T. F. Corkill, M.D.
Wellington General Hospital
New Zealand
1961

One has to wonder what thoughts prehistoric humans had when confronted with the still-birth of a baby entangled in its umbilical cord. Some insights from more recent times suggest the umbilical cord represented an omen, a sacred talisman, predictor of future fertility. In Europe, Australia, Africa, and Hawaii, the umbilical cord was dried and soaked in water for consumption to ensure future fertility. It was eaten, hung from tree branches, and stuffed in volcanic rock crevices at sites such as the "Birthing Stones" in Kukahiioko, Oahu (Figure 1). Chinese literature suggests the cord had medicinal properties.

European insights beginning with Galen (129 - 200 A.D.) suggested the umbilical cord served to nurture the fetus through arteries and veins. Leonardo da Vinci (1452 - 1519) observed that the cord was as long as the fetus at a given gestational age. Spiglius (1631) determined blood flow direction, and Harvey (1657) suggested that interruption of this blood flow could be the cause of fetal death if the cord was compressed.

Early descriptions of fetal loss from cord entanglement date as far back as 200 years ago. In 1750 the British obstetrician William Smellie (Figure 2) describes case #172 in Treatise on The Theory and Practice of Midwifery as a stillborn with four cords around the neck. (Figures 3 & 4). By the 1800s, many observations were recorded of distressed fetuses born with cord entanglement and cord abnormalities. A review of these early descriptions suggest clinical symptoms such as "pulling" sensations felt at the top of the uterus and excessive fetal movement followed by decreased fetal activity prior to fetal death.

Today, the field of obstetrics is confronted with the issue of umbilical cord complications - a timeless, almost prehistoric example of how imperfect reproductive evolution sometimes can be. Issues of birth-related blood loss, infection, and surgical intervention (C-section) have matured. Premature birth, congenital anomalies and toxemia still challenge the obstetrical community. Because umbilical cord accidents may represent a small number of fetal deaths, the motivation to investigate this reproductive tragedy may not be seen as urgent. However, out of 4 million births per year in the U.S., an estimated 4,000 umbilical cord related deaths occur. This is known as mortality.

What harm occurs to the live born fetus due to an umbilical cord complication is un-known. Obstetrical scientists call this harm morbidity. This morbidity is studied in terms of delivery "outcome," meaning what harm is noticeable and how much. This harm often goes unnoticed for years. What harm does occur is rarely recorded.

Prenatal umbilical cord compression is currently suspected to provide such morbidity as neurologic damage. This damage may be as subtle as mild learning disabilities or as obvious as cerebral palsy. This is currently considered speculative by most, but not all, reproductive scientists.

The Perinatal Umbilical Cord Project (PUCP), an ongoing project at The Pregnancy Institute, seeks to understand the issue of umbilical cord complications, an event particularly tragic to the mother. If mothers are to be comforted, an explanation of how these events happen is important. The PUCP has established a scientific method (protocol) of observation and has prospectively inspected over 700 pregnancy cases. (Figure 5)

Method: All patients receive standard prenatal care starting with an exam at 8 to 10 weeks. This includes a vaginal ultrasound, a second ultrasound at 20 weeks, and a third ultrasound study at 28 weeks screens for umbilical cord problems. Also, at every visit the fetal heart rate is studied for 10 to 15 minutes and recorded. Patients identified with umbilical cord abnormalities (UCA) are watched bi-weekly, Repeat studies with ultra sound and fetal heart rate monitoring occur as needed.

As evidence and data accumulate, the authors hope that a solution can be created which will allow successful management of the normal pregnancy threatened by an umbilical cord complication.

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