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Pregnant, Under Observation For Nuchal Cord Loop, Baby's Weight Is Low. Asked For C Section. Suggest?
Question: Hi my wife is presently 36 weeks pregnant. at 32nd week Dr.said that there is nuchal cord loop (once). since then she is under observations. The weight of the baby was 2.462 Kgs on 35 weeks 2 days.Now our Dr. is asking for C sec during 37th week. I feel that we can wait till 38 week so that baby weight would be atleast 2.900 Kgs.I asked for 30th august 13 days before her EDD, but they say to do before 25th august. Is i will be taking risk by posponing delivery by another 5 days. Can delivery happen normal or C sec is the option considering that she was done mcdonald stich earlier for 3.5 cms cervix
Brief Answer:
Hello XXXXX, I've read and absorbed your query.
Detailed Answer:
Hello XXXXX,
I've read and absorbed your query. Let me try and solve your dilemma this way:
First things first - as far as possible, the aim should be to deliver the baby at 39, or at least 38 completed weeks. One is then very sure that the systems and maturity of organs of the baby is complete. Mainly we are concerned with maturity of the lungs but other organ systems must also reach full maturity.
When would we like to have a baby out earlier than this? ----whenever there is some element of decreased supply of oxygen and nutrients to the baby as it happens when a baby has IUGR = Intra Uterine Growth Retardation. This means that the baby has not grown as much as it should because, for several reasons, it didn't get its supply of oxygen and nutrients.
Your baby does seem to be on the lower weight at 35 weeks, but only slightly so. Important will be - did your doctor at any time earlier mention that the baby is not growing well? I don't think this happened. So probably the baby has been growing ok so far, as per his/her growth potential.
Is there any evidence/proof of IUGR? Does this Ultrasound report mention the amount of 'liquor' or water around the baby? Does it say normal liquor or does it say less liquor? Look at the written report to find out.
How are the baby's functions, Bio Physical Profile (BPS) - movements, breathing movements etc on the ultrasound report?
So you see, what we need to know, other than the Estimated Birth Weight (EBW), is the amount of liquor and the BPS of the baby.
Remember also that ultrasound can estimate the baby weight +/- 15% so the baby could be more than what is reported on ultrasound.
If the liqour and BPS are ok, then, in my opinion, one can easily wait till the baby reaches maturity age, around 38-39 weeks.
Now,XXXXX, lets look together at the history of a MacDonald's Stitch in this pregnancy. This is a stitch put on the cervix to PREVENT preterm delivery. In such cases there is nothing wrong with the baby per se but the uterus which may go into labour earlier than the age at which the baby reaches maturity.
Can you understand what i'm getting at - just because there is a MacDonald Stitch, it doesn't cause the baby any harm. So the presence of the stitch should NOT make you take the baby out earlier.
In fact, if your wife goes into labour, the stitch is simply cut out at that time. Since she has already crossed 36 weeks, your baby will come to no harm and will be ok, but ELECTIVELY we may not want to take out this baby earlier than maturity. You see...
As far as the delivery is concerned, i can give you general guidelines. Its possible there may be some factors, which i don't know about in this particular case, which will decide whether to have normal delivery or C section.
Logically, any patient who has had a MacDonald stitch has had it done because either a previous pregnancy ended before time (premature contractions/labour) or in this pregnancy, as you said, the cervix was open. This fact, by itself, does not require that a C Section be done, because once the stitch is removed at maturity, the patient should go into labour, since the cervix is already open.
Now lets explore the issue of cord around the neck (once).
This is quite common. It should not be around the neck like a noose and should not be wrapped several times around the neck. A loose, once only cord around neck may cause absolutely no problem, especially if the baby is monitored very well for heart rate abnormalities during labour.
My suggestion - it may be wise to repeat an ultrasound and a Doppler - its possible that this cord around the neck may not be there anymore!
Further, at the time of the ultrasound, by placing the transducer on the heart of the baby and counting the baby's heart rate (machine does it automatically) every time the baby moves, one can know if the cord is strangulating the baby. This can also be done by a test called Non Stress Test (NST) if your doctor has this machine, otherwise one can do it with the ultrasound machine and get an idea.
In my own practice, i generally do not do a C Section for such a cord as you describe, but watch the baby as the delivery progresses.
I hope this answers the questions and doubts in your heart.
Other than that, i must congratulate you and your doctor for having 'pulled' this pregnancy so far since the cervix was open.
Relax and discuss with your doctor once again these issues in the light of our above discussion. Find out if your doctor has certain apprehensions or an inner feel about the actual situation which is determining her decisions.
My wishes for you. Take care.
Dr Nirja Chawla
Hello XXXXX, I've read and absorbed your query.
Detailed Answer:
Hello XXXXX,
I've read and absorbed your query. Let me try and solve your dilemma this way:
First things first - as far as possible, the aim should be to deliver the baby at 39, or at least 38 completed weeks. One is then very sure that the systems and maturity of organs of the baby is complete. Mainly we are concerned with maturity of the lungs but other organ systems must also reach full maturity.
When would we like to have a baby out earlier than this? ----whenever there is some element of decreased supply of oxygen and nutrients to the baby as it happens when a baby has IUGR = Intra Uterine Growth Retardation. This means that the baby has not grown as much as it should because, for several reasons, it didn't get its supply of oxygen and nutrients.
Your baby does seem to be on the lower weight at 35 weeks, but only slightly so. Important will be - did your doctor at any time earlier mention that the baby is not growing well? I don't think this happened. So probably the baby has been growing ok so far, as per his/her growth potential.
Is there any evidence/proof of IUGR? Does this Ultrasound report mention the amount of 'liquor' or water around the baby? Does it say normal liquor or does it say less liquor? Look at the written report to find out.
How are the baby's functions, Bio Physical Profile (BPS) - movements, breathing movements etc on the ultrasound report?
So you see, what we need to know, other than the Estimated Birth Weight (EBW), is the amount of liquor and the BPS of the baby.
Remember also that ultrasound can estimate the baby weight +/- 15% so the baby could be more than what is reported on ultrasound.
If the liqour and BPS are ok, then, in my opinion, one can easily wait till the baby reaches maturity age, around 38-39 weeks.
Now,XXXXX, lets look together at the history of a MacDonald's Stitch in this pregnancy. This is a stitch put on the cervix to PREVENT preterm delivery. In such cases there is nothing wrong with the baby per se but the uterus which may go into labour earlier than the age at which the baby reaches maturity.
Can you understand what i'm getting at - just because there is a MacDonald Stitch, it doesn't cause the baby any harm. So the presence of the stitch should NOT make you take the baby out earlier.
In fact, if your wife goes into labour, the stitch is simply cut out at that time. Since she has already crossed 36 weeks, your baby will come to no harm and will be ok, but ELECTIVELY we may not want to take out this baby earlier than maturity. You see...
As far as the delivery is concerned, i can give you general guidelines. Its possible there may be some factors, which i don't know about in this particular case, which will decide whether to have normal delivery or C section.
Logically, any patient who has had a MacDonald stitch has had it done because either a previous pregnancy ended before time (premature contractions/labour) or in this pregnancy, as you said, the cervix was open. This fact, by itself, does not require that a C Section be done, because once the stitch is removed at maturity, the patient should go into labour, since the cervix is already open.
Now lets explore the issue of cord around the neck (once).
This is quite common. It should not be around the neck like a noose and should not be wrapped several times around the neck. A loose, once only cord around neck may cause absolutely no problem, especially if the baby is monitored very well for heart rate abnormalities during labour.
My suggestion - it may be wise to repeat an ultrasound and a Doppler - its possible that this cord around the neck may not be there anymore!
Further, at the time of the ultrasound, by placing the transducer on the heart of the baby and counting the baby's heart rate (machine does it automatically) every time the baby moves, one can know if the cord is strangulating the baby. This can also be done by a test called Non Stress Test (NST) if your doctor has this machine, otherwise one can do it with the ultrasound machine and get an idea.
In my own practice, i generally do not do a C Section for such a cord as you describe, but watch the baby as the delivery progresses.
I hope this answers the questions and doubts in your heart.
Other than that, i must congratulate you and your doctor for having 'pulled' this pregnancy so far since the cervix was open.
Relax and discuss with your doctor once again these issues in the light of our above discussion. Find out if your doctor has certain apprehensions or an inner feel about the actual situation which is determining her decisions.
My wishes for you. Take care.
Dr Nirja Chawla
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
First of all I would like to thanks for your valuable advice. Regarding the cervix stitch it was not open but actually weak of 3.5 cms in the 18th week and they did this stitch. Now as far as the BPS and liqour is concerned, its fine. For last 25 days my wife is hospitalised for observation, since the loop was found which is once. Since then everyday they used to monitor the heart beat by CTG machine once in every four or five hour, and also they used to carry ultrasound screening every alternate day for last 25 days. till today all ultrasound is showing liquor as normal and they say all other things including hearbeat of the baby is going normal, my wife is getting mild pain in back and stomach for last two three days (only in nights) bcoz of gastic problem and since now she is taking Rantac tablets now she is ok. otherwise she is absolutely fine and even Dr say baby is fine and growing well, but I dont know why they are insisting us to fix the date as early as possible before 25th of this month. sometimes they say it will be difficult to take the baby out since it will grow large till 30 th aug the date which I am asking them to fix for Is the date of 30th Aug when 38 wk and 2 days will pass is that ok. shall I insist them for that date. I am also scared that by delaying I am not taking any risk, since this is our first baby after nine yrs of marriage.
Brief Answer:
Yes, can wait. Baby monitored-all is well.
Detailed Answer:
Hi XXXXX,
3.5 cms open/loose/weak cervix is an indication for the MacDonald Stitch. So that's ok.
Your wife is being monitored well with Ultrasound and CTG. So the liquor and baby are fine and baby is 'growing well'.
Very clearly, there is no risk, as per the reports, to the baby of any danger.
The date, 30th August, is, according to you 13 days before her recorded due date. In my opinion, one can easily wait till then. A baby can increase weight about 100-300 gms per week, not usually more than that unless the mother is diabetic. So the baby weight gain should not be a problem for a normal delivery (or C Section)especially as the cervix is already open/weak upto 3.5 cms.
So, in my opinion, one can easily wait till 30th August and sometimes, even a bit beyond, for the sake of achieving a normal delivery rather than a C Section.
The important part now coming up is the history of inability to conceive for several years. Your wife has had a previous pregnancy loss. So that would put this case in the category of 'Precious Pregnancy/baby'.
Despite this, my opinion is that one can wait - after all, the patient is in good hands of a doctor who is monitoring everything, albeit a little too much though :-)
In view of this being a precious baby (all babies are precious, this one more so because of infertility for so long), i would opine that after stitch is removed and the membranes ruptured to release the water bag, if the patient doesn't go into labour = have contractions, then one can go in for C Section at this point without waiting further. This is what i would like to do in such a case.
I would prefer not to give medicines in drip to such a patient to cause labour pains, for several valid, scientific reasons (sometimes drugs can 'overstimulate' the contractions causing decrease of oxygen to baby; this being baby conceived after infertility), but go in for C Section at the step i described.
This way, we give best chance to baby to grow and mature to its full growth potential and we give reasonable chance to mother to deliver normally. Its not as if C Section is something to very afraid of - nowadays its a safe procedure with advances in technique and anaesthesia. The issue is to be as natural as possible, with minimum interference - only as much required (otherwise scientific knowledge is a waste) and to inflict on a patient minimum operative procedures within safe limits.
Hope this solves your doubts.
Relax. All WILL be well.
Take care.
Dr Nirja Chawla
Yes, can wait. Baby monitored-all is well.
Detailed Answer:
Hi XXXXX,
3.5 cms open/loose/weak cervix is an indication for the MacDonald Stitch. So that's ok.
Your wife is being monitored well with Ultrasound and CTG. So the liquor and baby are fine and baby is 'growing well'.
Very clearly, there is no risk, as per the reports, to the baby of any danger.
The date, 30th August, is, according to you 13 days before her recorded due date. In my opinion, one can easily wait till then. A baby can increase weight about 100-300 gms per week, not usually more than that unless the mother is diabetic. So the baby weight gain should not be a problem for a normal delivery (or C Section)especially as the cervix is already open/weak upto 3.5 cms.
So, in my opinion, one can easily wait till 30th August and sometimes, even a bit beyond, for the sake of achieving a normal delivery rather than a C Section.
The important part now coming up is the history of inability to conceive for several years. Your wife has had a previous pregnancy loss. So that would put this case in the category of 'Precious Pregnancy/baby'.
Despite this, my opinion is that one can wait - after all, the patient is in good hands of a doctor who is monitoring everything, albeit a little too much though :-)
In view of this being a precious baby (all babies are precious, this one more so because of infertility for so long), i would opine that after stitch is removed and the membranes ruptured to release the water bag, if the patient doesn't go into labour = have contractions, then one can go in for C Section at this point without waiting further. This is what i would like to do in such a case.
I would prefer not to give medicines in drip to such a patient to cause labour pains, for several valid, scientific reasons (sometimes drugs can 'overstimulate' the contractions causing decrease of oxygen to baby; this being baby conceived after infertility), but go in for C Section at the step i described.
This way, we give best chance to baby to grow and mature to its full growth potential and we give reasonable chance to mother to deliver normally. Its not as if C Section is something to very afraid of - nowadays its a safe procedure with advances in technique and anaesthesia. The issue is to be as natural as possible, with minimum interference - only as much required (otherwise scientific knowledge is a waste) and to inflict on a patient minimum operative procedures within safe limits.
Hope this solves your doubts.
Relax. All WILL be well.
Take care.
Dr Nirja Chawla
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thanks once again for your advice. Yesterday i met my Dr. since she was asking to fix a date, accordingly I asked her for 30th Aug, she asked why you want to wait for so long, anyhow she agreed that she will decide on 30th aug only after doing and reviewing full scan on 16th aug. Regarding infertility, we have not given any treatment for infertility, it was only bcoz of low sperm count. Earlier also she conceived naturally and in 7 weeks got aborted since fetus was not grown due to unknown reason and no heartbeat came. This time also she conceived naturally and when the fetus screening test done earlier when around 25 weeks completed Dr informed us that it is a low risk pregnancy. Now the circumstances are that there is stitch, then she has gestational diabetic which is around 140-150 after food, which Dr say is ok its only gestational so nothing to worry. my doubts are that when this stitch has to be removed, and what happens normally after that. My family says that better to go for C sec since loop is there and they insist me that what is the problem of doing c sect on 25th aug instead of 30 th aug, my worry is what happen if I fix date 30th and before if the labor begins, will there be any risk. I am totally confused by not listening them and waiting till 30th aug am I taking a risk. I am in pressure bcoz Dr earlier asked to fix date before 25th earlier which my family knows and kept in mind now when I am asking to prolong they feel why I want to do so and as if I am unnecessarily postponing the same. Please clarify my doubts, what to do with stitches,will those be removed on C sect date or earlier, (((((what if labor starts before the date fixed for c sect, and what are all the risk involved by prolonging preganency till 30th aug when as per scan EDD is 11th sept))))),
Brief Answer:
Don't worry.Baby will be ok del after 21.8.13
Detailed Answer:
My dear, dear XXXXX,
I think i have already answered all your queries. Just check and see....
When you ask a question, you simply MUST listen to the answer. Listening is an art - not only will you absorb more than what a person speaks but the confusions go away. All confusions arise in a mind which is not silent.
So, in your 3rd query/post to me, the questions are:
1. ".....my worry is what happen if I fix date 30th and before if the labor begins, will there be any risk."
If labour begins before 30th, nature has taken the decision. There may be risks of prematurity to the baby if born before 37 completed weeks, but not if born anytime after that.
Your wife completes 37 weeks on 21st August.
2. ".....waiting till 30th aug am I taking a risk."
No, there appears to be no risk, in my opinion, but your doctor should be the best judge of the factual situation.
You mentioned the presence of Gestational Diabetes in your last post. If well controlled, and the baby is monitored by BPS, one can easily take such patients even uptil 40 weeks pregnancy.
3. "......what to do with stitches,will those be removed on C sect date or earlier,"
I talked in great detail about this in the earlier post - usually we remove stitches when planning to deliver patient normally. In your case if the decision is taken for Elective C Section, your doctor will likely remove them in the Operation Theatre just before performing the C Section.
4. ".......(((((what if labor starts before the date fixed for c sect, and what are all the risk involved by prolonging preganency till 30th aug when as per scan EDD is 11th sept))))),"
Please read Points 1. and 2.
Thank you for consulting with me.
Take care.
Dr Nirja Chawla
Don't worry.Baby will be ok del after 21.8.13
Detailed Answer:
My dear, dear XXXXX,
I think i have already answered all your queries. Just check and see....
When you ask a question, you simply MUST listen to the answer. Listening is an art - not only will you absorb more than what a person speaks but the confusions go away. All confusions arise in a mind which is not silent.
So, in your 3rd query/post to me, the questions are:
1. ".....my worry is what happen if I fix date 30th and before if the labor begins, will there be any risk."
If labour begins before 30th, nature has taken the decision. There may be risks of prematurity to the baby if born before 37 completed weeks, but not if born anytime after that.
Your wife completes 37 weeks on 21st August.
2. ".....waiting till 30th aug am I taking a risk."
No, there appears to be no risk, in my opinion, but your doctor should be the best judge of the factual situation.
You mentioned the presence of Gestational Diabetes in your last post. If well controlled, and the baby is monitored by BPS, one can easily take such patients even uptil 40 weeks pregnancy.
3. "......what to do with stitches,will those be removed on C sect date or earlier,"
I talked in great detail about this in the earlier post - usually we remove stitches when planning to deliver patient normally. In your case if the decision is taken for Elective C Section, your doctor will likely remove them in the Operation Theatre just before performing the C Section.
4. ".......(((((what if labor starts before the date fixed for c sect, and what are all the risk involved by prolonging preganency till 30th aug when as per scan EDD is 11th sept))))),"
Please read Points 1. and 2.
Thank you for consulting with me.
Take care.
Dr Nirja Chawla
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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