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Nuchal Cord - Somersault Maneuver

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Nuchal Cords: the perfect scapegoat from Midwife Thinking.  "The content of this post is based on a For a baby with a tight nuchal cord the worst thing you can do is clamp and cut!"

"So, if you are not going to cut or loop a nuchal cord what’s the point in digging about to see if it is there? Checking for a cord interferes with the physiological process of birth. It also reinforces the notion that this is a birth complication that endangers the baby, rather than a common situation. Telling the woman to stop pushing and putting your fingers into her vagina can be disempowering and painful."

Nuchal Cord - Somersault Maneuver

The idea that a midwife shoul

See also: Nuchal Cord on Ultrasound

Nuchal Cords: the perfect scapegoat from Midwife Thinking contains a great diagram of the somersault maneuver.

The Nuchal Cord at Birth: What Do Midwives Think and Do?, by Elaine Jefford, Kathleen Fahy and Deborah Sundin. Routinely checking for the nuchal cord is a common medical intervention in birth. Some evidence shows damage to the baby and mother. Results from the authors' study reflect the training midwives have received and their current practices in relation to a possible nuchal cord at birth. [Midwifery Today, Spring, 2009, Article not available online.]

Abstract Conclusion: "In the absence of clear evidence, firmly entrenched positions are being argued for and against routine checking.  The debate is infused with high emotion.  Those arguing for routine checking cite safety for the baby as their main concern.  Those arguing against checking cite the need to keep birth normal and the well-being of the baby as their primary concerns.  There is a need to reconsider how the possibility of nuchal cord at births should be conceptualized from a midwifery perspective to ensure woman-centred decision-making."

We are having a discussion in our unit about why midwives were taught to feel for the cord once the head was born and why they should clamp and cut a tight cord?
Does anyone know of any evidence supporting these practices?
I have looked into this in the past and could find no evidence to support it. I think it is just one of the many 'controlling' practices that was introduce and then has been perpetuated. Would be interested to see anything that does come to light. 

Maggie Banks, 7/24/09

And every time I see a tight nuchal cord I try to figure out the somersault maneuver, but am still hopelessly clueless. I can't figure out how a bent in half baby makes it out ! Its hard enough to get out heads and shoulders....shouldn't folding the baby in half be even harder? But I'm still working on this one........every time I see a nuchal cord I think "Is this the one that will somersault for me?" But I always chicken out.

I spent the morning looking through old texts to find just the right picture, but finally came upon a new text, "Varney's Midwifery", 3rd edition, that describes the trick just perfectly. It is on page 826 and describes it much better than I can. No pictures, but then I never had one either and learned how to do it.

Below is copy from the book:

Management of a nuchal cord is as follows:

The somersault maneuver does not require equipment, can be performed regardless of the number of times the cord is looped around the neck, can be used with the mother in any delivery position, and allows the cord to be cut under more calm and less risky circumstances.

Reference given in the book is: Schor, M.N., and Blanco, J.D. Management of the nuchal cord. J. Nurse-midwifery 36(2):132 (March/April) 1991

From there, I read: The somersault maneuver probably places some stretching stress on the cord, and it may not be applicable to all cases. (snip) Our specific recommendations for managing a nuchal cord are first, anticipate the problem when variable decels occur, particularly during descent. Second, recognize the problem by checking for loops of cord around the neck immediately after delivery of the head. Third, manage the situation depending on how tight the cord is wrapped. Fourth, attempt to reduce the cord. Fifth, if unable to reduce the cord, but it is somewhat loose, attempt to deliver through it, or attempt the somersaulting maneuver. Sixth, if the cord is too tight, then double-clamp and cut the cord prior to the delivery.

I have seen the somersault technique a few times with tight cord, but then experienced it on my own recently.  The mother didn't heed the warning to stop pushing when the head was born and tried to push the baby out in one push.  There was a loop of cord around the neck x1, and as I was trying to pull a loop up (as she was pushing) the baby just somersaulted himself out, all by himself.  Very interesting to watch.

[from ob-gyn-l]

I don't know about the rest of you, but for me it seems (WARNING: pure anecdote, no data!) that as often as not the body just plops out while I'm fumbling with trying to unwind or clamp & cut the cord.

Someone recently summarized Varney's approach to managing a nuchal cord, which were the methods I learned back in school. But just for discussion, I had one experienced preceptor who NEVER cut a nuchal cord, and had only evulsed one in her life. Her argument was that especially with a tight cord, it was important NOT to cut because the baby was probably already stressed prior to the birth of the head, and by carefully unwrapping the cord after the baby was born, and allowing the baby a few seconds to recover using oxygen from the cord blood, the babies had higher apgars and did better than when the cord was cut and the baby ventilated, though they might have a touch of jaundice later. This advice, of course, after I'd cut a tight nuchal cord and had a baby with apgars of 4/8.

I'm not sure I entirely agree with her, but as it has turned out, I haven't cut a cord on the perineum since!

Was on a birth last night, very straight forward, cord was around the neck 6 times. It looked so weird. Like the babe was wearing a turtleneck. Anyway, the somersault trick works great!

Cut Tight Cord:  A Midwife Responds
By Gail Hart

Someone wrote to ask me: does the baby keep coming if we don’t cut a tight cord; does the mom have to push harder to finish delivering the baby?

I owe the following observation to Dr. John Stevenson from Australia.  We were discussing cutting tight cords and the traditional medical teaching that a tight cord at birth will either tighten too much around the baby’s neck, or will prevent birth, or might pull the placenta off the uterine wall.
He said to watch the uterus as the baby descends and is born.  The fundus might be at the xiphoid at the beginning of labor, but it gets gradually lower as labor progresses due to the thickening upper uterus, and the descent of the baby.  The uterus follows the baby down!  By the time the head is out, the fundus is usually only a bit above the mom’s navel.  This is something we’ve all seen, but I never NOTICED in this way before he pointed it out.

The uterus “follows the baby” as it pushes the baby out – the same as your hand follows a pillow if you push it across the floor.  That’s the process which pushes the baby down through the birth canal.  He doesn’t wiggle out on his own and he isn’t squeezed out like toothpaste by the mom’s abdominal muscles.  He is PUSHED by the fundus.

When the baby is born the entire uterus is no more than about ten inches from the vulva!  Remember that the baby’s cord is at the center of his body.  A cord would have to be incredibly short to prevent the birth of the baby!  (You can model this by holding a baby or doll so its mid-abdomen is at the mom’s introitus.)  Even if the placenta were implanted in the fundus, there “should” be the few inches necessary to deliver the baby since the fundus follow the baby down, and the fundus will be near the mom’s navel as the baby emerges.
A cord that is too short, or relatively too short, to allow birth will probably be too short to allow descent and will cause a “hand up” in labor, fetal distress, or even malpresentation.  A cord that is long enough o allow birth of the head should definitely be long enough to allow the birth of the baby’s body.

So a tight or short cord should allow the birth of the baby.  But what about other problems?  Will a tight cord rip the placenta off the uterine wall?  Most of us have observed an overly enthusiastic practitioner doc with the cord wrapped around his hands, pulling on that placenta for all he’s worth trying to hurry third state – and that placenta just isn’t coming!  The cord will often detach before the placenta does! It’s not easy to pull of a normally implanted placenta before the uterus folds itself behind it and shears it off in the normal third stage process.  So, I’m sure it COULD happen, but rarely does.

Our major concern should be to avoid pulling on a taut cord.  We don’t want to increase the tension already there.  This is done one of two ways:  1) by cutting the cord from around the neck – the standard medical view; or (2) by keeping the baby close to the uterus as it is born, delivering through the loops or else using the “somersault maneuver.”  It’s a wise idea to keep the baby close anyway -  we want to avoid stretching or pulling the cord, especially if the mom is upright. ( None of us wants to see a baby do a bungee jump and dangle from his momma’s knees!  We do try to keep him close!)

As for the second part of the question, it shouldn’t make a difference how hard mom pushes, since the cord is not holding back the baby.
One other possible factor to consider: if a tight or short cord is slowing labor, then can the cord “stretch” to allow descent?  Theory says it could and that this is more likely than pulling the placenta off.  Tight cords can cause fetal distress, of course, and that’s what practitioners should be watching for.  If mild stress is present but the baby is coming quickly, then the baby will be better off if the midwife can keep the cord intact after birth.  He’s the kid who will really NEED an intact cord to help him recover.  But if we follow the advice of cutting the cord around the neck, we will be putting the baby through a good deal of additional stress!  It’s ironic to think that the baby who is most in need of an intact cord is the one whose cord we just cut!

I can’t say there won’t be the very rare case of a baby who really needs his cord cut after the birth of the head.  I will say I’ve seen more than a few who would have been cut following the old rule, but who were born through the loops or somersaulted out and were fine, vigorous babies.  But I can’t say I’ve seen any whose cords were cut at the neck who were vigorous high-Apgar babies!

Gail Hart, CPM, (NWSPM), CM (OMC) and retired Oregon LM is a practicing midwife and mother of five in Portland, Oregon with a special interest in researching evidence-based midwifery practices.

Checking for Cord at a Waterbirth

The idea that a midwife should feel for the umbilical cord around the baby's neck before it is born has never been part of Danish midwifery training/curriculum; at least, I have never encountered traces of such a practice.  I still remember how surprised I was when I heard about this practice the first time.  Of course it could happen,  that a Danish midwife will do such a maneuvre in a special situation,  but it is not part of routine practice.

I was taught to feel for cord and always did this. I started to question the practice when I attended a seminar with Yehudi Gordon, Janet Balaskas and Sheila Kitzinger here in New Zealand in 1990. Yehudi said that he no longer did this and that babies, even if they have cord around the neck will be born anyway without problems. If the cord is tight and causing problems for the baby then there will be delay with the second stage, fetal distress etc. that would already have alerted the practitioner to a problem. I decided to trial this in my own practice and have never gone back to routine feeling for the cord. I believe that many midwives in New Zealand do still do this though. Has any data been gathered on this? Is there any evidence to support feeling or not feeling for the cord?

My story is similar. At first I had my hands down there all the time - to feel the emerging head, not the perineum. This was more because of the way in which I taught how to 'deliver' a baby in the early 70's than for any other reason and because of that old notion that one had to feel for the nuchal cord and pull it over the head. (Incidentally, I do not even do this for land births now). My practice around waterbirth has changed enormously, both as a result of simply being with women and watching how they birth in water and from the work I did for my master's thesis. I rarely get my hands wet now; most of the women I care for let the baby out by themselves, by instinctively putting their hand over the emerging head to let it out gently, then bring the baby to the surface (I am always amazed at the ease with which babies unravel themselves from their cords when they need to in the water). At a recent home birth (3rd baby, 3rd waterbirth) the woman did her own VE to check for full dilatation ["I don't know where I am  at" - "why don't you have feel?" "Oh! The baby's right there"], she proceeded to catch the baby and bring it to the surface, then 20 minutes later birthed her placenta and placed it in a dish she had ready.

With regard to the perineum; most of the women I have had who birthed in water have had no perineal damage or smallish tears. Never a 3rd degree. I think this is because the water warms and supports the perineum and allows the head to move down without the women necessarily getting the strong expulsive pushing urge that can lead to tears.

This is a really interesting discussion. This is also part of my research and my literature review. Again, if anyone would like more detail/refs let me know. In summary: The interventions used to 'manage' a nuchal cord - looping a loose cord or cutting a tight cord - are at best unnecessary and at worst harmful (particularly cutting). Therefore, if you aren't going to do anything, why bother checking? It is still routine practice in the UK and Australia. As for numbers re. mw doing this: In a postal survey in the UK, Jackson, Melvin, and Downe (2007) found 87.8% of mw loop a loose cord over baby's head, 57.8% of mw would clamp and cut a tight cord.

These practices are a traditional/cultural thing - not based on any evidence. I also found that this was the biggest stumbling block when trying to implement waterbirth in a UK unit. It took a lot of work to convince the mw that women could birth without mws fiddling on during the emergence of the baby.

I noticed that when midwives talk about waterbirth, they sort of ignore the whole "checking for cord" step, which I couldn't figure out until I realized that the baby's just kind of unwind themselves if the cord is impeding their exit.

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