Well Rounded Birth Prep

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Friday, August 27, 2010

Myth-conceptions: cord wrapped around baby's neck

Hello, readers. Thanks for your patience with my spotty attendance. It's back-to-school time in our household of 4 kids age 7 and under, and that means homeschooling first and second grades simultaneously while attempting to throw a few Pre-K activities for my busy 4 y.o. son and nursing my toddler daughter as she wants up on my lap, then down, then back up again, and repeat. I've also spent a lot of time trying to secure a regular venue for my Well Rounded Birth Prep classes.

I would like to start a blog series called Myth-conceptions, addressing common myths regarding pregnancy, birth, and breastfeeding. I have so many things I'd like to address in this series that I don't know where to start. It's actually a bit daunting.

I've heard and read hundreds of birth stories over the years, and it didn't take long to begin to see patterns. Research has established the cause-and-effect relationship between routine birth interventions and potentially preventable complications.

Since I have to start somewhere, why not this one: "The cord was wrapped around his neck--twice!!!--and if we hadn't been in the hospital, we both would have died!" True cord emergencies are extremely rare. In God's perfect design for the umbilical cord, the two arteries and one vein that make up the cord are covered with a rubbery substance called Wharton's jelly that helps protect the cord from kinks. The normal blood pressure through the arteries and vein in the cord help put positive pressure outward on the cord to help keep it from kinking as well. Even in the event of a true knot in the cord, Wharton's jelly usually prevents problems for the infant by keeping the cord from compressing. A knot in the cord isn't typically discovered until after the birth anyway, which means that nothing could have been done to have foreseen or prevented any true cord issues.

I once read a comment in response to a friend's informative post about homebirths, stating something to this effect, "I'm glad that worked for you, but my wife and son would have both died had she not been in the hospital. The cord was wrapped around his neck 3 times, and it even had a knot in it. Then there were heart decels while she was pushing and the doctor had to perform an episiotomy to get him out faster."

Let's take a look at this scenario piece by piece, shall we? First off and foremost, having the cord around the neck (in and of itself) at birth is not an emergency. In fact, it occurs in about 30% of all births. OBs and midwives will check around the neck to see whether the cord is wrapped around the neck after the head has been born. If the cord is wrapped around the neck, they will gently slide the cord over the neck without any problem. If the cord is wrapped multiple times, they will attempt to slide the first loop over the baby's head and sometimes this gives enough slack to the rest of the loop that the body is delivered with no complication at that point. If there isn't enough slack for that, a midwife will hold the baby's head near mother's leg and allow the body to be delivered in a maneuver resembling a somersault (pictured below), which doesn't put extra strain on the cord around the neck. (Most doctors will not do this, as they have not been trained to do so.) In a rare, true wrapped-tight-cord situation, the birth attendant will clamp the cord twice and cut in between, then help the mother to deliver the baby quickly as his/her oxygen supply (cord) as been severed.

As for the knot in the cord, in this particular birth story, nothing was done about it during that birth (nor could anything have been done about it) and there was no indication that the knot caused any problems. When and how did this dad think that knot got there, anyway? True knots can only occur early on in pregnancy when baby has enough room in the uterus to flip and spin freely to do a loop-the-loop and create the knot. This knot had been present for months.

As for the fetal distress during delivery, it's hard to say, since no details were given in this man's account of his wife's birth. However, it is well established that fetal distress can be an indicator that the baby is not tolerating mother's position well. The first thing a midwife will suggest if baby's heartrate is dipping, is to switch positions to see whether baby's heartbeat responds in a more favorable way. Sometimes it's something as simple as baby's cord getting slightly compressed due to the mother's positioning. Changing positions to help baby's heart rate would be difficult if the mother had an epidural, which has issues all its own that I will address in a moment.

It's also well established that the lithotomy position (a.k.a. "stranded beetle" position, lying flat on her back: the most common position for pushing in America) can cause fetal distress. Remember how expecting moms are cautioned never to lie on their backs for extended periods of time beyond the 5th month of gestation, since sleeping or lying on their backs (for more than a few minutes) can cause the weight of the uterus to compress the main artery providing blood flow to the lower half of the body (including baby)? What makes anyone think this would suddenly be a good idea during labor and delivery????

Epidurals are sometimes responsible for fetal distress. I wonder how many women are told this before they get an epidural: blood pressure drop is a common epidural side effect. They try to combat this by giving IV fluids or medications, but it doesn't always work, which sometimes causes fetal distress. Directed pushing (a.k.a. "purple pushing" = "hold your breath and push as hard as you can while we count to 10") is also associated with higher incidence of fetal distress.

Was the mother on Pitocin (synthetic oxytocin, a drug given to speed up labor)? Pitocin can also cause fetal distress. Insiders from our local hospitals have told me that the overwhelming majority of labors they have attended are induced or augmented with Pitocin.

So, were there other factors with this particular fetal distress? I don't know. I'm just pointing out some common situations so that readers can have an understanding that "fetal distress" doesn't often happen out of the blue, and it's even more rare that it would happen "without any apparent reason." (Yes, I'm aware that it *can* happen that way. I'd just like to reassure readers that those are the rare exception, not the rule.) And as for that poor woman's episiotomy, was it truly medically necessary? Perhaps. They are medically indicated approximately 5% of the time. Sometimes true fetal distress means that an episiotomy would save 5-10 minutes of pushing time; if changing pushing positions and giving mother oxygen to help fetal oxygenation doesn't help, then the episiotomy can help. Most of the time, however, episiotomies are entirely preventable and amount to nothing more than genital mutilation.

I think this episode of Myth-conceptions has melded into many posts at once. I'll try to delve into the other topics in greater detail in future posts.

To sum it up, this guy's argument was that his wife and child would have died had they given birth anywhere but in the hospital. I totally respect their right to give birth anywhere they want, and that's their personal decision, but nothing he said indicated any care provided by hospital staff that would not have been available at a birth center or a homebirth (namely, episiotomy, which is available at either a birth center or homebirth but rarely performed since most midwives understand the true indicators for an episiotomies and do not perform them routinely).

I'll close by sharing a birth story that a local doula shared with me. One baby whose birth she attended at an independent birth center had his umbilical cord wrapped all around his body *five times* in different ways: around the neck, around the chest, above and under the arms, etc. The baby was fine. When the cord is wrapped multiple times like that, it is usually long enough to compensate.

The bottom line is that true cord issues are rare and unpreventable. There's no need to fear them. A skilled birth attendant (whether OB or midwife) knows to look for a cord around the neck, and knows what to do if it occurs. There's no need to panic, people. It's only birth.

See also : Doula'ing my nephew's gorgeous home waterbirth! My nephew was born with his cord wrapped twice around his neck.


  1. Love this! Thanks so much for helping to educate the general public on childbirth and non-emergencies.

  2. Thanks, Christy/puremotherhood! Right back 'atcha! I'm really enjoying your blog.

  3. Love it. Absolutely love it.
    I have an unassisted homebirth in January (1st actually, she was the first baby for 2010 in our county), my mom was catching. And the birth attendant didn't make it in time, and it didn't realize it was real labor until it was too late.
    We had the situation where the cord was wrapped around her neck twice, and there wasn't enough slack to unloop it. My mom instictivly put pressure on one side of the baby's shoulders and told me to push as hard as I could. That kept her head near my perineum and spun around as she came out.
    Moments later I was sittin up holding my newborn baby girl, breastfeeding her waiting for the cord to stop pulsating and for the placenta to deliver. Truly magical.

  4. Thanks for sharing your story, Christa. It's amazing how your mom instinctively knew what to do when baby's cord was tight, to facilitate the somersault.

    I've gotten quite a bit of response from this post from women who had successful vaginal births with nuchal cord and no complications. The public seems to be dreadfully misinformed on this topic. I hope we can get some good discussions started.

  5. I loved and appreciated reading this today. I gave birth to a baby boy 5 months ago, at home (my 4th baby - 4th home birth). His cord was wrapped around his neck 4 times. He also had heart decels toward the end of my labor - scary heart ...decels, and my midwife at one point told me "Okay, it's time to get this baby OUT!" She turned up the doppler (I was in water) so that I could hear the heart tones in an attempt to get me to deliver sooner, than later. Both midwives and myself were starting to get slightly alarmed. The decels went away as soon as the contraction ended, so we suspected it was a cord compression issue based on that alone. I wish I could post a photo here as well, because I have a GREAT one, of me standing up in the birth tub to switch positions, as you mentioned, to get the baby in a better position.

    I actually caught the baby myself, which brought a whole new level of empowerment into my realm! What a pleasure that was! But back to that cord - how surprised we were to discover a 4 x nuchal cord! And obviously, thinking of the above scenario about the man and his wife's birth story, there was no pitocin, epidural, lithotomy, episiotomy etc going on since ours was a home birth with an (experienced) lay midwife.

    Being a 4th time home birthing mother/family, we were never so grateful for the option of home birth and midwives after this experience. Our baby was also born SGA, and I know without a shadow of a doubt, that if we had been under OB care, I would have been heavily and constantly monitored for the small size, and no doubt ultrasounds would have detected that nuchal cord, which I'm quite sure would have robbed me from a mere trial of labor and I would have been sent straight to the OR. Yet, here I can sit now and can say that my baby was born safely at home, in the water, with his cord wrapped 4 times around his neck and he's a live, well, healthy and normal 5 month old baby today!

    Thanks for allowing me to share!

    Christine Marasco
    Marietta, OH

  6. I'm glad I found this blog! My second son was born at home last year and was a surprise breech! To top it off, he was a VBAC! Whenever people would ask about breech, I would simply say, "Breech is not a medical reason for Cesarean, and besides, my midwife is quite skilled with breech." So in a way I think I karma'd the breech! LOL
    I am eternally thankful I was not attempting a VBAC in the hospital because I know our outcome would not have been as good as it was! It drives me nuts when people are given the cord wrapping or breech speech as emergency scenarios! It's just no longer being taught in medical school, thank you malpractice insurance.

  7. my wife delivered a baby boy few days back. pre delivery every test including ultrasound (color dropper) was fine. but during birth baby was in "Abnormal Presentation" facing up-words..nurse pushed down the baby forcefully to make normal delivery possible.

    During baby had "cord around neck" and could not breath for 5 min, my baby was on ventilator for 5 days and could not survive..

    plz let us know who is to blame, n what precautions we should take in future..??

  8. Hello Amit Uniyal,

    I am so sorry for your loss. Regardless of the cause, baby loss is so tragic. I don't know your medical history, and there are too many possible variables to speculate. One thing that some parents do to help get more information and closure is to request a copy of their medical charts and bring them to another care provider (or have charts forwarded to another OB or midwife, or even discuss the details with your doula, if you had one for the birth). They can help you look at the details of the birth with an eye for cause-and-effect, so that you can potentially find out whether your situation was unpreventable, rare and tragic; or whether it was medical malpractice.

    I would certainly wonder what effect it would have had on the cord (cord compression and lack of oxygen) and spinal column from a "nurse push[ing] down forcefully to make normal delivery possible." Questions you could ask your care provider: was your wife induced or was the labor augmented (with Pitocin or other drugs)? Did she deliver on her back? Was her pushing directed (orders given when and how to push, hold breath for count of 10, etc.)? Was the baby's cord clamped and cut right away (it contains 40% of baby's blood volume and is essential in baby's oxygenation until baby's lungs have fully transitioned and expanded)? These are all factors in baby's oxygenation.

    Again, I'm terribly sorry for your loss. I hope that asking questions can bring you answers that may bring you closure, with time. I wish you peace and healing.

  9. the cord was wrapped around my son's neck two times. the nurse-midwife insisted that i deliver on my back. i wanted terribly to change positions. she cut the cord while his shoulders were still in and then it took several more pushes to get him out. he did not cry when he was born at all. he is healthy and very smart, but around age 3 started showing signs of being on the autism spectrum. at age 6 he was diagnosed with PDD-NOS (an autism spectrum disorder. do you think the events at his birth are related? He is seven years old now, and I would like to stop regretting my birth experience.

  10. My daughter was born at home 2 years ago with a true knot in her cord. My labour was really weird, i was dilating but with 4-6 contractions an hour, always irregular and of differing lengths. I just did what i could (i was sleeping between contractions when about 6-7cm open (doing my own VE's) and eating yogurt in what turned out to be transition at around 9cm!) and ended up calling my midwife to come because i was grunting through the peaks of my 1:10 contractions and could no longer feel much of anything except anterior vaginal wall, but still not believing i was in labour because of the irregular gaps and lengths and strengths of contractions. My mw arrived, managed to listen in once with the doppler, baby was tachycardic throughout the contraction, up around 180 i think. She did a VE on my request, head was at spines and i was fully dilated. I pushed for 6 minutes. My baby arrived with her shoulders in transverse, salmon pink and screaming, with apgars of 10, 10 and 10. We saw the knot right away and it explained everything. She screamed for the whole 20minutes it took for me to complete the 3rd stage, then went silent as soon as we'd cut the knotted cord off and began to look to nurse. When the placenta was born we saw it was heart-shaped and there was also a marginal and velamentous insertion!

    From birth she smiled as she fell asleep, every time. We have many many photos of her doing it. I know, "it's just gas" - uh-hu...

    Over a year later i defrosted her placenta to bury it under a new plant in the garden and on a whim i unknotted the cord. She was asleep in her cot but woke, let out a long piercing scream then went back to sleep! It was VERY eerie!

    I'm so, SO glad i was at home, i know as a multip i'd have been under pressure to augment those weird 1:10 or less contractions i'd had all night (and tired and confused i might have agreed!), and i'm sure augmentation would have killed her. I'm so grateful to my calm independent midwife who assessed the tachycardia, looked at my bulging perineum and merely made sure her emergency resus kit was all ready just in case. Ultimately her birth really taught me that babies are smart, and can take care of themselves better than we think. I'm positive the labour pattern was so careful because she was only triggering the contractions she could handle and i'm so glad i wasn't anywhere where someone might think they knew better than her. She remains a smart little cookie, and someone who still acts daily like she's really grateful to be here.

    1. Wonderful proof that baby is also an active participant in the birthing process.

  11. i had a son back in 1980 born in a hospital, natural childbirth. He kept moving down a little but then would reach the end of his cord and move back up, the monitors on him and his heart rate kept flat lining and each time it did this it stayed there a little longer, finally 5 min before an emergency c section was to be preformed his head started to come out...long story short the cord was wrapped around his neck 5 times and he barely had enough left to make it out the birth canal without being choked to death, I just closed my eyes and prayed real hard and now he is 6ft 5in and 33 years old with 2 children of his own.

  12. I was induced at 39 weeks and dr had to break my water after 21hrs I delivered after 4hrs the baby couldnt come they used vacuum only to find out that he was wrapped with the cord around his neck, the baby was admitted in neonatal icu for 10 days due to that and he had seizures he was put on medication which was stopped gradually and he had not shown any signs of seizures since we stopped medication


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