Speaking of umbilical cords--can anyone talk with me about knotted cords?

[loraxc]

My DD was born with a triple nuchal cord and a "true knot" in her cord. I saw it--yep, just an overhand knot. It had not tightened all the way.

She was born in a hospital with a midwife after a 34-hour labor (she was also posterior). I had planned a birth center birth, but we transferred after 24 hours of labor with broken waters (I was GBS+) had stalled me out at 4 cm for hours.

During my labor at the birth center, I was monitored with a doppler only very intermittently. Nobody ever said anything about a problem, so I assume there wasn't one. At the hospital I initially was hooked up to one of those monitoring bellybands, but my midwife allowed me to take it off after a few hours and do Dopplers instead. There was never an indication of fetal distress at any point that I am aware of, and she was born pink and yelling, with a 9 Apgar.

Yet every time I think about another baby I get freaked out about having another knotted cord. I have heard that one true knot increases the risk for another baby with a true knot. I definitely don't feel like fetal heartrate was being monitored all that much, which normally I agree with. But I am wondering if I actually would want continuous EFM for another baby. Would there be a point to that? Can that be done in a birth center? Or should I have an u/s late in pregnancy to check the cord?

Does anyone with midwifery training have an opinion? I would like to try another birth center birth or a homebirth, but...learning about the knot scared the holy hell out of us. We could have lost our girl.

[sevenkids]

Boy, some babies are true acrobats! You gotta wonder how they manage to get themselves all wrapped up like that.

I don't understand why having one true knot increases the risk of having another, unless pre-natal acrobatics are genetic, or super duper long cords.
But I do know that the Wharton's jelly does a fantastic job of protecting the cord from just such gymnastics compressing the cord to a dangerous point.

If it had been a problem, your baby would not have been a very happy little girl, and would have let your C/P's know with her heartrate. I recently was at a birth with a nuchal cordx3 and a true knot, and that baby was happy as a clam too. it's definately one of those things that makes you take a deep breathe and say "PHEW!"

[pamamidwife]

knots typically are NOT a problem - and here's the main reason why: surrounding the vessels and artery is something called wharton's jelly. It's super thick and gelatinous - this is like cushion and protection for the baby. It's protects the vessels and artery from serious compression.

I'd say that most babies do fine even with a true knot. The only time cords ever pose an issue is if they're super short and any pull as the baby descends means it comprimises any folds or knots. This is very, very rare. Cord accidents are extremely rare, but are given as a "catch all" diagnosis/reason for stillbirths....usually when we don't really know why they happen.

In my practice, I've seen four true knots in the cord. None of these ever posed an issue. The most wraps I've seen around the neck was five. Again, not an issue.

Our babies and bodies are perfectly designed for these sorts of things for a reason. I would hesitate to do an u/s for this reason simply because babies move all the time and it's more than likely ok, whereas it could create alot of fear where there shouldn't be.

Part of this, too is asking yourself what you will do with the information....induce early in the hospital? schedule a cesarean before the due date? want more frequent monitoring? Perhaps that will help give you some idea of what you are able to control and not control in instances like this.

[Synchro246]

My opinion is similar. While true knots can in theory become problematic, most do not. As far as your question about continuous monitoring I have this to say: research shows that intermitant fetal monitoring by a trained ear is superior to continuous fetal monitoring. If it is true that one true knot is correlated with increased risk for true knots in subsequent pregnancies I would definitly want intermitant fetal monitoring NOT continuous electric fetal monitoring.
I really just wouldn't worry too much about it and go ahead and plan normal deliveries with midwives who are skilled at fetal monitoring (which every woman should do anyway).

[USAmma]

I can only speak of limited experience. A woman at my workplace lost her baby in early third tri due to a true knot in the cord. But from what I understand most of the time the babies are perfectly fine. I think she was just one of the rare unfortunate ones who didn't make it.

[JesseMomme]

After I had my third at home we noticed there was a true knot in the cord. He was my biggest baby and there was never a problem.

[ldsapmom]

My first had a true knot and we had no issues. My second and third did not have knots.

[loraxc]

Thank you so much for your replies--very reassuring.

I can't quite figure why having one knot puts you at increased risk for another, but I read it somewhere. Maybe it's that knots are correlated with long cords, and long cords tend to repeat? I don't know, but she was a very, very active baby in utero and I wasn't surprised to learn that she had been doing crazy stuff in there.

Part of this, too is asking yourself what you will do with the information....induce early in the hospital? schedule a cesarean before the due date? want more frequent monitoring? Perhaps that will help give you some idea of what you are able to control and not control in instances like this.

Yes, a very good point. I don't want to do ANY of those things...unless (oh, that small "unless") they are the things that would save my baby. KWIM? But the chances are so small. And right--what would I DO if I found out a baby had a knot when I was say, 28 weeks? Ugh. That would be SO stressful.

Thanks again--I really appreciate the nonalarmist midwife viewpoint.

[Synchro246]

[QUOTE=loraxc]
I can't quite figure why having one knot puts you at increased risk for another, but I read it somewhere. Maybe it's that knots are correlated with long cords, and long cords tend to repeat?
[QUOTE]

Cords are created the same way all other body tissues are- from a genetic plan, so yes long cords tend to repeat. (Having a long cord is just a predisposition to knots, not a guanantee) Now, someone correct me if I'm wrong on this, but I seem to remember learning that it's the father's DNA that programs for placenta and cord. The mom doesn't have much to do with that aspect (placental placement she affects because it's her body). Does anyone know? I want to say I learned it from a reputable source. . . but you know how that goes.

ETA- I don't know how I screwed up the quote.

[pamamidwife]

it was my understanding that the more active the baby, the longer the cord. like when the baby moves and pulls on the cord, the cord naturally lengthens for the baby. ?

knots in the cord are definitely not something that repeats. in fact, they're pretty unusual - so unusual that I always wish I got pics when the cords are nice and fat right after the birth.

[Synchro246]

ONe of the midwives that taught the CBE course had a birth with two true knots (everyone was fine) and she took a picture. I want to say that it made it in "Midwifery Today", but I don't know.

[loraxc]

I found the site where I got the idea this might repeat...what do you all think? It seems to be an OB's site, and he seems to be VERY into lots of tests and monitoring and interventions, yada yada, in the name of preventing umbilical cord incidents.

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

UCA (umbilical cord accident) can also repeat in the same patient. Reported cases have described subsequent pregnancies with similar UCA (Constriction, ELUC-excessively long umbilical cords) although not necessarily stillbirth. (75), (76) Cases collected by us (on file) have reported as many as 4 separate deliveries from the same mother, each with a true knot. It is not unusual for a nuchal cord to be repetitive in pregnancies from the same mother and family. It is not unusual to see similar patterns of UCA repeat from case to case. For instance, the pattern of most nuchal cords (>80%) are wrapped right to left around the fetal neck. Most torsion is (>70%) counterclockwise (sinestral, left-handed) away from the fetus. This suggests the fetus maneuvers in the same direction most of the time when stimulated. Is there an inherent reflex, similar to Moro's reflex which allows for this? The fetus can develop entanglement and escape from it. It is possible for a 20 week fetus with a triple nuchal cord to free itself of the loops by 28 weeks.(77),(78) Did the loops unwind or did they slip over the fetal body? Nuchal loops may slip over the fetal body as the most common form of escape from entanglement. Because in case reports these patterns are similar, it suggests UCA stillbirths are not random but due to specific intrauterine behavior of the fetus. These behaviors are limited in scope, just as a newborn is limited in its' movements. Because there are purposeful reasons for UCA, the same factors can lead to repeat events in the same mother. UCA can no longer be dispelled as random.

Then they ahve stuff like this:

With these factors in mind, management of UCA requires an awareness of possibilities as there are few absolute facts at this time. Patients who report hyperactivity, especially during maternal sleep could have at least a NST .(582),(583) A persistence of unusual fetal movements, whether hyperactive or hypoactive, or fetal hiccups (on a daily basis) could include an ultrasound study to specifically look for cord compression or UCA. If a site of cord compression or UCA is seen , the patient could be informed to be aware of the fetal diurnal rhythm of movement and report any change which is uncharacteristic. If necessary, the patient could be admitted for observation and maternal-fetal monitoring overnight. Special attention should be given to maternal vital signs every hour and fetal heart rate patterns during 2-4 a.m. Presence of a non-reassuring fetal heart rate should lead to current obstetrical practices being followed. Ultrasound identification of UCA is possible and follow up of these fetuses requires current obstetrical practices of NST, Biophysical profile , and induction when indicated. Special attention during labor and delivery may help avoid an unexpected UCA adverse event in an otherwise normal pregnancy.(584)

Look at that--these people are obviously starting down the road to recommending c/s when an umbilical cord issue is ID'd:

The interval from 36-38 weeks may require more scrutiny of the fetus, especially where a UCA is identified. Once more information is known about UCA, it may ultimately be recommended to consider delivery of the fetus at term and not manage the UCA associated fetus postdates.

Hmmmm....

DD WAS indeed VERY hiccupy during late pregnancy--every day, often, for weeks. I never thought anything of it.

[~*~MamaJava~*~]

Hey, this happened to us.

Our 2nd ds had 6 nuchal loops and a 7th under his shoulder, and had two true knots in his cord, one pulled tight and the other looser. I don't remember his Apgars but he was completely fine. I thank God for this every day! He's 19 months old now.

Anyways, what I wanted to tell you is that my doctor was completely shocked. So was the staff. We kept having these little debriefings post-birth, where one of the nurses who was there would wander into my room and tell me how amazing it was. (I was totally traumatized by all this and cried for days, I felt guilty, I felt so sorry for him).

DS was small - 19 1/2 inches and 6 lbs 8 oz is not an unusual size, but he had very little fat on him. Just a bony little thing he was. Dr. said that part was due to the knot.

I have never heard that it's something that repeats. I have not worried about it, because of the miracle we were given this time, I guess. I don't think his cord was necessarily unusually long but I don't know. I could only deliver his head and then they cut and clamped a bunch of times to ensure nothing got pulled any tighter. There was not much space between him and the placenta at that point, either. He was born 23 1/2 hrs after my water spontaneously broke (in the bank, fwiw). Contractions that I could feel only lasted about 18 hrs, I think....no, less than that.

As for detection...I was overdue with him, and my dr is test happy, and I was given NST after NST. I think I had 4 or 5. Two days before he was born I had a U/S, and it showed nothing abnormal (obviously, since it can't see a cord) and none of the stress tests were very odd. His heartbeat dropped down to 90 occasionally but I was told they thought he was lying on the cord. Sounds a little fishy to me, in retrospect, but I think if they thought there was any risk they would have recommended a section. In that case although I am totally pro natural birth, I know I would have panicked and said yes - if I knew about the knots etc.

Additionally, he was a very, very quiet baby. To the point of worrying me frequently. DS1 was a wild thing in utero, he really hurt me very often with his kicks and pushes. No cord issues with him all. I assume #2 was as quiet as he was because he was in a nuchal straitjacket, but there's no way to know how long he was like that. Additionally, he is a very quiet child, too.

Here's my perspective: I am going to have a homebirth for my next child, whenever it wants to come along! I am not worried, and neither is DH. Our extended family is very worried - but they were not there.

So from one miracle's mama to another - it's a very scary thing even seen from this way, I think. I was terrified after the fact. What if, what if.

[loraxc]

to you too, MamaJava! 6 nuchal loops--wow! He really tangled himself up in there! I could tell my midwife was startled by the knot, but I had no idea what it meant till we got home and I eventually Googled it, just out of curiosity...and most of the hits were memorial pages for stillborns. I was so grateful and so freaked.

(Did you know that Carter's baby on ER "died" of a true knot? I'm glad I somehow missed that show!)

It's very interesting that your NSTs showed nothing. My DD was 8 lbs even, a pretty big firstborn, so I don't think her growth could have been affected.

I am still hoping someone will come back and comment on that website--it's an odd one, and I don't know what to make of it.

[fremontmama]

to you too, MamaJava! 6 nuchal loops--wow! He really tangled himself up in there!

ditto! we had 5 nuchal loops with dd and i was completely shocked as was the hospital staff (we had an emergency transfer after 28 hours of laboring at the birth center). but 6! holy moly! i am so glad you are both okay!

(Did you know that Carter's baby on ER "died" of a true knot? I'm glad I somehow missed that show!)

I actually saw that show while I was pregnant and it really freaked me out, then about 2 weeks later had an ultrasound where they found my little tater (we didnt know her gender) had 2 nuchal loops. I was so distraught.


This thread is very informative with those articles and links! Thanks mamas!

[Synchro246]

It's good to remember just how common nuchal cords are- 1 in 3 babies will be born with one wrap, then I think it's 1 in 9 for two wraps. After that I can't remember the commonality, but obviously it gets more and more rare for more wraps. Thankfully most of the time nuchal cords don't pose much of a danger, although they are often implicated in slow labors.
I myself had a slow labor and my babe had a very tight nuchal cord- I don't think it was the only factor in my slow dilatation, but it certainly contributed. When the doc went to slip the cord over my son's head she almost fell out of her chair twice because it slipped away from her; I think she even swore.

BTW- I keep meaning to read over the site that was given up above, but every time I do I get irritated then the baby cries. . . so far what I read seems a little dubious (more than once they allude to 'not really knowing')

[pamamidwife]

my take on that website?

it's all just speculation, trying to "blame" something for some rather unexplainable issues/deaths. It almost sounds like one of those attorney sites for medical malpractice.

It would be nice if we could really know what causes some babies to die in utero, but we don't. Nor do I think we have the capability to really understand it all. Then again, if we did, perhaps we wouldn't intervene so much in normal labors.

[mamapajama]

my second ds had a true knot pulled tight (I'm sure due to delivery) and twice around the neck. He was huge and healthy.

[LoveChild421]

ds didn't have any knots, but had his cord around his neck 3 times. I want to offer a different take on knots, loops, etc. When I hear about knots, loops, and other unusual things occuring during birth, instead of making me worry it makes me trust birth and the delicate balance all of us hang in everyday even more. Knowing that, yes that knot could have gotten pulled too tight at any moment and something bad could have happened- and yet- it didn't. It makes me realize how little really depends on physical probabilities and how much depends on something greater, whether you call it God or the divine or whatever. I would take the experience of having a baby with a knot in the cord as an affirmation that, while life has the possibility of being taken away at any moment, for some reason beyond our knowledge she was born perfectly healthy!

[JENinOR]

My first son had a knot in his cord and he was healthy. He was a major acrobat at first in the womb and hiccuped constantly. I have read that hiccuping in the womb can be associated with cord knots. My second had no knot. I would have to say that if I had another hiccuper that was associated with lack of movement...I would probably get some closer monoritng before and during birth.