Nuchal Cord Management and Nurse-Midwifery Practice

Abstract

Nuchal cord, or cord around the neck of an infant at birth, is a common finding that has implications for labor, management at birth, and subsequent neonatal status. A nuchal cord occurs in 20% to 30% of births. All obstetric providers need to learn management techniques to handle the birth of an infant with a nuchal cord. Management of a nuchal cord can vary from clamping the cord immediately after the birth of the head and before the shoulders to not clamping at all, depending on the provider's learned practices. Evidence for specific management techniques is lacking. Cutting the umbilical cord before birth is an intervention that has been associated with hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, and cerebral palsy. This article proposes use of the somersault maneuver followed by delayed cord clamping for management of nuchal cord at birth and presents a new rationale based on the available current evidence.

Full text

Nuchal Cord Management and Nurse-Midwifery Practice
Judith S. Mercer, CNM, DNSc, Rebecca L. Skovgaard, CNM, MS,
Joann Peareara-Eaves, CNM, MS, and Tracey A. Bowman, CNM, MS
Nuchal cord, or cord around the neck of an infant at birth, is a common finding that has implications for
labor, management at birth, and subsequent neonatal status. A nuchal cord occurs in 20% to 30% of births.
All obstetric providers need to learn management techniques to handle the birth of an infant with a nuchal
cord. Management of a nuchal cord can vary from clamping the cord immediately after the birth of the head
and before the shoulders to not clamping at all, depending on the provider’s learned practices. Evidence for
specific management techniques is lacking. Cutting the umbilical cord before birth is an intervention that has
been associated with hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, and cerebral palsy.
This article proposes use of the somersault maneuver followed by delayed cord clamping for management
of nuchal cord at birth and presents a new rationale based on the available current evidence. J Midwifery
Womens Health 2005;50:373–379 © 2005 by the American College of Nurse-Midwives.
keywords: nuchal cord, somersault maneuver, umbilical cord clamping, resuscitation
INTRODUCTION
“...the practice of severing the umbilical cord
prior to the delivery of the body of the fetus,
proposed in some textbooks as routine procedure, is
a dangerous technique, which should be avoided.”
1
Umbilical cord around the neck of an infant, or nuchal
cord, may affect the infant’s status during labor, at birth,
and after birth. Nuchal cords occur in 20% to 30% of
births,
2– 4
requiring that all providers learn management
techniques to handle the birth of an infant with a nuchal
cord. However, evidence is lacking to support a provider’s
choice in management techniques.
Management of a nuchal cord varies. Some providers
clamp the cord immediately after the birth of the head and
before the shoulders, whereas others do not clamp at all.
Standard medical management recommends one attempt to
slip the cord over the infant’s head just before delivery of
the body or, should the cord be too tight, to clamp and cut
prior to delivery of the shoulders.
5
Although most infants appear to tolerate this process
with minimal distress, there is evidence that cutting the
cord before delivery of the shoulders can result in neonatal
morbidity and even mortality.
1
A review of the literature on
nuchal cord reveals that it is associated with increased risk
for hypovolemia,
6
anemia,
7
cerebral palsy,
8,9
and even
death.
2
Iffy proposes that it is the cutting of the cord before
birth of the shoulders that leads to hypoxic-ischemic
encephalopathy and recommends the use of the somersault
maneuver,
10,11
which keeps the cord intact during this
critical time.
1
This simple procedure involves somersault-
ing the infant’s head toward the mother’s thigh as the infant
emerges, immediately unwinding the cord, and allowing the
infant to reperfuse.
The purpose of this article is to encourage the use of
somersault maneuver for management of nuchal cord at
birth and offer a sound rationale for its use based on the
available current evidence. The anatomy and physiology
related to the nuchal cord are reviewed, followed by
neonatal transitional physiology and the literature on nuchal
cord and immediate cord clamping. A discussion of man-
agement options offers the somersault maneuver as the
preferred practice in the presence of a nuchal cord to
prevent disruption of the physiologic neonatal transition
and avoid neonatal morbidity and mortality.
10
NUCHAL CORD PHYSIOLOGY
Interventions during birth should be based first on thorough
understanding of relevant concepts of physiology to build
one’s rationale for practice. In nuchal cord management,
the relevant physiologic mechanisms include properties
related to nuchal cord, physiology of the fetal-placental
circulation, and neonatal transitional physiology.
Incidence and Etiology of Nuchal Cords
Nuchal cord occurs in approximately 25% of births.
3
Recent prenatal ultrasonographic evaluation reveals nuchal
cords are dynamic in nature, forming and resolving over the
course of a pregnancy.
12
Even at 10 to 14 weeks’ gestation,
8% of fetuses may have nuchal cords.
13
The occurrence of
nuchal cord increases with gestational age; at 42 weeks,
29% of births have nuchal cord present.
2
The mean length of the umbilical cord is approximately
60 cm (range 50 to 70 cm).
2
Nuchal cords occur more
frequently among fetuses with longer cords. In utero, the
umbilical cord appears to lengthen in response to tensile
forces caused by fetal movement.
12
Maximal cord length
appears to be achieved around 30 weeks’ gestation, with
little growth in length beyond that time.
12
Fetuses in vertex
presentations have been found to have longer cords than
those in breech presentations.
Address correspondence to Judith S. Mercer, CNM, DNSc, FACNM, Nurse-
Midwifery Program, University of Rhode Island College of Nursing, 2
Heathman Road, Kingston, RI 02881-2021. E-mail: jmercer@uri.edu
Journal of Midwifery & Women’s Health •www.jmwh.org 373
© 2005 by the American College of Nurse-Midwives 1526-9523/05/$30.00 •doi:10.1016/j.jmwh.2005.04.023
Issued by Elsevier Inc.

Structure of the Umbilical Cord
The umbilical cord usually consists of two arteries and one
vein, surrounded by Wharton’s jelly, and enclosed in a thin
layer of amnion. An extensive network of collagen fibrils
within Wharton’s jelly forms a “soft skeleton” surrounding
the umbilical vessels and provides some protection and
support.
14
However, it is the high venous and arterial
pressures in the blood flow that keeps the umbilical cord
distended and prevents interruption of blood flow even
during compression or torsion.
15
The collapsed vessels
typically seen on inspection after ligation at birth are
misleading. The vessels with intact fetoplacental circulation
are distended and take up the greatest portion of the
cross-sectional area of the cord.
15
The arteries are narrower
in diameter than the vein, having both more muscular and
thicker walls. They maintain a pulsatile flow of blood at
systolic and diastolic pressures of about 60 and 30 mm Hg,
respectively. Blood flow through the relatively larger,
thin-walled umbilical vein is much less pulsatile, at a
pressure of about 20 to 25 mm Hg.
Effects of Pressure
In the fairly closed system of the intrauterine environment,
pressure is more or less evenly distributed, and the free-
floating cord is not greatly affected by the increase in
pressure brought about by contractions. However, segments
of cord encircling the fetal neck or other body part cannot
float freely and may be compressed by the substantial
pressure from the contracting uterine musculature. The vein
is easier to occlude than the arteries, and compression
commonly results in variable decelerations of the fetal heart
rate that, when severe, may affect fetal tolerance of labor.
16
When the umbilical vein is regularly occluded, there is a
net transfer of blood from the fetus to the placenta. As
pressure on the cord and compression increases, the mus-
cular-walled, high-pressure arteries may continue to move
blood from the fetus to the placenta, whereas return flow to
the fetus in the thin-walled vein is impeded. The loss of
fetal blood volume may be particularly severe when the
recovery time between contractions is short. Neonatal
status may be compromised by the uncorrected physiologic
effects of hypoxia as well as reduced blood volume.
Fetal Heart Rate Changes With Nuchal Cord
The fetal heart rate variable decelerations commonly attrib-
uted to cord compression can occur as a result of umbilical
vessel occlusion. According to Weiss et al.,
17
Doppler
studies have demonstrated that, for many variable deceler-
ations, a sharp decrease in umbilical vessel perfusion
precedes the drop in the fetal heart rate by a few seconds.
The interruption of umbilical perfusion stimulates dis-
charge of the parasympathetic nervous system via the vagus
nerve and results in fetal bradycardia.
Other Important Factors
Factors, such as amniotic fluid volume, the number of
encirclements, presence of knots, and tightness of the cord
may influence the impact of nuchal cords on fetuses and
newborns. Strong et al.
18
found that oligohydramnios
worsened the effect of nuchal cords on fetal status during
labor. The same appears to be true of multiple nuchal cord
encirclements.
4
FETAL TO NEONATAL TRANSITION
To protect the physiologic processes at birth, one must
understand the role that blood volume plays in the success
of the fetus-to-neonate transition. The following model
explains how an adequate blood volume promotes a normal
physiologic neonatal transition and helps to protect the
infant from harm.
Blood Volume Model of Neonatal Transition
A shift is needed in thinking about the fetus-to-neonate
transition, from the current focus on immediate respiration
only to the role that blood volume plays in a successful
transition.
19
The blood volume model states that the limit-
ing factor at birth may be the availability of adequate red
blood cells and volume for tissue oxygen delivery.
19
During fetal life, only 8% to 12% of the fetal cardiac
output goes to the fetal lungs, whereas 45% to 50%
circulates through the placenta.
20
The alveoli during fetal
life are filled with lung fluid. Immediately after birth, the
lung must structurally change from a fluid-filled organ to
one filled with air. Functionally, it must change from an
organ of fluid production to an organ of gas exchange.
Immediately after birth, 50% of the neonate’s cardiac
output must flow to and through the lungs to effect
appropriate gas exchange. A volume of blood (at least 40
mL) must be available to expand the pulmonary capillary
bed.
21
However, the volume of blood available to the baby
for this purpose is limited to the amount that was in the
neonate at the time the cord was clamped. If the blood
volume needed to expand the lung does not come from the
placenta through an intact umbilical cord, it must be
forfeited from other organ systems and the general circu-
lation in the neonate’s body.
22
Judith S. Mercer, CNM, DNSc, FACNM, is a faculty member of the
University of Rhode Island College and Principal Investigator for a random-
ized controlled trial on delayed cord clamping in preterm infants funded by
National Institutes of Health.
Rebecca Skovgaard, CNM, MSN, is an assistant professor of clinical
obstetrics and gynecology, University of Rochester School of Medicine and
Dentistry.
Joann Peareara-Eaves, CNM, MSN, is a 2004 graduate from the University of
Rhode Island.
Tracey A. Bowman, CNM, MSN, is an expert in the use of water birth; in her
own practice, she provides gynecologic care and a homebirth service.
374 Volume 50, No. 5, September/October 2005

A full-term fetus has approximately 110 to 115 mL/kg of
blood that is distributed in the fetal and placental compart-
ments. Prior to birth, about two-thirds volume perfuses the
fetal body, whereas one third flows through the placenta. A
3000 g fetus will have approximately 330 to 345 mL of
blood in the fetal-placental circulation. The average blood
volume of infants after immediate cord clamping is 70
mL/kg versus 90 mL/kg in infants after delayed cord
clamping. For the 3000 g infant, this difference is 210 mL
versus 270 mL for the circulating blood volume.
23
Delayed
cord clamping will provide an extra 60 mL of blood to the
infant for circulatory adjustments. This 60 mL of blood is
needed for lung volume expansion as the neonatal cardiac
output to the lung increases from 40% to 50% of the cardiac
output, in contrast to the fetal flow of 8% to 12%.
20
The millions of capillaries covering the alveoli are
actually cemented to the alveoli by an intracellular ma-
trix.
24
At birth, these capillaries fill with blood for the first
time, causing the capillary plexuses to expand with blood
and become erect. This process of capillary “erection”
opens the alveoli and provides the “scaffolding” structure to
keep them open.
25
Air pressure does not keep lungs open,
because lungs have only atmospheric pressure. It is the
hydrostatic exoskeleton generated by the capillary network
that maintains alveolar expansion and prevents the alveoli
from closing or collapsing on expiration. Surfactant helps
keep the alveoli open due to reduction in the surface
tension, but surfactant does not directly support the alveolar
structure. Adequate blood flow to the lung clears the lung
fluid during the initial breaths because higher colloidal
osmotic pressure of the blood in the capillaries draws the
fluid from the alveoli. As respiration continues, a higher
level of systemic oxygen stimulates the respiratory centers
of the brain and causes the oxygen-sensitive umbilical
arteries and ductus arteriosus to close.
26
Normal neonatal
respiration and circulation is then established (Figure 1).
Stembera and colleagues documented that blood flow in
the umbilical vein continues at an average of 75 mL/min for
an average of 100 to 120 seconds after birth.
27
Anatomic
sections of the cord after birth show the arteries are open
when the cord is clamped immediately and constricted
when clamping is delayed for a few minutes. This postnatal
placental circulation continues to support the infant during
the transition to breathing. Even in compromised infants,
Stembera found a flow of about 50 mL/kg per minute.
28
Symptomatic polycythemia and hyperbilirubinemia are
the two concerns most commonly associated with delayed
cord clamping. The idea that delayed cord clamping causes
either problem is based on two reports from a study from
the 1960s, which did not randomly allocate subjects and has
not been replicated.
29,30
Systematic reviews of the literature
reveal that neither risk has been validated in randomized
controlled trials of delayed cord clamping involving pre-
term or term infants.
31–33
Further discussion can be found
in a comprehensive review of the literature on cord
clamping.
31
LITERATURE REVIEW ON EFFECTS OF NUCHAL CORD
Immediate cord clamping after birth has been shown to
result in a 25% to 40% reduction in blood volume at birth.
23
Clamping the cord before birth removes the infant from the
placental life support system before the infant is born and
increases blood volume loss. The basic cause of hypoxia is
interruption of the normal blood flow between the fetus and
Figure 1. The blood volume model of neonatal transition.
Journal of Midwifery & Women’s Health •www.jmwh.org 375

the placenta. The practice of clamping the cord before birth
places the infant at high risk of hypoxia, hypovolemia, and
related problems. If there is a delay in delivery of the
shoulders, this practice can lead to morbidity and mortality.
It also necessitates an abrupt, rather than gradual, adapta-
tion to extrauterine breathing.
19,34
Potential adverse effects from premature ligation of
nuchal cords and the resulting blood loss include hypovo-
lemia, hypotension and shock,
6,35
anemia,
7
and cerebral
palsy.
1,8,9
An infant who presents with a nuchal cord may
already be compromised because of compression of the
umbilical cord during contractions, which prevents normal
blood flow and correction of acid-base imbalance. If the
cord is not cut before or immediately after birth, the infant
may be able to equalize these imbalances after birth when
the nuchal cord is reduced.
Hypotension and Hypovolemic Shock
In 1973, Cashore and Usher reported that tight nuchal cords
at birth resulted in neonatal hypovolemia in a case series of
11 infants.
6
Infants requiring cord ligation prior to delivery
of the shoulders had a 20% reduction of red blood cell
volume after birth. The diminished blood flow to the fetus
accounted for a decrease in body iron content, resulting in
anemic, pale, and hypotensive infants after birth.
6
In a case report, Vanhaesebrouck described two term
infants who suffered from acute hypovolemic shock result-
ing from a tight nuchal cord, despite unremarkable preg-
nancies and labors.
35
Early clamping and cutting of the
cords was deemed necessary for delivery because the
nuchal cords were too tight to slip over the infants’ heads.
These infants exhibited pallor, irregular respirations, low
Apgar scores, gasping, tachycardia, weak peripheral pulses,
hypotension, and acidemia. Resuscitation efforts included
intubation and ventilation as well as blood transfusions to
restore blood volume. The authors suggested “fetoplacental
hemorrhage” due to tight nuchal cord was the cause of the
infants’ condition.
Anemia
An observational study by Shepherd examined tight or
loose nuchal cord as a potential cause of neonatal anemia in
437 newborns consecutively admitted to the nursery.
7
Anemia was defined as any venous hemoglobin level less
than 13.2 g/dL or hematocrit of less than 39.2%. She found
that 16% of 57 neonates with a nuchal cord were anemic
within the first 24 hours after birth. Three infants in the
nuchal cord group developed hypotension requiring blood
transfusions, but no anemia was found in the group without
a nuchal cord.
Nuchal Cord and Shoulder Dystocia
Shoulder dystocia occurs in 1.7% of births and is most
often an unanticipated event. A few case reports suggest
that clamping and cutting the nuchal cord before delivery of
the infant’s shoulders can influence outcomes after shoulder
dystocia. Iffy described several cases of cerebral palsy after
nuchal cords were cut, and subsequent shoulder dystocia
delayed birth by as little as 3 minutes.
8
All of the fetuses
were considered healthy prior to the onset of labor. The
infants were all born with low Apgar scores and developed
signs of hypoxic-ischemic encephalopathy. The authors
highly advise avoiding nuchal cord ligation prior to full
delivery whenever possible. Iffy remarked that, in Europe,
it is routine to deliver the infant’s head and then wait for the
next contraction to effect restitution and deliver the shoul-
ders.
1
The diagnosis of shoulder dystocia is not made until
after this second contraction. This is in contrast to the
practice in the United States of attempting delivery of the
shoulders immediately after delivery of the head.
Reduction in Birth Weight
Three large studies document reduction in weight of 60 to
80 g in infants after immediate or prebirth cord clamping,
due to either a nuchal cord or immediate clamping during
active management of third stage. Records of 10,509
Canadian births were examined and revealed that 25%
(2699) of infants born with a nuchal cord had mean weights
about 60 g less than infants without nuchal cords (n ⫽8710
or 74.3%).
3
Typical practice in these settings when a nuchal
cord was noted was to cut and clamp the cord before the
body of the baby is delivered. This reduction in birth weight
is similar to that found in the Hinchingbrooke and Bristol
Active Management of Third Stage Trials.
36,37
Both of
these randomized controlled trials studied the incidence of
maternal and fetal morbidity after routine active manage-
ment of the third stage of labor versus expectant or
physiologic management. Their definition of active man-
agement of third stage included immediate cord clamping;
physiologic management included delayed cord clamping.
The Bristol trial evaluated 1695 women, with 849 randomly
assigned to the active management group and 846 in the
physiologic management group. The mean birth weight of
the babies in the physiologic management group was 85 g
higher than that of babies in the active group.
36
The
Hinchingbrooke trial involved 748 women in the active
management of third stage group and 764 women in the
physiologic management group. The infants in the physio-
logic management group had birth weights that averaged
67 g more than the infants in the active management of the
third stage group. The authors attributed the difference to
the additional blood that infants receive prior to cord
clamping.
37
Infant Outcomes
There are no studies comparing long-term outcomes of
differences in cord clamping times. Suggested long-term
impact on infants from premature ligation of the umbilical
376 Volume 50, No. 5, September/October 2005

cord at birth or before birth includes anemia and neurode-
velopmental delays.
32,38
A review of controlled trials of early versus late cord
clamping at delivery evaluated the potential of delayed cord
clamping to improve the iron status in infants at 2 to 3
months of age.
32
The authors determined that late cord
clamping at delivery significantly improved hemoglobin
status in term infants at 2 to 3 months of age and did not
increase adverse outcomes.
Clapp
38
conducted the only prospective study that
followed infants who experienced a nuchal cord at birth
until 1 year of age. He enrolled a group of 190 women
who had normal pregnancies, attended the births, and
completed developmental testing at 1 year of age in all of
the infants. Sixty-six (35%) of the women had infants
with nuchal cords at birth. Twenty-one (11%) had a
nuchal cord at birth as an incidental finding with no signs
during labor. However, 24% were symptomatic for
nuchal cord during labor, as evidenced by abnormal fetal
heart rate patterns during labor or the finding of meco-
nium-stained amniotic fluid at birth. At 1 year, scores on
the Bayley Scales of Infant Development were signifi-
cantly, albeit slightly, lower (116 versus 120 mental, and
101 versus 107 on psychomotor testing; P⬍.01) in the
infants who had experienced nuchal cords. This differ-
ence was more pronounced among the infants who had
extreme tightness or multiple loops. No information on
the management at birth was offered.
LITERATURE ON MANAGEMENT OF NUCHAL CORD AT BIRTH
No research was found on management of nuchal cords at
birth, except for theoretical discussions, case reports, and a
survey of midwifery practices. In 1991, Schorn and Blanco
first described the somersault maneuver as a management
option when a nuchal cord is present at a birth.
10
It involves
1) slow delivery of the shoulders without manipulation of
the cord, 2) flexing the neonate’s head toward the mother’s
thigh as the shoulders are delivered, 3) keeping the infant’s
head close to the perineum and letting the body “somer-
sault” out with feet pointing toward the mother’s feet, and
4) unwrapping the cord and proceeding with normal man-
agement. The four maneuvers are described in Figure 2.
A survey of active members of the American College of
Nurse-Midwives was conducted to inquire about cord
clamping practices, beliefs, and nuchal cord management.
39
Fifty-seven percent of the respondents chose the option
“Clamp and cut the nuchal cord only when very tight.” The
somersault maneuver
10
was selected by 40% of the partic-
ipants as their best option for managing nuchal cord, and
only 3.2% stated that they clamp and cut prior to birth of
the shoulders in most cases of nuchal cord. Ninety-six
percent of certified nurse-midwives surveyed avoid imme-
Figure 2. Somersault maneuver. The summersault maneuver involves holding the infant’s head flexed and guiding it upward or sideways toward the pubic bone
or thigh, so the baby does a “somersault,” ending with the infant’s feet toward the mother’s knees and the head still at the perineum.
1. Once the nuchal cord is discovered, the anterior and posterior shoulders are slowly delivered under control without manipulating the cord.
2. As the shoulders are delivered, the head is flexed so that the face of the baby is pushed toward the maternal thigh
3. The baby’s head is kept next to the perineum while the body is delivered and “somersaults” out.
4. The umbilical cord is then unwrapped, and the usual management ensues.
Journal of Midwifery & Women’s Health •www.jmwh.org 377

diate clamping and cutting of the cord when confronted
with a nuchal cord.
39
NUCHAL CORD MANAGEMENT: IMPLICATIONS FOR PRACTICE
Maintaining the integrity of the nuchal cord as much as
possible may decrease neonatal risks of hypovolemia,
6
anemia,
35
and hypoxic-ischemic encephalopathy, espe-
cially if birth is delayed by even a mild shoulder dysto-
cia.
1,8
Management of a presenting nuchal cord should be
tailored to protect intact umbilical circulation. Techniques
to preserve an intact nuchal cord depend on how tightly the
cord is wrapped around the infant’s neck. If the cord is
loose, it can easily be slipped over the infant’s head. The
infant can be delivered normally and placed on maternal
abdomen as desired. If the cord is too tight to go over the
infant’s head, the provider may be able to slip it over the
infant’s shoulders and deliver the body through the cord.
The cord can then be unwrapped from around the baby after
birth. Finally, if the cord is too tight to slip back over the
shoulders, one may use the somersault maneuver, as de-
scribed by Schorn and Blanco.
10
Resuscitation
Resuscitation of the infant after reduction of a nuchal cord
should take place between the mother’s legs or on her
abdomen, with the umbilical cord intact. Unwinding the
cord allows the placental circulation to reperfuse the infant
in the first minutes after birth so that the infant will not lose
the essential blood volume necessary to oxygenate vital
organs.
27,28
Allowing time for this reperfusion while con-
ducting resuscitation should improve the newborn’s
outcome.
Infants at the greatest risk of severe hypovolemia present
with white, “drained” bodies (or mottled blue and white),
no tone, no reflexes, and no respiratory efforts. However,
they usually have heart rates above 100. If the cord is left
intact during resuscitation, they will reperfuse as the blood
trapped in the placenta returns to the infant’s body, correct-
ing any acid-base imbalance that occurred in the process.
Evidence for correction of the acid-base balance is that the
tone returns about the same time that the baby begins
breathing.
11
If the heart rate is not above 100, drying
(stimulation) and lowering the infant below the level of the
perineum,
40
or milking the cord
11
support resuscitative
efforts. Bag and mask or even intubation can be done, as
indicated, at the perineum (on a dry pad) without clamping
the umbilical cord of the vulnerable infant. Once the infant
has regained tone and color (reperfused) and breathing
stabilizes, the infant can be put skin-to-skin on the mother’s
abdomen.
SUMMARY AND CONCLUSION
Nuchal cords occur in approximately 25% of births. Med-
ical evidence indicates that clamping and cutting the cord
prior to full delivery of the infant and/or immediately after
birth increase the infant’s risk of developing hypovolemia,
anemia, hypovolemic shock, and rarely, cerebral palsy, if
the birth is complicated by a shoulder dystocia after the
cord has been cut. To provide a safe birth with minimal
harmful intervention, obstetric providers need to fully
understand how management impacts the normal physio-
logic processes of the newborn.
This literature review supports the use of the somersault
maneuver with nuchal cord births. The maneuver, easily
applied, is physiologically compatible with the normal
fetus-to-infant transition processes and is based on a sound
understanding of the form and function of the umbilical
cord. The blood volume theory provides the theoretical
rationale for the use of the somersault maneuver instead of
clamping the cord before or immediately after birth.
A comprehensive inquiry into the normal physiologic
fetus-to-newborn transitional process as well as the promo-
tion of safe methods (i.e., somersault maneuver) for man-
aging nuchal cords should be included in all midwifery and
medical curricula. Educational and clinical preceptors can
provide students with the opportunity to practice the som-
ersault maneuver on dolls/models. Learning begins with
awareness and exposure.
The current standard of practice is to immediately cut the
cord to resuscitate the infant at the warmer. However,
resuscitation at the perineum allows the infant to reperfuse
and regain blood trapped in the placenta via postnatal
placental circulation. In many institutions, responsibility
for the mother–infant unit becomes divided at the time of
birth. Obstetric and neonatal providers, with the best
interest of the neonate at heart, can negotiate management
to provide neonatal care that decreases, rather than in-
creases, risk to the infant. Providers need to examine new
views of neonatal transitional physiology in building ratio-
nale to avoid practices that have been shown to compromise
the health of the infant.
This work was supported by the National Institutes of Health, National
Institute for Nursing Research, Grant No. K 23 NR008027-01-02.
REFERENCES
1. Iffy L, Varadi V, Papp E. Untoward neonatal sequelae deriving
from cutting of the umbilical cord before delivery. Med Law 2001;
20:627–34.
2. Dhar K, Ray S, Dhall G. Significance of nuchal cord. J Indian
Med Assoc 1995;93:451–3.
3. Osak R, Webster K, Bocking A, Campbell M, Richardson B.
Nuchal cord evident at birth impacts on fetal size relative to that of
the placenta. Early Hum Dev 1997;49:193–202.
4. Larson J, Rayburn W, Harlan V. Nuchal cord entanglements
and gestational age. Am J Perinatol 1997;14:555–7.
5. Cunningham F, McDonald P, Gant N, et al. Williams obstet-
rics. New York: McGraw-Hill, 2001:319 –20.
378 Volume 50, No. 5, September/October 2005

6. Cashore W, Usher R. Hypovolemia resulting from a tight
nuchal cord at birth. Pediatr Res 1973;7:399.
7. Shepherd A, Richardson C, Brown J. Nuchal cord as a cause of
neonatal anemia. Am J Dis Child 1985;139:71–3.
8. Iffy L, Varadi V. Cerebral palsy following cutting of the nuchal
cord before delivery. Med Law 1994;13:323–30.
9. Nelson K, Grether J. Potentially asphyxiating conditions and
spastic cerebral palsy in infants of normal birth weight. Am J Obstet
Gynecol 1998;179:507–13.
10. Schorn M, Blanco J. Management of the nuchal cord. J Nurse
Midwifery 1991;36:131–2.
11. Mercer J, Skovgaard R. Fetal to neonatal transition: First, do no
harm. In Downe S, ed. Normal childbirth: Evidence and debate.
Edinburgh: Elsevier, 2004:152.
12. Collins J. Tight nuchal cord morbidity and mortality. Am J
Obstet Gynecol 1999;180:251.
13. Schaefer M, Laurichesse-Delmas H, Ville Y. The effect of
nuchal cord on nuchal translucency measurement at 10 –14 weeks.
Ultrasound Obstet Gynecol 1998;11:271–3.
14. Vizza E, Correr S, Goranova V, et al. The collagen skeleton of
the human umbilical cord at term. A scanning electron microscopy
study after 2N-NaOH maceration. Reprod Fertil Dev 1996;8:885–94.
15. Reynolds S. Mechanism of placentofetal blood flow. Obstet
Gynecol 1978;51:245–9.
16. Ball RH, Parer JT. The physiologic mechanisms of variable
decelerations (discussion 1688-9). Am J Obstet Gynecol 1992;166:
1683– 8.
17. Weiss E, Hitschold T, Berle P. Umbilical artery blood flow
velocity waveforms during variable deceleration of the fetal heart
rate. Am J Obstet Gynecol 1991;164:534 – 40.
18. Strong Jr, T Sarno A, Paul R. Significance of intrapartum
amniotic fluid volume in the presence of nuchal cords. J Reprod Med
1992;37:718 –20.
19. Mercer J, Skovgaard R. Neonatal transitional physiology: A
new paradigm. J Perinat Neonatal Nurs 2002;15:56 –75.
20. Blackburn S. Maternal, fetal, and neonatal physiology, 2nd ed.
Philadelphia: WB Saunders, 2003:286 –7.
21. Carlton D. Pediatrics and perinatology. In Gluckman P, Hey-
man M, eds. Pulmonary vasculature. London: Arnold, 1996:820.
22. Wardrop C, Holland B. The roles and vital importance of
placental blood to the newborn infant. J Perinat Med 1995;23:
139 – 43.
23. Yao A, Moinian M, Lind J. Distribution of blood between
infant and placenta after birth. Lancet 1969;2:871–3.
24. Dunsmore S, Rannels D. Extracellular matrix biology in the
lung. Am J Physiol 1996;270:L3–L27.
25. Jaykka S. Capillary erection and lung expansion; an experi-
mental study of the effect of liquid pressure applied to the capillary
network of excised fetal lungs. Acta Paediatr 1957;46:1–91.
26. Baier R, Hasan S, Cates D, Hooper D, Nowaczyk B, Rigatto H.
Effects of various concentrations of O
2
and umbilical cord occlusion
on fetal breathing and behavior. J Appl Physiol 1990;68:1597–1604.
27. Stembera Z, Hodr J, Janda J. Umbilical blood flow in healthy
newborn infants during the first minutes after birth. Am J Obstet
Gynecol 1965;91:568 –74.
28. Stembera Z, Hodr J, Janda J. Umbilical blood flow in newborn
infants who suffered intrauterine hypoxia. Am J Obstet Gynecol
1968;101:546 –53.
29. Saigal S, O’Neill A, Surainder Y, Chua LB, Usher R. Placental
transfusion and hyperbilirubinemia in the premature. Pediatrics 1972;
49:406 –19.
30. Saigal S, Usher R. Symptomatic neonatal plethora. Biol Neo-
nate 1977;32:62–72.
31. Mercer J. Best evidence: A review of the literature on umbilical
cord clamping. J Midwifery Womens Health 2001;46:402–14.
32. Rheenen P, Brabin B. Late umbilical cord-clamping as an
intervention for reducing iron deficiency anaemia in term infants in
developing and industrialised countries: A systematic review. Ann
Trop Paediatr 2004;24:3–16.
33. Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed
umbilical cord clamping in preterm infants. Cochrane Database Syst
Rev 2004:CD003248.
34. Morley G. Cord closure: Can hasty clamping injure the new-
born? Obg Management 1998:29 –35.
35. Vanhaesebrouck P, Vanneste K, De Praeter C, Van Trappen Y,
Thiery M. Tight nuchal cord and neonatal hypovolaemic shock. Arch
Dis Child 1987;62:1276 –7.
36. Prendiville W, Harding J, Elbourne D, Stirrat G. The Bristol
third stage trial: Active versus physiological management of third
stage of labour. BMJ 1988;297:1295–300.
37. Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A,
Elbourne D. Active versus expectant management of third stage of
labour: The Hinchingbrooke randomised controlled trial. Lancet
1998;351:693–9.
38. Clapp III, J Lopez B, Simonean S. Nuchal cord and neurode-
velopmental performance at 1 year. J Soc Gynecol Investig 1999;6:
268 –72.
39. Mercer J, Nelson C, Skovgaard R. Umbilical cord clamping:
Beliefs and practices of American nurse-midwives. J Midwifery
Womens Health 2000;45:58 – 66.
40. Yao A, Lind J. Effect of gravity on placental transfusion.
Lancet 1969;2:505– 8.
Journal of Midwifery & Women’s Health •www.jmwh.org 379