I was asked this question earlier this week. And it’s a very good question. There are so many conflicting thoughts, ideas, and beliefs regarding the role of the umbilical cord in stillbirth. So why is there so much confusion? And, what is the truth?
The truth is that umbilical cord accidents CAN cause stillbirth. There are numerous studies that have shown this to be the case. The percentage of stillbirths caused by cord accident is not as clear. Depending on the study, it can range from 5-30% of all stillbirths. The Stillbirth Collaborative Research Network (SCRN) of the NICHD recently published well-respected results from their comprehensive, 5-site study. In this paper, 11% of the stillbirths studied were attributed to cord issues. This is a significant number, but it is also likely to be a conservative number because they required physical evidence of a cord accident to be present during autopsy for this diagnosis.
There are many types of umbilical cord issues that can cause problems. The more common issues include true knots, velamentous or marginal insertions, hyper or hypo coiling, lack of Wharton’s jelly, 2-vessel cords, and compression. Characteristics like long cords, short cords, nuchal cords, or body loops may not directly cause interruption in the blood flow, but they present a situation where compression may be more likely.
Why do so many people insist that cords (especially nuchal cords) don’t cause problems? I think it’s because most OBs and midwives have seen hundreds of healthy babies that are born with nuchal cords (the cords wrapped around the baby’s neck). This leads many people to believe that it’s not a big deal. The problem is that it CAN be a big deal for some babies. Just because it isn’t a problem for ALL babies, doesn’t mean it isn’t a problem. I know people who smoke and don’t have lung cancer. That doesn’t mean that smoking is safe. The second issue with this is that nuchal cords are just one type of cord issue that could be problematic.
Why are cord accidents difficult to diagnose? There may be physical evidence of cord compression or other type of cord accident present after birth. However, this is not always the case. Plus, many stillbirths are not evaluated by someone trained in placenta and cord pathology to identify this evidence. In fact specially trained placental pathologists are few and far between.
Another significant problem in diagnosis is that we lose possible evidence with delivery. It is almost impossible to know (or even guess) where the cord and all other structures were when a problem occurred if we only look at the baby and cord AFTER they have been delivered. I think all stillbirths should have a comprehensive ultrasound at the time of diagnosis to evaluate the umbilical cord, baby’s position, placental location, and amount of amniotic fluid. This is information that is impossible to determine if we don’t look at the “scene of the crime” before it has been disrupted by the birth process.
With all of these issues, why are so many parents told that an umbilical cord accident was the cause of their child’s death? This is a very good question. Anecdotally, I hear much more than 11% of stillbirths being attributed to cord accidents. Personally, I think this may be true in many of these cases. I also think it feels like an ‘easy’ answer to give parents. It is relatively simple to understand (as opposed to genetic alleles and complex medical conditions) and doesn’t appear to require a lot of explanation or proof for most families. Plus, the term ‘accident’ gives the impression that is wasn’t anybody’s fault or that it was a freak occurrence – wrong place at the wrong time type of scenario. I’ve heard people say the word accident makes it less likely the parents will blame their providers, and also that it brings a sense of closure if it’s “just one of those things”. Regardless, it should not be a default diagnosis because it’s easy. If that’s really the best educated guess of the provider, then this should be explained to the family.
I am also very irritated by the connotation that nothing can be done about issues called accidents. In many cases, there are signs or symptoms that are not identified or addressed. What these symptoms are and how they should be managed is not something I’ll get into here – but we need to start having frank discussions with expectant families and loss families about symptoms they have/had and if they could be signals of a baby in distress.
If it’s so simple, why is there so much confusion about cord accidents?? I think this is the result of the above issues in combination. During pregnancy, parents are told umbilical cords don’t cause problems. But if a loss occurs, many of these same parents are told that a cord accident is the likely cause of their child’s death. We can’t have it both ways.
How do we clear up the confusion? In my opinion, several things should happen.
- First, we need to STOP telling expectant parents that cord issues aren’t a cause for concern.
- Second, we should be encouraging families to have the baby (or at least the umbilical cord and placenta) evaluated after a stillbirth to attempt to identify the cause of death without guessing.
- Third, we need more information about how to identify these cord issues and how to manage them – this needs more research.
Until we have more research, we should be looking for signs of distress in pregnancies, and we should be looking at umbilical cord characteristics during any and all ultrasounds. If cord issues or distress are identified, the parents deserve to be told and it needs to be addressed immediately. Our OBs and midwives deserve more research and education to guide them in prevention of stillbirth from cord accidents.
With the highly sophisticated medical technology available today, I firmly believe this is a cause of stillbirth that is highly preventable! We need to work together to make it happen!
Help us learn more about umbilical cord accidents and all stillbirths – PLEASE participate in the STARS Study and encourage others to do the same. We need women who have EVER had a stillbirth after 28 weeks gestation, women who have had a baby in the last 3 weeks, and women who are currently pregnant (28 weeks or more).
Click on the logo on the left or go here to participate: http://starlegacyfoundation.org/stars1/