THE UNIVERSITY OF ZAMBIA

SCHOOL OF MEDICINE
DEPARTMENT OF ANATOMY

A study of the umbilical cord length and foetal outcome at Kanyama First
Level Hospital, Lusaka, Zambia

Dr. Kelvin Muma

2018242679

Principle supervisor: Prof Krikor Erzingatsian

V3. 09/10/2020.(KM)
Chapter 1 : INTRODUCTION

1.1. Background
The Umbilical cord is a structure that attaches to the navel before birth and connects the foetus to
the placenta; contains the umbilical arteries and vein (Marieb et al)
It is the essential life-sustaining connection of the developing baby and many scholars refer to it
as “baby’s life-line” as (Donald, 1994) put it, “the baby’s life hangs by a cord.”

The umbilical cord is the most important part of the foetoplacental unit. Studies have shown that
complete obstruction of the cord leads to foetal demise and partial obstruction has been
associated with brain damage while foetal distress in utero has been found to occur due to
umbilical cord abnormalities. (Balkawade et al, 2012)

Different authors associate umbilical cord length with foetal activity and movement even though
it is not completely understood what controls cord length, Nevertheless, it is believed that
sufficient space in the amniotic cavity for movement and the tensile force applied to the
umbilical cord during foetal movements are two main factors that determine cord length
(Benirschke. 2004)

There is wide variation in the length of the umbilical cord with extremes varying from no cord
(achordia) to 300 cm, with diameters up to 3 cm (Berg and Rayburn, 1995). About 5% of cords
are shorter than 35 cm, and another 5% are longer than 80 cm (Berg and Rayburn, 1995).

The fully developed umbilical cord is on average some 50 – 60 cm long. The vessels of the
umbilical cord are rarely straight, and are usually twisted into either a right – or left – handed
cylindrical helix. The number of turns involved ranges a few to over 300. (Grays 40th edition).

1.2. Statement of the Problem

Obstetricians often deal with unexplained cases of foetal distress, failure of the foetus to descend
properly, placental abruption and stillbirths. Complications associated with long or short
umbilical cord may explain some of these cases (Balkawade et al, 2012). There has been an
established relationship between excessively short umbilical cords and placental abruption, foetal
distress, delay in second stage of labour, birth asphyxia and uterine inversion. Excessively long
 cords are associated with nuchal cords, cord prolapse, emergency caesarean section, cord
entanglements and true knots. (Balkawade, 2012)

And a study done in the United States of America showed that up to 10 % of all stillbirths are
due to umbilical cord abnormalities (Collins et al, 2012).

A study done by Balkawade et al, found cases of short-cord group had maximum cases of
caesarean section (40.7 %), than cases with long (24.5 %) or normal (23.6 %) cord length.
Normal-cord group cases had maximum number of vaginal delivery cases (76.4 %) more than
75.5 % for long-cord group and 59.3 % for short-cord group. Short-cord group was associated
with significantly higher (p < 0.05) incidence of caesarean section cases (Balkawade, 2012).

1.3. Rationale
The umbilical cord length has very important clinical correlates especially as it concerns the
growth, wellbeing and the survival of the new-born (Ogunlaja et al, 2015)

In his book, (Collins, 2014) said that it has been estimated that 30% of births have some type of
umbilical cord anomaly. This statistic implies a potential for foetal harm that may not be
appreciated by scientific and public health authorities. Not knowing how many foetuses are
harmed by their umbilical cords prevents research into the issue. If neurological harm can occur
as the result of umbilical cord problems, then mechanism of harm to the foetus needs to be
investigated. (Collins, 2014)

Currently in Zambia there is no published study on morphology of the umbilical cord in

particular length. Therefore, there is need to undertake a study in order to establish the average
length of the umbilical cord in a labour ward of a first level hospital and determine if there is any
correlation that may exist between umbilical cord lengths and foetal outcome utilising the
APGAR score and foetal weight. The study will also look the relationship between the umbilical
cord and mode of delivery as well as the gender of the foetus.

Chapter 2 : RESEARCH FOCUS

1.1. Research Questions

1. What is the average length of the umbilical cord seen at Kanyama First Level Hospital?
2. Does umbilical cord length contribute to poor foetal outcome at Kanyama First Level
Hospital?
 3. What common umbilical cord abnormalities are seen at Kanyama First Level Hospital?

1.2. Objectives

1.2.1. General Objectives

1. To establish the umbilical cord lengths commonly seen in our local Kanyama first
level hospital and their relationship with foetal outcome.

1.2.2. Specific Objectives

1. To determine the average length of the umbilical cords.
2. To establish the relationship between umbilical cord length and foetal outcome
3. To establish the common umbilical cord abnormalities seen at Kanyama First level
Hospital.

Chapter 3 : LITERATURE REVIEW

Various studies conducted around the world on the length of the umbilical cord have shown that cord
abnormalities are not a strange phenomenon. There are various types of umbilical cord abnormalities
including length

A study was conducted by (Balkawade, 2012) on 1000 deliveries. The mean length of the cord was
found to be 63.86+/-15.69 cm ranging from 24cm to 124cm. Short cords were associated with
increased rates of LSCS whereas variability in foetal heart rate and birth asphyxia were associated
with long cords.

Suzuki et al studied the perinatal outcome of 11, 029 singleton women in association to length of the
umbilical cord. In his study, the mean length of the cord was 56.2+/-11.7cm. Author of this study
considered the length less than 38cm (-1.5SD below the mean) as Short cord and the length greater
than 74cm (+1.5SD above the mean) as a Long cord, which occurred in 0.9% and 5% respectively.
In this study both long and short cords were not associated with any maternal and foetal impairment.

According to (Georgiadis et al), many complications of pregnancy and delivery are associated with
umbilical cord length. And in this study, significantly shorter cords where found in women with
placental abruption. (Suzuki ,2012)
Another study conducted in Norway a population-based register study of all singleton births during
the period of 1999 – 2013 found that short cords were associated with a 50% increased risk of
abruption in the total population of 856 300 and a double risk of abruption at term. (Linde et al,
2018)

Chapter 4 : METHODOLOGY

4.1. Study site and population

The study site for this study will be at Kanyama First Level Hospital, a Government District
hospital. The hospital was selected because the maternity ward is among the busiest in the
country with 40 deliveries per day and an average of 900 deliveries every month. The target
population is all singleton births from October 2020 to November 2020.

4.2. Study design

The study design is a cross section study.

4.3. List of variables

Independent variables

1. Umbilical cord length

Dependent variables

1. APGAR score
2. Foetal weight
3. Mode of delivery

4.4. Inclusion and exclusion criteria

Inclusion criteria

1. Singleton deliveries
2. Healthy women with gestational age 37 – 42 weeks
3. Delivery via vaginal or caesarean section

Exclusion criteria
 1. Preterm deliveries (i.e. <37 weeks) or postdates (i.e. >42 weeks)
2. Previously diagnosed intrauterine foetal death
3. Multiple pregnancies
4. All patients with a manually removed placenta

4.5. Sample size and sampling methods

A total of 250 umbilical cords will be examined for length and for any other findings such as
site of insertion, and number of umbilical vessels.

Simple random sampling will be used to select the participants.

4.6. Data collection

Data will be collected by the principle investigator and recorded in the data collection tools.

Careful examination of the umbilical cord and measuring its length will be done and while
measuring the stump on the baby, sterile surgical gloves, caps, face masks and protective
gowns will be worn by the principle investigator to prevent infection of the new-born.

The data collecting tool will also capture the foetal parameters such as gender, birth weight,
Apgar score and mode of delivery

4.5. Data processing and analysis

Data will be processed and analysed by using the latest SPSS.

4.6. Data dissemination and use

The findings of the research study will be made available to appropriate stakeholders such as
ethics committees, the Ministry of health and the University of Zambia among others. The
research will also be submitted for publication in a peer reviewed journal as part of my
academic input to the body of knowledge.

4.7. Ethical considerations

Ethical clearance and approval for the study will be attained from the University of Zambia
Biomedical Research Ethics committee (UNZABREC). Application for permission to carry out
the study will be made to the Medical Superintendent at Kanyama First Level Hospital.
Participants will be issued a written informed consent to obtain permission for their
 participation in the study it will also be explained that they may also withdraw from the study
at any time if they wish to do so The respondents will also be given explanations of the
benefits of the study which includes taking an active participation in the improvement of the
health sector. The study poses a risk of infection to the neonate and this will be explained. As
part of infection prevention, sterile examination gloves, face masks, caps and gowns will be
used during examination. Respect and human dignity will be upheld. Confidentiality will also
be assured by using study codes unlike names; lastly, the data obtained will be kept in closed
cabinets only accessible by the researcher.
The placentae together with the umbilical cord will be collected and stored in formalin
containers and after examination will be disposed of in accordance with hospital policy using
biohazard medical waste bags.

Chapter 5 : WORK PLAN

June July August Septembe October November Decembe January
2020 2020 2020 r 2020 2020 2020 r 2020 2021
Proposal
development
Approval
Ethics
Data
collection
Data Analysis
and
interpretation
Report
Writing
Dissertation
presentation
and
submission
Chapter 6 : BUDGET
Item description Quantity duration Unit price Total cost
Pens 10 K3 K30
Notebook 1 K25 K25
Files 2 K20 K40
Realm of paper 1 K60 K60
Ethics K1000
Printing, 1day K900
photocopying and
binding proposal
Data collection and 2month K6000
transport
Lunch 2month K1500
Biohazard medical 60 K20 K 1200
waste bags

Printing, binding of 1day K1,500

reports
Storage buckets 10 K70 K700

Examination gloves 300 K10 K3000

Caps 20 K5 K100
Gowns 20 K70 K1400
Face masks 20 K20 K400
Grand Total K 17, 855
Chapter 7 : REFERENCES

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Hanan & AlZoubiadi, Aisha. 2016, Effect of long and short umbilical cord on perinatal
outcome. International Journal of Reproduction, Contraception, Obstetrics and Gynecology.
5. 10.18203/2320-1770.ijrcog20164042.
2. Balkawade, Nilesh & Shinde, Mangala. 2012, Study of Length of Umbilical Cord and Fetal
Outcome: A Study of 1,000 Deliveries. Journal of obstetrics and gynaecology of India. 62.
520-525. 10.1007/s13224-012-0194-0.

3. Benirschke, K 2004, The Umbilical Cord. Neo Reviews. 2004; 5(4):34

4. Berg TG, Rayburn WF 1995, Umbilical Cord Length and Acid- Base Balance at Delivery. J
Reprod Med 1995; 40: 9-12.75
5. Collins Jason H. 2014, Silent Risk: Issues about the Human Umbilical Cord. 2014; 20
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23/06/2020), [http://www.preginst.com/UmbilicalCordAccidents2.pdf]
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doi:10.1186/1471-2393-12-S1-A7 (accessed 23/06/2020)

8. Georgiadis L, Keski-Nisula L, Harju M, Räisänen S, Georgiadis S, Hannila M.L. 2014,

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