Intrapartum Fetal Heart Rate Pattern Evolution Associated With Septuple Nuchal Cord Loops: A Case Report

Although a nuchal cord is a common observation, multiple nuchal cord loops are rare. A few reports suggest that multiple nuchal cords are associated with adverse perinatal outcomes, such as cesarean or operative vaginal deliveries for fetal distress and neonatal asphyxia. However, there are controversies regarding antenatal detection and perinatal management of multiple nuchal cord loops. Herein, we report a case of live vaginal birth with septuple nuchal cords demonstrating a distinct pattern of fetal heart rate evolution during labor.

A 31-year-old primigravida was referred to our facility at 34 weeks of gestation with multiple nuchal cords. Transabdominal ultrasonography revealed a three-vessel cord with extreme loops around the fetal neck. The antenatal course was uneventful with appropriate fetal growth, amniotic fluid index, and reactive nonstress testing until the last checkup. The patient underwent labor at 38 weeks of gestation. The admission test on the fetal heart rate tracing indicated nonrecurrent but mild variable decelerations with an "atypical" feature. Subsequently, there were recurrent, severe decelerations and an elevation of the baseline rate during the second stage of labor. The patient delivered a male infant, weighing 2455 g (10.5 percentile of normal weight) vaginally via vacuum extraction. The umbilical arterial gas analysis at birth showed a pH of 7.31, a partial pressure of oxygen of 23.4 mmHg, a base excess of -6.4, and 1/5-min Apgar scores of 8/9. The cord was 112 cm long with septuple nuchal cords.

As umbilical cord abnormalities have a risk of fetal heart rate compromise in the prelabor or first stage of labor, prenatal detection of umbilical cord pathology may be beneficial for the early recognition of potential fetal compromise and prompt decision-making for operative intervention.