Original Article

Electronic Fetal Monitoring and Neonatal Outcomes

when a Nuchal Cord Is Present at Delivery
Ebony B. Carter, MD, MPH1 Cheryl S. Chu, MD1 Zach Thompson, BS1 Methodius G. Tuuli, MD, MPH1
George A. Macones, MD, MSCE1 Alison G. Cahill, MD, MSCI1

1 Division of Maternal-Fetal Medicine, Department of Obstetrics and
Gynecology, Washington University School of Medicine, St. Louis, Missouri
Am J Perinatol
Address for correspondence Ebony B. Carter, MD, MPH, Division of
Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,
Washington University School of Medicine, 660 South Euclid Avenue,
Maternity Building, 5th Floor, Campus Box 8064, St. Louis, MO 63110
(e-mail: cartere@wustl.edu).

Abstract Objective To determine the association between nuchal cord, electronic fetal
monitoring parameters, and adverse neonatal outcomes.
Study Design This was a prospective cohort study of 8,580 singleton pregnancies.
Electronic fetal monitoring was interpreted, and patients with a nuchal cord at delivery

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were compared with those without. The primary outcome was a composite neonatal
morbidity index. Logistic regression was used to adjust for confounders.
Result Of 8,580 patients, 2,071 (24.14%) had a nuchal cord. There was no difference
Keywords in the risk of neonatal composite morbidity in patients with or without a nuchal cord
► nuchal cord (8.69 vs. 8.86%; p ¼ 0.81). Nuchal cord was associated with category II fetal heart
► neonatal morbidity tracing and operative vaginal delivery (OVD) (6.4 vs. 4.3%; p < 0.01).
► electronic fetal Conclusion Nuchal cord is associated with category II electronic fetal monitoring
monitoring parameters, which may drive increased rates of OVD. However, there is no significant
► fetal heart rate association with neonatal morbidity.

There is continued debate regarding the clinical significance
of a nuchal cord (NC) at the time of delivery. Multiple prior
studies have concluded that there is no risk of neonatal
morbidity associated with an NC.1–5 However, other studies
have reported an increased risk of certain neonatal outcomes
including decreased birthweight,7,8 shoulder dystocia,6,7
Apgar score < 7,9–14 neonatal intensive care unit (NICU)
admissions,7,10,11 need for respiratory resuscitation,10 and
fetal distress.13,14 This uncertainty leads to frustration for
providers and patients who often believe that an NC at the
time of birth is associated with poor neonatal outcomes.15
Additionally, despite its ubiquitous use, intrapartum elec-
tronic fetal monitoring (EFM) and its association with NC and
neonatal outcomes have not been widely studied. Earlier
reports have generally been in disagreement and have not
systematically examined specific EFM parameters;1,8,10,13,16–19
thus, there is a need to further assess the risk of neonatal
morbidity in the setting of both NC and EFM parameters.
We studied the association between EFM, NC, and neo-
natal outcomes among women laboring at term with single-
ton pregnancies to estimate whether the presence of an NC at
the time of delivery was associated with nonreassuring EFM
parameters and adverse neonatal outcomes. We hypothe-
sized that women with NC would be more likely to have
category II EFM characteristics, such as variable decelera-
tions, than women without NC but both groups would have
similar neonatal outcomes.
Materials and Methods
This was a planned secondary analysis of a prospective
cohort study of 8,580 women with consecutive singleton
pregnancies in labor at or beyond 370/7 weeks.20 The
primary purpose of the cohort was to examine the relation-
ship between intrapartum EFM and perinatal outcomes.
The study was approved by the Washington University

received Copyright © by Thieme Medical DOI https://doi.org/

August 3, 2018 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-1679866.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
January 12, 2019 Tel: +1(212) 584-4662.
Electronic Fetal Monitoring and Neonatal Outcomes
Medical School Human Research Protection Office (IRB ID
#201102438).
This secondary analysis compared patients with a neona-
tal NC at the time of delivery with those without. NC was
diagnosed at birth and was defined as the umbilical cord
wrapped 360 degrees or more around the fetal neck. Exclu-
sion criteria included unknown NC status, major fetal anom-
aly, scheduled cesarean delivery without labor, failure to
reach the second stage with pushing, and gestational age
< 37 weeks. Trained research staff collected detailed data
from participant’s medical records.
The primary outcome of the study was composite neona-
tal morbidity, defined as one or more of the following events:
neonatal death before hospital discharge, seizure(s),
hypoxic–ischemic encephalopathy, need for hypothermic
treatment, respiratory morbidity, hypotension requiring
vasopressor therapy, and suspected sepsis. A diagnosis of
hypoxic–ischemic encephalopathy required moderate-to-
severe neonatal encephalopathy, defined by the National
Institute of Child Health and Human Development criteria,21
or seizure activity) in the setting of an abnormal umbilical
artery cord gas (pH < 7.0 or base deficit more than 16), 5-
minute Apgar score < 5, or need for respiratory support at
10 minutes of life. Respiratory morbidity included need for
ventilator support or respiratory distress diagnosed clini-
cally by nasal flaring, subcostal/intercostal retractions, and
need for supplemental oxygen to main oxygen saturation
> 95%. Secondary outcomes included components of the
composite as well as NICU admission, umbilical artery cord
pH < 7, and 5-minute Apgar score < 7.
Gestational age was calculated based on the woman’s first
ultrasound examination in the pregnancy and last menstrual
period.22 A woman was considered to have diabetes mellitus
if she had a diagnosis of type 1/type 2 in the medical record or
gestational diabetes mellitus based on the National Diabetes
Group criteria.23 A hypertensive disorder in pregnancy was
defined as chronic hypertension, gestational hypertension,
or preeclampsia.24 Maternal and neonatal demographic data
obtained from the medical record included type of labor
(spontaneous or induced), oxytocin use, mode of delivery
(vaginal, cesarean, operative vaginal), use of regional
anesthesia, neonatal birth weight, and maternal complica-
tions. Maternal complications were classified as those during
delivery (shoulder dystocia, fever, retained placenta, and
other) or postpartum (wound infection, fever, transfusion,
hemorrhage, endomyometritis). Small for gestational age
was defined as birth weight < 10th percentile based on
the Alexander growth curve reference.25
Obstetric research nurses, formally trained to system-
atically review EFM patterns using the National Institute of
Child Health and Human Development criteria,26 were
blinded to all clinical data and extracted EFM patterns in
the 120 minutes prior to delivery. These patterns were
categorized according to fetal heart rate (FHR) baseline,
variability, number of accelerations, and number/type of
decelerations.27 Decelerations were considered repetitive if
they occurred with 50% of uterine contractions in any
20-minute window. Prolonged decelerations were defined
American Journal of Perinatology
Carter et al.
as a decrease in FHR from the baseline of 15 bpm, lasting
between 2 and 10 minutes. The characteristics of EFM
patterns were defined and compared using the Eunice
Kennedy Shriver National Institute of Child Health and
Human Development 3-tier category system.27
Data analysis was performed with descriptive and bivari-
ate statistics using an unpaired Student’s t-test or Mann–
Whitney U test for continuous variables and using a chi-
square or Fisher’s exact test for categorical variables, as
appropriate. The Kolmogorov–Smirnov test was used to
test the normal distribution of continuous variables. Rates
of the primary and secondary outcomes were estimated
within groups. Multivariable logistic regression models for
the primary and secondary outcomes were developed to
adjust for potential confounders. Covariates that were asso-
ciated with the presence of NC in bivariable analyses were
included in the initial model and were removed sequentially
with the use of a backward stepwise approach. Covariates
that were considered in the model included advanced mater-
nal age (AMA; maternal age  35), Black race, obesity (body
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mass index  30), diabetes, hypertension, history of previous
cesarean delivery, and oxytocin use. Final models included
black race and oxytocin use and were tested using the
Hosmer–Lemeshow goodness-of-fit test. We explored spe-
cific features within the category II FHR patterns to identify
whether NC in the setting of specific features conferred risk.
All statistical analyses were performed using STATA software
(version 10.0 [special edition], StataCorp, College Station, TX).
Results
Among 8,580 patients meeting the inclusion criteria, 2,071
women (24.14%) had an NC at the time of delivery. Women
with an NC at delivery were more likely to be white and of
AMA and were less likely to have a prior cesarean delivery
(►Table 1).
There was no significant difference in the risk of the
primary outcome of neonatal composite morbidity (adjusted
odds ratio [aOR]: 0.99; 95% confidence interval [CI]: 0.83–
1.18) (►Table 2). There were also no differences in the
components of the composite with the exception of sei-
zure(s), which was associated with a higher risk (aOR: 2.62;
95% CI: 1.03–6.68) in neonates with an NC. All infants with
seizures underwent magnetic resonance imaging (MRI) of
the head, and the results were normal in 3/8 neonates with
NC versus 5/10 neonates without NC. Rates of NICU admis-
sion, arterial cord pH < 7, and low 5-minute Apgar score < 7
were also similar between groups (►Table 2). With regard to
labor characteristics, patients with NC were more likely to
receive oxytocin (aOR 1.15; 95% CI: 1.04–1.28) and have an
operative vaginal delivery (OVD) (6.4 vs. 4.3%; p < 0.01; aOR
1.47; 95% CI: 1.18–1.81) and less likely to deliver by cesarean
(13.4 vs. 18.1%; p < 0.01; aOR 0.73; 95% CI: 0.63–0.84)
(►Table 3). The most common indication for both cesarean
section and OVD was nonreassuring fetal status.
We further examined the FHR characteristics in the
30 minutes prior to delivery. The presence of an NC was
associated with a significant increase in repetitive late
 Electronic Fetal Monitoring and Neonatal Outcomes Carter et al.

Table 1 Comparison of baseline characteristics in the presence decelerations (aOR: 1.45; 95% CI: 1.12–1.87), repetitive
or absence of a nuchal cord variable decelerations (aOR: 1.41; 95% CI: 1.27–1.58), and
overall category II tracings (aOR: 1.53; 95% CI: 1.38–1.70)
Nuchal cord, No nuchal cord, p-Value (►Table 4).
N ¼ 2,071 N ¼ 6,509
Among patients with an OVD, those with an NC were more
Maternal age 25 (21–31) 25 (21–30) <0.01
than twice as likely (aOR: 2.40; 95% CI: 1.14–5.02) to have
median (IQR)
repetitive late decelerations, but the rates of repetitive
AMA (35 years) 223 (10.77) 541 (8.31) 0.01
variable decelerations were similar in the presence or
Race
absence of an NC (►Table 5).
Black 1,265 (61.08) 4,300 (66.06) <0.01
White 524 (25.30) 1,417 (21.77)
Discussion
Latino/Hispanic 161 (7.77) 452 (6.94)
Asian 7 (0.34) 22 (0.34) Our study demonstrates that NC at delivery is common and
Native American 85 (4.10) 233 (3.58)
associated with category II EFM parameters and higher rates
of OVD in infants at or beyond 37 weeks. However, there is no
Other 14 (0.68) 38 (0.58)
significant association between NC and neonatal morbidity;
Unknown 15 (0.72) 47 (0.72)
thus, reassurance can be provided to parents when NC is
Obese 1,141 (55.09) 3,586 (55.09) 0.99 diagnosed and there is likely no utility for NC screening.
Asthma 281 (13.57) 896 (13.77) 0.85 Previous literature has shown opposing results regarding
Diabetes 85 (4.10) 272 (4.18) 0.90 the significance of an NC. In some reports, presence of an NC

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Chronic hypertension 95 (4.59) 310 (4.76) 0.76 has been associated with poor neonatal outcomes including
Hypertensive 414 (19.99) 1,317 (20.23) 0.81 unexplained quadriplegia,28 fetal distress, birth asphyxia,
disorder during and neonatal death.29 Several small retrospective studies
pregnancy found NC to be associated with increased rates of nonreas-
Medical or 678 (32.74) 2,118 (32.54) 0.87 suring FHR patterns (variable decelerations, fetal bradycar-
antepartum
complication
dia), meconium-stained amniotic fluid, operative delivery,
and acidic umbilical artery pH.1,8,10,13,16–18 In general, how-
Prior cesarean 158 (7.63) 603 (9.26) 0.02
section ever, the majority of previous studies have found no increase
Prior preterm birth 180 (8.69) 611 (9.39) 0.34
in the risk of neonatal morbidity associated with NC at
delivery.3,7
Nulliparity 891 (43.02) 2,780 (42.71) 0.80
The results of this study are in agreement with the
Alcohol use 27 (1.30) 63 (0.97) 0.19
suggestion that there is no significant risk of neonatal
Tobacco use 286 (13.81) 883 (13.57) 0.78 morbidity when an NC is present at delivery. Furthermore,
Drug use 229 (11.06) 762 (11.71) 0.42 in contrast to many earlier studies, our large study did not
find any significant association with neonatal death, cord
Abbreviations: AMA, advanced maternal age; IQR, interquartile range.
Note: Data are presented as n (%) unless otherwise noted. Values in bold acidosis, birth weight, low Apgar score, NICU admission, or
denote statistical significance (p < 0.05). respiratory morbidity.

Table 2 Comparison of neonatal outcomes in the presence or absence of a nuchal cord

Nuchal cord, No nuchal cord, p-Value OR aORa

N ¼ 2,071 N ¼ 6,509
Neonatal composite morbidity 180 (8.69) 577(8.86) 0.81 0.98 (0.82–1.17) 0.99 (0.83–1.18)
Neonatal death 2 (0.10) 2 (0.03) 0.23 3.14 (0.44–22.34) 3.34 (0.47–23.88)
Seizure 8 (0.39) 10 (0.15) 0.04 2.52 (0.99–6.39) 2.62 (1.03–6.68)
Hypoxic–ischemic encephalopathy 2 (0.10) 14 (0.22) 0.39 0.45 (0.10, 1.98) 0.43 (0.10, 1.92)
Need for hypothermic treatment 9 (0.43) 33 (0.51) 0.68 0.86 (0.41–1.79) 0.84 (0.40–1.75)
Respiratory morbidity 90 (4.35) 242 (3.72) 0.20 1.17 (0.92–1.51) 1.20 (0.94–1.54)
Hypotension requiring treatment 2 (0.10) 4 (0.06) 0.60 1.57 (0.29–8.59) 1.54 (0.28–8.47)
Suspected sepsis 144 (6.95) 483 (7.42) 0.48 0.93 (0.77–1.13) 0.94 (0.78–1.15)
NICU admission 33 (1.59) 99 (1.52) 0.83 1.05 (0.71–1.56) 1.04 (0.70–1.54)
Arterial cord pH < 7 6 (0.29) 19 (0.29) 1 0.99 (0.40–2.49) 0.95 (0.38–2.39)
5-minute Apgar < 7 57 (2.75) 151 (2.32) 0.27 1.19 (0.88–1.62) 1.22 (0.90–1.67)

Abbreviations: aOR, adjusted odds ratio; NICU, neonatal intensive care unit; OR, odds ratio.
Note: Data are presented as n (%). Values in bold denote statistical significance (p < 0.05)
a
Adjusted for maternal age, black race, and prior cesarean section.

American Journal of Perinatology

Electronic Fetal Monitoring and Neonatal Outcomes Carter et al.

Table 3 Comparison of pregnancy outcomes in the presence or absence of a nuchal cord

Nuchal cord, No nuchal cord, p-Value OR aORa

N ¼ 2,071 N ¼ 6,509
Gestational age (weeks)
Early term (37–38.6) 719 (34.72) 2,332 (35.83) 0.23 Reference Reference
Term (39–40.6) 1,185 (57.22) 1.06 (0.96–1.19) 1.05 0.94–1.17)
Late term (41) 167 (8.06) 3,597 (55.26) 0.93 (0.77–1.13) 0.91 (0.75–1.11)
580 (8.91)
Oxytocin use 1,437 (69.39) 4,309 (66.20) <0.01 1.16 (1.04–1.29) 1.15 (1.04–1.28)
Epidural 1,861 (89.86) 5,822 (89.45) 0.59 1.05 (0.89–1.23) 1.09 (0.93–1.29)
Small for gestational age 318 (15.35) 929 (14.27) 0.22 1.09 (0.95–1.25) 1.13 (0.99–1.30)
Induction of labor 937 (45.24) 2,850 (43.79) 0.24 1.06 (0.96–1.17) 1.05 (0.95–1.16)
Indication for delivery
Non-reassuring fetal status 289 (13.95) 894 (13.73) 0.80 1.01 (0.88–1.18) 1.05 (0.91–1.21)
Mode of delivery
Spontaneous vaginal delivery 1,660 (80.15) 5,045 (77.51) <0.01 Reference Reference

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Operative vaginal delivery 133 (6.42) 279 (4.29) 1.45 (1.16–1.79) 1.47 (1.18–1.81)
Cesarean delivery 278 (13.42) 1,181 (18.14) 0.71 (0.61–0.82) 0.73 (0.63–0.84)
Meconium 462 (22.31) 1,351 (20.76) 0.13 1.10 (0.97–1.24) 1.11 (0.98–1.25)

Abbreviations: aOR, adjusted odds ratio; OR, odds ratio.

Note: Data are presented as n (%). Values in bold denote statistical significance (p < 0.05).
a
Adjusted for maternal age, black race, and prior cesarean section.

Table 4 Fetal heart rate characteristics in 30 minutes prior to delivery in the presence or absence of a nuchal cord

Nuchal cord, No nuchal cord, p-Value OR aORa

N ¼ 2,071 N ¼ 6,509
Baseline
> 160 66 (3.19) 210 (3.23) 0.93 0.99 (0.75–1.31) 0.97 (0.73–1.29)
< 110 3 (0.14) 17 (0.26) 0.44 0.55 (0.16–1.89) 0.56 (0.16–1.91)
Variability
Moderate variability 1,016 (49.06) 2,931 (45.03) <0.01 1.18 (1.06–1.30) 1.16 (1.05–1.28)
Marked variability 2 (0.10) 9 (0.14) >0.99 0.70 (0.15–3.23) 0.75 (0.16–3.46)
Absent variability 0 1 (0.02) >0.99 – –
Accelerations/decelerations
Repetitive late decelerations 91 (4.40) 193 (2.97) <0.01 1.45 (1.13–1.88) 1.45 (1.12–1.87)
Repetitive variable decelerations 696 (33.61) 1,671 (25.67) <0.01 1.42 (1.27–1.58) 1.41 (1.27–1.58)
Repetitive prolonged decelerations 43 (2.08) 109 (1.67) 0.31 1.20 (0.84–1.72) 1.20 (0.84–1.71)
Category
1 35 (1.69) 185 (2.84) <0.01 0.59 (0.41–0.85) 0.58 (0.40–0.83)
2 1,410 (68.08) 3,772 (57.95) <0.01 1.54 (1.39–1.72) 1.53 (1.38–1.70)
3 0 1 (0.02) >0.99 – –

Abbreviations: aOR, adjusted odds ratio; OR, odds ratio.

Note: Data are presented as n (%). Values in bold denote statistical significance (p < 0.05).
a
Adjusted for maternal age, black race, and prior cesarean section.

A unique component of this study is the inclusion of EFM between NC and abnormal EFM parameters.30 In contrast,
data and its relation to neonatal morbidity. Few prior studies Sheiner et al reported that nonreassuring EFM patterns are
have evaluated the characteristics of EFM that are associated associated with NC.3 Our study found significant associations
with NC at delivery. Peregrine et al found no association with NC and category II EFM parameters. However, the lack of

American Journal of Perinatology

 Electronic Fetal Monitoring and Neonatal Outcomes
Table 5 Fetal heart rate characteristics in 30 minutes prior to delivery in the presence or absence of a nuchal cord among patients
with an operative vaginal delivery
Nuchal cord, No nuchal cord,
N ¼ 133 N ¼ 279
Repetitive late decelerations 16 (12.03) 15 (5.38)
Repetitive variable decelerations 47 (35.34) 78 (27.96)
Abbreviations: aOR, adjusted odds ratio; OR, odds ratio.
Note: Data are presented as n (%). Values in bold denote statistical significance (p < 0.05).
a
Adjusted for maternal age, black race, and prior cesarean section.
significant neonatal outcomes and interventions associated
with an NC calls into question whether its association with
nonreassuring FHR patterns is clinically relevant. Our results
suggest that the higher rates of OVD in the NC group were in
response to category II EFM. Therefore, it is possible that this
intervention improved the rates of neonatal morbidity in the
NC group.
Multiple factors support the validity of our study. Pro-
spective interpretation of FHR tracings by nurses who are
blinded to clinical outcome is a major strength. Additionally,
to the best of our knowledge, this is the largest prospective
study to date of patients with an NC at delivery. Our EFM
analysis was limited to the final 30 minutes prior to delivery
since the impact of an NC is most likely to be experienced
during the second stage of labor with the descent of the fetus.
Limiting our patient population to women reaching
the second stage and the final 30 minutes of monitoring
helped us discriminate between variables most likely caused
by an NC versus other sources.
Given the large sample size and small amount of missing
data, due to our prospective study design, findings can be
applied widely and support the generalizability of our
findings.
Despite strengths, this study has some potential limita-
tions to be considered when evaluating our results. As with
all cohort studies, confounding is a concern. We used appro-
priate statistical techniques to adjust for confounders, but
there is a possibility of residual confounding by unmeasured
factors. For example, the presence of nuchal is not routinely
noted on ultrasound reports at our institution. However, we
do not know whether clinicians managing labor had knowl-
edge regarding the presence of an NC by bedside ultrasound
prior to delivery and, if so, whether this knowledge altered
management. It is also possible that neonatal outcomes were
similar between groups because there was a higher level of
intervention, such as OVD in the NC group in response to
category II EFM parameters or an undefined aspect of the
clinical picture. Our findings may not be generalizable to
other hospital settings since we are a regional referral center
with a high level of acuity due to a significant chronic disease
burden in our patient population and a robust transport
service, which drives our high rate of medically indicated
labor induction. Additionally, we did not differentiate the
number of times the NC was wrapped around the neonate’s
neck. Some prior studies found significant neonatal risk
associated specifically with a tight or multiple NC.
Carter et al.
p-Value OR aORa
0.02 2.40 (1.16–5.02) 2.40 (1.14–5.02)
0.14 1.40 (0.90–2.19) 1.42 (0.91–2.22)
The use of a composite outcome may be viewed as a
limitation of this study. However, we believe that the use of
a composite was necessary because the individual components
of the composite are rare complications. In addition, the
neonatal outcomes that were considered as part of the com-
posite are more clinically meaningful than more commonly
occurring surrogate measures of morbidity, such as low Apgar
score, but they are short term, and we are unable to comment
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on any long-term sequelae of NC at the time of delivery.
In summary, NC at delivery is associated with category II
EFM parameters, which likely influences provider behaviors
and increases the likelihood for OVD. Fortunately, concerning
EFM patterns do not translate into fetal compromise—either
because the NC is innocuous or clinical practice patterns
cause providers to intervene before fetal compromise occurs
in the second stage. Either way, parents and providers alike
can be reassured that there is no significant association
between NC and short-term neonatal morbidity within the
context of current obstetric practice patterns.
Funding
This study is supported by the National Institute of Child
Health and Human Development (NICHD) grant number
R01H061619–04 (PI: Alison Cahill). Dr. Carter was sup-
ported by a National Institutes of Health T32 training
grant (5T32HD055172–05) and the Robert Wood Johnson
Foundation #74250. The contents of this publication are
solely the responsibility of the authors and do not neces-
sarily represent the official view of the Robert Wood
Johnson Foundation.
Conflict of Interest
None declared.
References
1 Mastrobattista JM, Hollier LM, Yeomans ER, et al. Effects of nuchal
cord on birthweight and immediate neonatal outcomes. Am J
Perinatol 2005;22(02):83–85
2 Shrestha NS, Singh N. Nuchal cord and perinatal outcome. Kath-
mandu Univ Med J (KUMJ) 2007;5(03):360–363
3 Sheiner E, Abramowicz JS, Levy A, Silberstein T, Mazor M, Hersh-
kovitz R. Nuchal cord is not associated with adverse perinatal
outcome. Arch Gynecol Obstet 2006;274(02):81–83
4 Ghosh GS, Gudmundsson S. Nuchal cord in post-term pregnancy -
relationship to suspected intrapartum fetal distress indicating
operative intervention. J Perinat Med 2008;36(02):142–144
American Journal of Perinatology
Electronic Fetal Monitoring and Neonatal Outcomes
5 Hoh J-K, Sung Y-M, Park M-I. Fetal heart rate parameters and
perinatal outcomes in fetuses with nuchal cords. J Obstet Gynae-
col Res 2012;38(02):358–363
6 Ogueh O, Al-Tarkait A, Vallerand D, et al. Obstetrical factors
related to nuchal cord. Acta Obstet Gynecol Scand 2006;85(07):
810–814
7 Henry E, Andres RL, Christensen RD. Neonatal outcomes following
a tight nuchal cord. J Perinatol 2013;33(03):231–234
8 Schäffer L, Burkhardt T, Zimmermann R, Kurmanavicius J. Nuchal
cords in term and postterm deliveries–do we need to know?
Obstet Gynecol 2005;106(01):23–28
9 Assimakopoulos E, Zafrakas M, Garmiris P, et al. Nuchal cord
detected by ultrasound at term is associated with mode of delivery
and perinatal outcome. Eur J Obstet Gynecol Reprod Biol 2005;123
(02):188–192
10 Jauniaux E, Ramsay B, Peellaerts C, Scholler Y. Perinatal features of
pregnancies complicated by nuchal cord. Am J Perinatol 1995;12
(04):255–258
11 Narang Y, Vaid NB, Jain S, et al. Is nuchal cord justified as a cause of
obstetrician anxiety? Arch Gynecol Obstet 2014;289(04):795–801
12 Onderoğlu LS, Dursun P, Durukan T. Perinatal features and umbi-
lical cord blood gases in newborns complicated with nuchal cord.
Turk J Pediatr 2008;50(05):466–470
13 Rhoades DA, Latza U, Mueller BA. Risk factors and outcomes
associated with nuchal cord. A population-based study. J Reprod
Med 1999;44(01):39–45
14 Singh G, Sidhu K. Nuchal cord: a retrospective analysis. Med J
Armed Forces India 2008;64(03):237–240
15 Kong CW, Lee DH, Chan LW, To WW. Impact of nuchal cord on fetal
outcomes, mode of delivery, and management: a questionnaire
survey of pregnant women. Hong Kong Med J 2015;21(02):143–148
16 Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiple nuchal
cord entanglements and intrapartum complications. Am J Obstet
Gynecol 1995;173(04):1228–1231
17 Miser WF. Outcome of infants born with nuchal cords. J Fam Pract
1992;34(04):441–445
18 Hankins GD, Snyder RR, Hauth JC, Gilstrap LC III, Hammond T.
Nuchal cords and neonatal outcome. Obstet Gynecol 1987;70(05):
687–691
19 Weiner E, Fainstein N, Schreiber L, Sagiv R, Bar J, Kovo M. The
association between umbilical cord abnormalities and the devel-
American Journal of Perinatology
Carter et al.
opment of non-reassuring fetal heart rate leading to emergent
cesarean deliveries. J Perinatol 2015;35(11):919–923
20 Cahill AG, Tuuli MG, Stout MJ, López JD, Macones GA. A prospec-
tive cohort study of fetal heart rate monitoring: deceleration area
is predictive of fetal acidemia. Am J Obstet Gynecol 2018;218(05):
523.e1–523.e12
21 Shankaran S, Laptook AR, Ehrenkranz RA, et al; National Institute
of Child Health and Human Development Neonatal Research
Network. Whole-body hypothermia for neonates with hypoxic-
ischemic encephalopathy. N Engl J Med 2005;353(15):1574–1584
22 American College of Obstetricians and Gynecologists. ACOG Prac-
tice Bulletin No. 101: ultrasonography in pregnancy. Obstet
Gynecol 2009;113(2 Pt 1):451–461
23 Expert Committee on the Diagnosis and Classification of Diabetes
Mellitus. Report of the expert committee on the diagnosis and
classification of diabetes mellitus. Diabetes Care 2003;26
(Suppl 1):S5–S20
24 American College of Obstetricians and Gynecologists. Hyperten-
sion in Pregnancy. Available at: https://www.acog.org/~/media/
Task%20Force%20and%20Work%20Group%20Reports/public/
HypertensioninPregnancy.pdf. Accessed October 6, 2015
25 Alexander GR, Himes JH, Kaufman RB, Mor J, Kogan M. A United
States national reference for fetal growth. Obstet Gynecol 1996;87
Downloaded by: Washington University. Copyrighted material.
(02):163–168
26 American College of Obstetricians and Gynecologists. ACOG Prac-
tice Bulletin No. 106: intrapartum fetal heart rate monitoring:
nomenclature, interpretation, and general management princi-
ples. Obstet Gynecol 2009;114(01):192–202
27 Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T. The 2008
National Institute of Child Health and Human Development
workshop report on electronic fetal monitoring: update on defi-
nitions, interpretation, and research guidelines. Obstet Gynecol
2008;112(03):661–666
28 Nelson KB, Grether JK. Potentially asphyxiating conditions and
spastic cerebral palsy in infants of normal birth weight. Am J
Obstet Gynecol 1998;179(02):507–513
29 Dhar KK, Ray SN, Dhall GI. Significance of nuchal cord. J Indian
Med Assoc 1995;93(12):451–453
30 Peregrine E, O’Brien P, Jauniaux E. Ultrasound detection of nuchal
cord prior to labor induction and the risk of Cesarean section.
Ultrasound Obstet Gynecol 2005;25(02):160–164