it takes to restrict blood flow in an umbilical cord; they got the cords from babies who had csections within 15 min , they applied 40 angstroms of pressure to the knots-

" Cord morphometric analysis was performed on 193 cords. During experimental cord knotting with applied traction, the susceptibility to venous occlusion was increased with low cord mass index, low cord hydration index and low venous flow capacity. These cord characteristics were associated with low fetal body weight and intrauterine growth restriction. An increased susceptibility to cord occlusion may contribute to the higher perinatal morbidity and mortality in growth restricted pregnancies."
So there are some attributes that are not simple to find prenatally that contribute to the riskiness of cords that are long and have true knots and that will cause growth restriction or fetal demise.

[turnquia]

I am by no means an expert on this. But another discussion board mama I know had a child die of a cord accident. She has since participated in a study done on cord accidents and genetics. I will post the link in a second to the project. But this doc has spent YEARS researching this and has found many cord anomolies some seem to be genetic and others not so much. Its a very interesting read but can be quite upsetting.

It does talk about stillbirths and other sad things.

I did actually read the entire 83 pages (yes lol i know) but I thought the whole thing was quite fascinating.

The summary is the only risk of a stillbirth related to a cord accident is a long cord. Sometimes long cords are genetic and mama makes a long cord for every baby especially if others in her family make long cords. For some women a long cord is a fluke and a total accident. It talks about many other factors as well for cord accidents such as the whartons jelly in the cord and a history of nuchal cords on other babies.

http://www.preginst.com/pucp.html

I hope you can find the answers your looking for, without too much worry!

[JessicaS]

Hello!

Women in my family occasionally have a child with a short cord. I do believe that it could be genetic because it has happened three times in my immediate family.

My dd had a short cord and a true knot. All the people I spoke with while planning a vbac were very comfortable that it was a fluke thing, unlikely to be repeated.

You should certainly discuss it with your m/w if you have concerns. I did have a lot of similar concerns during my second pregnancy.

[mwherbs]

Sorry wrong site

[MsBlack]

Originally Posted by GuildJenn

It makes sense - I didn't really mean you in particular as I think your perspective is balanced as you've been there, and you were mostly providing information.

I've just heard a lot of people really negate the dangers of cord accidents and of course it's true on the one hand - the stats are in everyone's favour.

Thanks for that!

I do like it when people like the OP can get perspective on various concerns, especially if it's in their history or family history and accompanied by understandably strong feelings about it--but not necessarily clear info/evidence. And of course, as a hb mw and strong advocate of homebirth and Informed Consent both, I like to put info out there.

But with my clients, I definitely do NOT want anyone to believe that low risk--no matter HOW low risk--means NO risk or any sort of guarantee. I think any birth choice is 'best' for a family when they are informed as much as they want to be, and making clear choices knowing that well, birth is as safe as life itself--and ONLY as safe as life itself. I won't work with people afraid to talk to about the possibility of transfer of care and the worst case scenarios...even though I greatly trust birth...because birth is a matter of life and death. We all (fams and caregivers) need to be able to confront that, to be able to deal with whatever comes.