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BRIEF REPORTS

Midwives and the Fetal Nuchal Cord: A Survey ofPractices and Perceptions

Hilary Jackson, BSc, ADM, RM, RGN, Cathie Melvin, BA, MA, RM, andSoo Downe, BA, RM, MSc, PhD

A systematic search of studies of intrapartum management of the nuchal umbilical cord at term foundno published controlled studies in this area. A postal survey containing both structured and openquestions and a request for local protocols and guidelines was sent to all 637 midwives in 7 maternityunits in England. There were 401 (63%) responses. There appeared to be no unit guidelines for this areaof practice. Midwife approaches to nuchal cord during birth varied, and included clamping and cuttingof loose nuchal cords and a hands-off approach to tight nuchal cords. Reasons for specific actionsincluded doing what had been taught during midwifery training and learning from previous personalexperiences. Theories of diffusion of innovation and of planned behaviour may provide a conceptualbasis for understanding the adoption of specific practices. Future qualitative and controlled studies areneeded to explore the nature and consequences of varying approaches to intrapartum nuchal cordmanagement. J Midwifery Womens Health 2007;52:49 –55 © 2007 by the American College ofNurse-Midwives.

keywords: diffusion of innovation, nuchal cord, midwifery practice, umbilical cord management

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NTRODUCTION

s a team of clinical and academic midwives, weecame interested in the topic of how to manage theuchal cord before the birth of the fetal shouldersollowing local episodes of shoulder dystocia after thembilical cord had been cut. The survey reported inhis paper provides a description of current practice inne region of England as a basis for designing futurerospective studies. The topic was developed in col-aboration with a group of clinical midwives andcademics who are interested in undertaking appliedlinical research (the North West Clinical Midwivesesearch Group).

ACKGROUND

he prevalence of nuchal cord at birth occurs inetween 1 in 201 to 1 in 3 of all births.2 A range oforbidities have been associated with nuchal cord,

ncluding intrapartum fetal heart anomalies,3– 6 neona-al asphyxia,5,7 increased rates of cerebral palsy,8 andubclinical deficits in neurologic development perfor-

ddress correspondence to Hilary Jackson, Midwife Matron, Women’s

mealth Unit, Burnley General Hospital, Casterton Avenue, Burnley,ancashire, BB10 2PQ, England. E-mail: hilary.jackson@elht.nhs.uk

ournal of Midwifery & Women’s Health • www.jmwh.org

2007 by the American College of Nurse-Midwivesssued by Elsevier Inc.

ance at 1 year of age.6 These morbidities could beaused by antepartum or peripartum factors, includinghe management of the nuchal cord at the time of birth.owever, most of these associations are based on

etrospective studies. In critiquing the claims of mor-idity associated with nuchal cord, Greenwood andmpey9 noted a significant risk of recording bias inany studies in this area; that is, clinicians are more

ikely to remember and to record that a nuchal cordas present when a neonate suffers morbidity thanhen no such problems are experienced.There has been extensive discussion of when and

ow to cut the umbilical cord after the birth of thenfant.10 New theories of neonatal adaptation, such ashe blood volume model of neonatal transition, haveaised questions about the wisdom of early severing ofhe umbilical cord.11 Mercer and Skovgaard11 con-lude that early cord cutting may lead to neonatalypovolemia with the consequent risk of asphyxia inhe neonatal period, and possible risks of anaemiaater. Empirical evidence is now emerging that delayedord clamping improved iron status in the infant up tomonths of life, an effect that is more pronounced in

nfants who were born to mothers with low ferritinevels prior to birth, and those who did not receiveron-fortified formula.12

There appears to be less clarity around the optimum

anagement of a nuchal cord after the fetal head is

49

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elivered but before the shoulders appear. Some au-horities maintain that delayed clamping and cuttingay lead to neonatal asphyxiation by strangulation

nd/or anoxia.13 Case studies have demonstrated thatarly cord cutting at this stage may deprive the fetus ofital oxygenated blood, especially in the case of delay,hich can occur with shoulder dystocia.14,15 Recentnglish and American midwifery textbooks note that

here is debate in this area. They recommend looseningnuchal cord if possible, or, if this is not possible, that

he cord should be cut prior to the birth of thehoulders.16 –19

To assess the best approach to this area, we plannedsystematic review of studies of neonatal outcomes

elated to the management of nuchal cords in the termeonate. The Appendix outlines our search strategy.Our search strategy generated 1010 hits. We read

itles for these articles, and the abstracts for any thatppeared to fit our inclusion criteria. We sought 6 fullext papers based on the abstract review. None of theseet our criteria for inclusion (Figure 1). We reached

he conclusion that a well designed, prospective studyith long-term follow up was needed in this area to

nform optimum practice, and that the first step in thisrocess should be to establish current clinical practicen this area. While undertaking the review, we onlyocated one relevant descriptive study of midwiferyractice.20 This was a national study undertaken byercer et al., based in North America, which surveyedrandom sample of members of the American Collegef Nurse-Midwives. The main focus was on the timingf umbilical cord management after the birth of thenfant, but one section of the survey asked aboutuchal cord management. The return rate was 56%157/303). The authors found that 40% of their respon-ents would use the somersault manoeuvre in mostases. Just over half (57%) would clamp and cut theord when it was very tight, and 3% would clamp andut the cord in most circumstances where a nuchalord was present. The majority of respondents werenable to provide supporting references for theiruchal cord clamping practices.In the absence of definitive evidence in this area, our

rst step, prior to exploring the feasibility of conduct-ng a randomised controlled trial of management

ilary Jackson, BSc (Hons), ADM, RM, RGN, holds the post of Midwifeatron in East Lancashire Hospitals NHS Trust in Burnley, England. She

s a member of the North West Clinical Midwives Research Group.

athie Melvin, BA (Hons), MA, RM, is the Midwifery Research Coordi-ator for East Lancashire Hospitals NHS Trust, covering two hospital sitest Blackburn and Burnley in England. She is a member of the North Westlinical Midwives Research Group.

oo Downe, BA (Hons), RM, MSc, PhD, is the Professor of Midwiferytudies at the University of Central Lancashire (UCLan) in England. She

tirects the Midwifery Studies Research Unit at UCLan, and she chairs theorth West Clinical Midwives Research Group.

0

pproaches, was to establish the approaches to andvidence base for management of the nuchal cord byidwives in the Northwest region of England. As far

s we are aware, this is the most comprehensive studyf this area of midwifery practice that has reported toate.

ETHODS

postal questionnaire was designed iteratively with theembers of the group. The Hospital Trust’s research and

evelopment lead referred us to the Central Office foresearch Ethics Committees’ Web site for guidance

egarding the need to seek formal ethics approval. Thisas not required, because the research was being con-ucted to define current midwifery practice. To ensureonfidentiality, the returned questionnaires were anony-ous. Return of the questionnaire was deemed to indi-

ate consent to participate. Local clinical governancerocedures were followed.The items included in the final tool were based on

ur systematic review, the clinical expertise of theroup members, and the feedback from midwivesnvolved in the pilot phase. It comprised 4 sections,ith a total of 8 closed and open questions. The 4

ections addressed the following: 1) demographics; 2)anagement of the nuchal cord when it is not tight; 3)anagement of the nuchal cord when it is tight; and 4)

he rationale for practice. We requested a copy of theocal guidelines for the management of nuchal cords.ive different management approaches were presenteds options, based on the findings of our literatureeview. Respondents were invited to check the boxext to all those that applied to their own usualractices and to provide a rationale for these practices.hey could also add to the list of possible practices.sychometric scales were not used.Face and content validity were assessed by piloting

ith 10 midwives working on the labour ward of oneospital. These midwives were also invited to recordow long it took to complete the form, to comment onhe clarity and appropriateness of the questions, and touggest any additional questions. The tool wasmended following the results of the pilot.

Questionnaires were sent to all midwives in the 7aternity units that had representatives on the Northest Clinical Midwives Research Group. All mid-ives within each maternity unit received one ques-

ionnaire (total 637). The questionnaires were returnedy post, in a prepaid envelope, to the lead author.Analysis of the demographic data, the responses to

he listed approaches to nuchal cord management, andhe existence of local guidelines was by simple de-criptive statistics (numbers and percentages). Simple

hematic analysis was applied to all qualitative data.

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his process was undertaken iteratively by two of theuthors on the basis of debate and consensus. Afternitial analysis, the emerging themes were revisited toheck for disconfirming data. This process resulted ingreement on the final themes.

ESULTS

he participating hospital trusts included consultant andidwife-led units (Table 1). There were 401 replies

63%) representing practice from all 7 units. The re-ponse rate by unit ranged from 33.7% to 84.7%. Twoundred and fifty-four (64%) respondents had been quali-ed for more than 10 years, and 320 (81%) reported that

hey were experienced in intrapartum care.Eleven respondents reported that a local guideline

xisted in this area of practice, but they were contra-icted by other respondents from the same unit whotated that there were no such guidelines. No protocolsr guidelines were submitted.

idwives’ Response to A Nuchal Cord

nly 3.8% of respondents stated that they wouldlamp and cut a loose nuchal cord (Table 2). Thisesult resonates with the findings of Mercer et al.20 Inur survey, some respondents selected more than oneay of managing a loose nuchal cord. The majority

Sear

1010 titles identifd

Title an

Full text review: 6

Meets criteria: 0 Rejected:

Opinion or reviNo data on corData on cord m

Figure 1. Flow diagram of sele

87.8%) stated that they would usually ease a loose p

ournal of Midwifery & Women’s Health • www.jmwh.org

ord over the baby’s head. A small minority (9%) saidhey would “do nothing” in this circumstance.

For a tight cord, 57.8% of midwives in this surveyhose the option of clamping and cutting, againlosely echoing Mercer’s findings (Table 3). However,pproximately half would attempt to ease the cordver the infant’s neck or body if circumstances per-itted (51.4%). A very small minority (3.5%) still

tated that they would “do nothing” in this circum-tance.

easons for Nuchal Cord Management Decisions

he responses to the open questions indicated somenconsistency between what had been taught and whatas practiced. A number of respondents commented that

hey had changed their practice over time:

“I was trained always to clamp and cut a nuchalcord whether loose or tight, but I have modifiedthis in my own practice when the cord is loose.”

“I think over the years midwives have becomemore confident in managing nuchal cord. Early inmy practice, I would feel very concerned about it,but with experience and support from seniorcolleagues, you become confident that most cordswill slip over the shoulders.”

Untoward events, such as shoulder dystocia, often

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1004 rejected

Not on topic: 982Opinion/case study: 15Duplicates of included studies across databases: 6 Physiology: 1

y: 4 gement: 1 ment, but not on neonatal outcomes: 1

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“� was taught to clamp and cut as a student, buthaving seen two shoulder dystocias after clamp-ing and cutting, baby floppy—one brain dam-aged—now after qualifying, will usually wait �”

Comments also indicated that the “norms” in thisrea appear to have changed over time, although theespondents were rather vague about how and why:

“I used to � ease cord over baby’s head but nowI don’t do anything. (I think another midwife toldme you didn’t need to.) I heard or read that if youcut a tight cord before shoulders were deliveredthis would deprive baby of O2 if shoulders gotstuck, which seems to make sense.”

It is of interest that 3 respondents spontaneously notedhat they became less likely to intervene in this situationfter observing the straightforward births of babies withuchal cords during water births.

ISCUSSION

here were similarities and differences in practiceoth within and between the units represented in thistudy. Clamping and cutting of a tight nuchal cordanged from 33.5% to 80.4% by unit. Easing a looseord over the head ranged from 66.7% to 100% bynit. Doing nothing with a loose cord ranged from.8% to 33.3% by unit. In the unit where most

Table 1. Demographics by Unit

Unit A B

ype CU CUumber of births 2005 3684 2943ormal birth rate 2005 52% 42%aesarean section rate 2005 22% 24%espondents

No. of years qualified (range) 1 to 39 1 to 35No. of years practising (range) 1 to 35 1 to 31Percent currently providing

intrapartum care75.47% 85.14%

U � hospital unit, mainly consultant-led care; MLU � midwife unit, geographica

Table 2. Management at Birth of A Nuchal Cord That is Not TightAround the Baby’s Neck (N � 401)

ManagementYes

n (%)No

n (%)No Reply

n (%)

. Ease over baby’s head 352 (87.8) 47 (11.7) 2 (0.5)

. Ease over shoulder 185 (46.1) 214 (53.4) 2 (0.5)

. Clamp & cut 15 (3.7) 384 (95.8) 2 (0.5)

. Somersault manoeuvre 10 (2.5) 389 (97) 2 (0.5)

. Do nothing 36 (9.0) 363 (90.5) 2 (0.5)

t. Other 57 (14.2) 340 (84.8) 4 (1.0)

2

espondents would “do nothing” with a loose cord, theinimum number of years of qualification as a mid-ife was 5. In the unit where midwives had the highest

verage of years experience (16.7 years) more respon-ents would “do nothing” with a tight cord (6.8%) thann any other unit. The only unit in which none of theespondents would ever clamp and cut a loose cordas a midwife-led birth centre that was approximatelymiles from the referral consultant-led hospital unit.

rom these data, and from the qualitative responses, itan be hypothesised that the more experienced theidwives are, and the more autonomously they prac-

ise, the less likely they are to intervene with a nuchalord. The accuracy of this hypothesis will need to beested in future studies.

In addition to the variation in practice noted here,he use of the somersault manoeuvre was selected by auch lower proportion of midwives who participated

n this study than by nurse-midwives in the Unitedtates20 (2.5% for loose and 3.5% for tight in thisurvey, versus 40% overall in the U. S. survey).owever, the overall percentage of midwives whoould clamp and cut a cord was remarkably similar to

hat of the respondents in the survey by Mercer et al.While it is possible that nonresponders have a

ifferent pattern of practice in this area, the responseate indicates that these findings describe the practicef the majority of midwives working in the unitsurveyed. The qualitative data, and the synergy withhe findings of Mercer et al., except in the area of these of the somersault manoeuvre,20 raise a number ofuestions about what factors influence variation andhanges in practice, and about how practices with nopparent evidence base diffuse within and beyondospital, regional, and even international boundaries.his may be an area for future studies to pursue.ogers’ Diffusion of Innovation theory provides aotential framework for understanding the process ofdoption of innovation.21 Ajzen’s theory of plannedehaviour provides a theoretical basis for measuring

D E F G

MLU CU CU MLU258 2457 3933 15298% 45% 49% 98%0% 22% 20% 0%

31 5 to 30 0.5 to 38 1 to 31 2.5 to 3631 5 to 28 0.5 to 36 0.5 to 31 2.5 to 30

88.89% 82.76% 80.95% 92.31%

ate from referral hospital, midwife-led care.

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0.5 to0.5 to78.72%

he potential for change in individuals.22 It may be that

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urther study in the area of nuchal cord management inarticular, and in the diffusion of maternity carenterventions in general, could be undertaken on theasis of a framework incorporating these theories.Given the uncertainty in the area of nuchal cordanagement, and the potential harms that could result

or neonates from either cutting the cord prior to theirth of the shoulders too early (potentially riskingypovolaemia and anaemia) or too late (potentiallyisking severe cord compression and neurologic dam-ge), we propose that this area of practice should nowe subject to a controlled trial and to further in-depthualitative work. On the basis of the strong beliefsxpressed by the respondents to our survey, assess-ent of practitioner equipoise will be an essential

lement in the design of any such trial.

ONCLUSION

anagement of the nuchal cord is a complex issue.ur systematic review did not find any comparative

tudies examining the short- and long-term effectselating to nuchal cord management. The survey weeport here indicates that there is wide variation inractice with little consistent rationale underpinning it.oth the clinical impacts of the practitioner response

o this particular phenomenon, and the general ques-ion about how midwifery practice is diffused andisseminated, are now in need of further study ifell-being for mothers and neonates is to be maxi-ised, and harm minimised.

We would like to thank the North West Clinical Midwives ResearchGroup for their contribution to the systematic review and question-naire design and for distribution of the questionnaires. This groupcurrently comprises members from the University of Central Lancash-ire and the following NHS Trusts: Blackpool, Fylde & Wyre NHS HospitalTrust, East Lancashire Hospitals NHS Trust, Lancashire TeachingHospitals NHS Trust, and Southport & Ormskirk Hospitals NHS Trust.Our gratitude is also extended to the Department of Women’s Healthand R&D office, East Lancashire Hospitals NHS Trust, for approval andsupport in undertaking this project.

Table 3. Management at Birth of A Tight Nuchal Cord That is TightAround A Baby’s Neck (N � 401)

ManagementYes

n (%)No

n (%)No Reply

n (%)

. Ease over baby’s head 206 (51.4%) 177 (44.1%) 18 (4.5%)

. Ease over shoulder 159 (39.6%) 224 (55.9%) 18 (4.5%)

. Clamp & cut 232 (57.8%) 151 (37.6%) 18 (4.5%)

. Somersault manoeuvre 14 (3.5%) 369 (92%) 18 (4.5%)

. Do nothing 14 (3.5%) 369 (92%) 18 (4.5%). Other 92 (22.9%) 293 (73.1%) 16 (4.0%)

ournal of Midwifery & Women’s Health • www.jmwh.org

EFERENCES

1. Chatterjee AK, Sengupta S. Cord around the neck of theetus. J Obstet Gynaecol India 1989;39:660–4.

2. Jauniaux E, Ramsay B, Peellaerts C, Scholler Y. Perinataleatures of pregnancies complicated by nuchal cord. Am J Perina-ology 1995;12:255–8.

3. Hankins GD, Snyder RR, Hauth JC, Gilstrap LC 3rd, Ham-ond T. Nuchal cords and neonatal outcome. Obstet Gynecol

987;70:687–91.

4. Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multipleuchal cord entanglements and intrapartum complications. Am Jbstet Gynecol 1995;173:1228–31.

5. Dhar KK, Ray SN, Dhall GI. Significance of nuchal cord.Indian Med Assoc 1995;93:451–3.

6. Clapp JF, Lopez B, Simonean S. Nuchal cord and neurode-elopmental performance at 1 year. J Soc Gynaecol Invest 1999;:268–72.

7. Puri M, Rathee S, Garg R, Aggarwal A, Khosla A. Nuchalncirclement of the umbilical cord-incidence and significance.Obstet Gynaecol India 1989;39:58–60.

8. Nelson KB, Grether JK. Potentially asphyxiating conditionsnd spastic cerebral palsy in infants of normal birthweight. Am Jbstet Gynecol 1998;179:507–13.

9. Greenwood C, Impey L. The association of nuchal cord witherebral palsy is influenced by recording bias. Early Hum Dev002;68:15–9.

10. Mercer JS. Current best evidence: A review of the literaturen umbilical cord clamping. J Midwifery Womens Health 2001;6:402–14.

11. Mercer J, Skovgaard R. Fetal to neonatal transition: First, doo harm. In: Downe S, editor. Normal childbirth, evidence andebate. Edinburgh: Churchill Livingstone, 2004.

12. Chaparro CM, Neufeld LM, Tena Alavez G, Eguia-Lizedillo R, Dewey KG. Effect of timing of umbilical cord clampingn iron status in Mexican infants: A randomised controlled trial.ancet 2006;367:1997–2004.

13. Schorn MN, Blanco JD. Management of the nuchal cord. Jurse Midwifery 1991;36:131–2.

14. Iffy L, Varadi V, Papp E. Untoward neonatal sequelaeeriving from cutting if the umbilical cord before delivery. Medaw 2001;20:627–34.

15. Iffy L, Varadi V. Cerebral palsy following cutting of theuchal cord before delivery. Med Law 1994;13:323–30.

16. Downe S. Transition and the second stage of labour. In:raser DM, Cooper MA, editors. Myles textbook for midwives14th ed). London: Churchill Livingstone, 2003. pp. 498–9.

17. Downe S. Care in the second stage of labour. In: Henderson, Macdonald S, editors. Mayes midwifery: A textbook for mid-ives (13th ed). London: Bailliere Tindall, 2004. p. 502.

18. Varney H, Kriebs JM, Gegor CL. Varneys midwifery (4th ed).oston: Jones and Bartlett Publishers, 2004. p. 1244.

19. Cunningham F, Hauth JC, Leveno KJ, Gilstrap L, Bloom

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L, Wenstrom KD. Williams obstetrics (22nd ed). New York:cGraw-Hill Medical Publishing Division, 2005.

20. Mercer JS, Skovgaard RL, Peareara-Eaves J, Bowman TA.uchal cord management and nurse-midwifery practice. J Mid-

ifery Womens Health 2005;50:373–9. D

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21. Rogers EM. Diffusion of innovations (4th ed). New York:he Free Press, 1995.

22. Ajzen I. The theory of planned behavior. Organ Behav Hum

ecis Process 2002;50:179–211.

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Appendix. Search Strategy for Review of Management of Nuchal Cord.

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