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The purpose of this study was to examine if a short umbilical cord might give rise to fetal distress of such a severity that would necessitate operative delivery. Review of the literature gave little clarification. Out of a database consisting of 7212 births, 5885 were included in the study according to pre-set criteria. The incidence of operative delivery was then compared with cord length. A significantly higher incidence of forceps deliveries and vacuum extractions was found when cord length was less than 40 cm. The incidence of cesarean section was also higher for the shorter cords. There was no increased need for neonatal resuscitation for the babies with the shortest cords.

Umbilical cord length in 35,779 neonates was analyzed to determine values after mid-gestation and to see if abnormal values have clinical significance. Growth slowed after twenty-eighth week of gestation but did not stop before term. Cord length had a positive correlation with maternal height, pregravid weight, pregnancy weight gain, socioeconomic status, and the fetus being male. Short cords were associated with subsequent psychomotor abnormalities, but taken alone their predictive value was low because the normal range of cord lengths is large. Short cords were much better predictors of subsequent impairments when they were combined with other neonatal predictors. Short cords doubled or tripled the predictive values of low Apgar scores and several other neonatal abnormalities for subsequent low IQ values and neurologic abnormalities.

Embryonic vestiges of the umbilical cord are classic findings in routine morphologic examination of the placenta. In order to evaluate their clinicopathologic significance, we examined samples from the fetal and placental ends of 1,000 umbilical cords and collected the principal clinical findings of the corresponding newborns. Microscopic evidence of embryonic remnants were found in 231 cases (23.1%) divided into remnants of the allantoic duct (63%), the omphalomesenteric duct (6.6%), and the embryonic vessels (30.4%), including one case of hemangioma and an accessory small artery. There were no significant clinical differences between the three vestigial groups, and no particular association with congenital malformations or perinatal complications. In 70.9% of the cases, the embryonic remnants were found at the fetal end of the umbilical cord, where most tumors of the cord develop.

A biphasic fetal heart rate variable deceleration pattern (W-sign) was investigated and found to be significantly associated with a greater length of umbilical cord (73.07 +/- 17.1 cm) than was found in patients without this pattern (56.47 +/- 11.4 cm) during the first stage of labor (P less than .001). The possible etiology of this variable deceleration pattern and its relative benignity are discussed.

A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth-weight, short umbilical cord and primiparity.

From previous research, which gave standard curves for the evolution of uterine height and umbilical perimeter according to gestational age in the case of single pregnancies, the authors propose curves which show the variations of these two parameters in twin pregnancies. The observed differences are sufficient to allow a diagnosis of twin pregnancy as soon as the 18th week of amenorrhea. This observation is interesting because, until now, a systematic early B-scan examination has not been performed as a rule.

Neurohistochemical techniques were used to determine the distribution of adrenergic and cholinergic nerves in the human placenta and the umbilical cord adjacent to the chorion. These morphologic studies demonstrate the absence of neural elements in these sites. The significance of these findings to the placental innervation controversy is discussed.

The purpose of this study was to evaluate the origin, direction, and relevance of the umbilical cord twist. We initially hypothesized that the direction of the helix or twist of the human umbilical cord at birth correlated with the eventual handedness of the child. Among 2801 singleton placentas in this study, only 5% had no twist, and the left twist outnumbered the right twist by 7 to 1, a ratio that is strikingly similar to the predominance of right-handed persons to non-right-handed persons in the general population. Forty-five 3- and 4-year-old children with previously documented cord twists were evaluated with respect to hand preference and performance. The direction of the cord twist was independent of the handedness of the child as well as the mother. We have documented an increased incidence of absent twist and right twist in association with single umbilical artery, suggesting that the impetus for the cord twist is independent on hemodynamic forces in the umbilical cord itself. We further document an increased incidence of absent twist among intrauterine fetal deaths and twins, suggesting that decreased fetal movement can impede the forces leading to normal twisting of the umbilical cord. Absence of cord twist may be associated with adverse prognosis.

Although cord knots and/or encirclements account for 1 in 10 stillbirths of infants weighing 2,500 g or more, no problem due to this cause was encountered in a prospective study of 1,115 vaginal deliveries. In this study there were 6 cases of cord knot (0.5%) and 158 of cord encirclement (14.2%). The range of cord length was 27-122 cm, the 10th, 50th and 90th percentiles being 40, 52 and 69 cm respectively. In this study there was no clinical warning (fetal distress) of cord encirclement or knot during pregnancy, labour or delivery.

Umbilical cord length may be a function of fetal movement. Agents that cause decreased fetal movement may cause short umbilical cords. This investigation examined the effect of the beta-blocker atenolol on umbilical cord length in rabbits. Fetuses of rabbits treated with atenolol had significantly shorter cords than control animals (p less than or equal to 0.0005). Since short cords are associated with problems in labor, low Apgar scores, and abruption, we recommend careful surveillance of mothers and fetuses who are given beta-blocking agents in the first 30 weeks of pregnancy.

It seems to be a widely held notion that the uterine cavity is larger during a woman's later pregnancies than during her first pregnancy. The direct evidence for this is, however, scarce. The umbilical cord length at term is one measure of the fetal intrauterine mobility, and therefore indirectly of the space in which the fetus moves. If the uterine cavity is larger during later pregnancies, the cord length of the babies in these pregnancies should be longer. We have compared the cord lengths of 1839 babies, divided into three groups: babies born of primiparous, secundiparous and tertiparous women. The difference in mean cord length is statistically significant between the first and the third group. This supports the theory of a larger intra-uterine space in later pregnancies. We also examined 159 mothers, measuring the umbilical cord length of their first and second babies. A significant positive correlation was found, in that the first baby tended to have the shorter cord. A control group with matching, but unrelated babies showed no such correlation. The results seem to us to support the stated theory further.

A current hypothesis on the linear growth of the umbilical cord states that cord length is a function of fetal intrauterine motor activity. If there is some type of intrauterine constraint, the tensile forces on the cord will be diminished, and cord length at term will be shorter than if no such constraint is present. One would expect that the voluntary movements of twins would develop under a constraint and that they would have less free space to move compared with single fetuses. If this hypothesis is valid, cord lengths of twins at term would be shorter than those of single pregnancy infants. We measured the cord lengths of 118 infants in 59 twin births and compared them with cord lengths in 9601 single pregnancies. We found that on the average, the umbilical cord length of the twins was 7.90 cm shorter than that of single pregnancy infants.

The site of umbilical cord attachment in ruminants indicates the limited segment of the uterus where the blastocyst attachment occurs and could have potential significance for locating presumptive nidation sites. Measurements of the site of cord attachment were made on impala (Aepyceros melampus) and common duiker (Sylvicapra grimmia) at several stages of gestation. Both implant only in the right uterine horn although they ovulate from either ovary. Relative to uterine length, cord attachment in impala is somewhat closer to the cervix than it is in common duiker. As pregnancy advances in common duiker, the relative position of cord attachment becomes closer to the tubal end. This relationship was not seen in impala and may perhaps to be attributed inadequate data. Upon extrapolation of the data from common duiker, a presumptive attachment area is suggested for this species. This region is located at about 41% of the distance from the internal cervical os to the uterotubal junction. Similar cord attachment data could be used in any ruminant species to indicate the existence and location of a specific nidation site.

A simple, noninvasive clinical test for detecting nuchal cords late in pregnancy and during labor is based on recording the changes in the fetal heart rate produced by transabdominal manual compression of the fetal neck area. The test was applied in 88 women close to full term and to 67 women in labor. Overall, the sensitivity of the test was 82.3% and specificity, 89.1%. The results were statistically significant in both late pregnancy and labor. A positive test implies an impending risk of cord compression and is an indication for close electronic fetal monitoring, particularly during labor. Routine use of the nuchal cord test can contribute to decreasing perinatal morbidity and mortality by diminishing the impact of cord problems.

Length, extensibility, and absolute strength of umbilical cords were determined in litters of pigs at term. Length was also determined in fetuses earlier in gestation and in hypophysectomized fetuses. Mean cord length at term was 34.6 cm (range, 17 to 50 cm) and its length was correlated with length and birth weight of pigs. Cords were significantly (P less than 0.01) shorter in hypophysectomized fetuses, but cord length was not influenced by sex, position in the uterus, or twisting of the cord. Although the umbilical cord was capable of being stretched considerably, the degree varied among pigs. Tension required to break portions of the cord ranged from 545 to 2,000 g. Variations in length, elasticity, and strength of the cord may influence safe delivery, birth asphyxiation, and perinatal mortality in pigs.

The umbilical cord is an amniotic structure histologically resembling amnion lining the basal plate and reflected chorion. Prostaglandin E2 is secreted by amnion and is present in amniotic fluid. This study measured prostaglandin E2 production by amnion from all three locations to determine the relative contributions of prostaglandin E2 to amniotic fluid at term. Total surface areas and weights of umbilical cord, basal placental plate, and reflected chorionic amnion were measured in afterbirths from 20 normal patients delivered at term by elective repeat cesarean section before the onset of labor or vaginally after spontaneous onset of labor. Subsequently, 2 cm lengths of umbilical cord and 8 cm2 disks of basal placental plate and reflected chorionic amnion were incubated in perfusion chambers, and prostaglandin E2 production was measured by radioimmunoassay. Umbilical cord accounted for the least surface area (16% to 17%) but greatest tissue mass (75% to 76%). Both basal placental plate and reflected chorionic amnion increased prostaglandin E2 production 2.3-fold and 4.1-fold, respectively, after labor versus before labor, whereas umbilical cord prostaglandin E2 output was unchanged. However, umbilical cord accounted for 66% and 44% of the total prostaglandin E2 output before labor (697 +/- 169 ng/hr) versus (1201 +/- 380 ng/hr) after labor. Thus, of the three amniotic locations, umbilical cord represents the principal site of prostaglandin E2 production within the gestational sac.

Our experience in 65 patients using a "fetoscope" and local anesthesia prior to saline abortion is described. Visualization of the intrauterine contents improved with experience, was optimum at 16 to 18 weeks' gestation, and was superior to the quality of photographic records. Four fetal skin biopsies and 6 amnion biopsies were done. Six blood samples were taken from the fetal surface of the placenta. The limitations of this instrument are described. No significant complications have occurred. Current and probable future indications for fetoscopy are reviewed. Until both the safety of the procedure is proved and problems of visualization due to limitation of visual field are solved, extreme caution is urged in the employment of this instrument in genetic high-risk pregnancy.

Fifty umbilical cords were prepared and examined and their venous perfusion pressures measured with and without a true knot in the cord. Contrary to information in the literature, a loose umbilical cord knot did not affect the venous perfusion pressure. With a tightened knot, the smaller the umbilical cord diameter, the greater was the pressure required to perfuse past the knot. The umbilical vessels, protected by the myxomatous structure of the Wharton's jelly, were rarely completely occluded. These findings correlate clinically with the relatively high incidence yet low fetal mortality rate actually due to a true knot in the umbilical cord.

Expectant management of prolonged pregnancy is predicated on reassuring biophysical testing. However, even the combination of a reactive nonstress test and normal amniotic fluid volume may not prevent subsequent morbidity. To test the hypothesis that diminished cord Wharton's jelly incurs risk of peripartum cord compression in addition to decreased amniotic fluid, 68 patients with confirmed gestational age greater than or equal to 41 weeks were evaluated prospectively with semiweekly nonstress tests and weekly ultrasound examinations. Amniotic fluid volume was assessed, and umbilical cord diameter was measured and then correlated with the quantity of Wharton's jelly at delivery, determined by cord circumference. A significant correlation between cord circumference and umbilical cord diameter was observed, even in those patients with decreased amniotic fluid volume. Either an amniotic fluid volume less than 3.8 cm or an umbilical cord diameter less than 1.6 cm was associated with significant cord compression patterns. Peripartum morbidity was greatest in the presence of a smaller cord and decreased fluid, suggesting a synergism between these two factors for the risk of cord compression in prolonged pregnancy.

The umbilical cords of 21 days old rat foetuses were investigated using histochemical methods for acetylcholinesterase and catecholamines. An AChE positive nerve plexus is situated only around the vitelline vessels. At regular intervals the bundles of this plexus exhibit small ganglia. These ganglia are made up of nerve cells, which are AChE positive and show formaldehyde induced fluorescence, thus indicating an adrenergic nature of these cells. No innervation could be found in the allantoic part of the umbilical cord.

Nine patients who were 34-36 weeks pregnant underwent magnetic resonance (MR) imaging. Sagittal images using spin echo technique (TR 2.0 sec, TE 28 msec) were optimal for delineating fetal anatomy. The fetal cardiovascular, pulmonary, and central nervous systems were depicted in all cases. The heart and major vessels were readily seen due to the natural contrast of flowing blood. The intensity of the fluid-filled lungs greatly increased with a longer TR or TE, delimiting thorax from liver. The brain was relatively featureless due to the lack of gray-white matter differentiation. The umbilical cord within the amniotic fluid and its insertion into the placenta and fetus was identified in all cases. MR is a new modality for fetal imaging that offers tissue-characterization information that complements the superior anatomic detail of ultrasound scanning.

A short umbilical cord was found in newborns for whom there was evidence of early intrauterine constraint and in those with gross structural or functional limb defects that limited intrauterine movement. These findings were interpreted as showing that umbilical cord growth occurs in response to tensile forces relating to intrauterine space availability and fetal movement during early development. Thus, the finding of a short umbilical cord may indicate diminished fetal movement from either early intrauterine constraint or fetal limb dysfunction.

The umbilical cord is the lifeline of the fetus and of the neonate in the first few minutes after birth. Care of the cord and stump in the immediate neonatal period varies according to social, cultural, economic, and geographic factors. Measures taken to insure sterility in cutting, tying, and painting the umbilical cord may prevent serious diseases such as tetanus neonatorum. Care of the umbilical cord may be less than optimal in babies born at home in unsupervised "home delivery." Minor congenital anomalies of the umbilical cord, such as umbilical hernia, and major anomalies, such as gastroschisis and omphalocele, are reviewed in this article. Survival in babies with major anomalies of the cord has been improving steadily because of early diagnosis (including prenatal diagnosis), better operative procedures, and better understanding of the fluid and nutritional requirements of the neonate postoperatively. Diseases of the cord include omphalitis and, rarely, tumors.

We examined 100 selected placentas concerning architecture and distribution of the vessels of the chorionic plate. The eccentric insertion of the umbilical cord as well as the mixed type of distribution of the chorial arteries and equal areas of arterial blood supply were found to be most frequent. In no case the anastomosis of Hyrtl was absent. A marginal and a very eccentric cord were more frequent in combination with a mixed and magistral type of distribution of the vessels that the lesser eccentric and the central type of insertion. There was no significant correlation between insertion of the cord and the infants' birth weight. Arteries pass over the veins when they cross. Serial sections of 15 crossing vessels have been examined, one specimen was reconstructed graphically. When crossed by major arteries the veins bypass below whereas small arterial branches override larger veins not affecting their course. The cross-like vessels are wrapped up in connective tissue and anchored to the chorion plate. There are equivalents in the morphology of the vessels of the chorion and the retina. Both vessel systems are embedded in hollow bodies exposed to an inner pressure, however, sharing a common media, the crossing artery and vein of the retina represent a more intense anatomical unity. The connective mesenchymal frame of the crossing vessels of the choroin plate, the thickened arterial wall-segments and the venous wall-sectors let functional valves suspect as is known from other areas of blood supply.

Two hundred and seventy one infants were enrolled in a study to compare six different methods of treating the umbilical cord. Antimicrobial control was equal for all methods. Repeated triple dye application was considered least acceptable by staff and parents and had the longest attachment time. Povidone-iodine was associated with the shortest attachment time and was most liked. If there is no special need to treat a specific nosocomial outbreak, duration of cord attachment and satisfaction of staff and parents can help clinicians decide on a cord care regimen.

Bleeding from the site of cordocentesis can be detected by ultrasound examination, but significant hemorrhage into the amniotic fluid rarely occurs. To evaluate the relative contribution of amniotic fluid thromboplastins and the quantity of Wharton's jelly in facilitating coagulation at the puncture site, amniotic fluid samples and umbilical cord segments were obtained at cesarean section from 20 patients. After puncture of the umbilical vein, bleeding times were measured in amniotic fluid and 0.9% sodium chloride. The quantity of Wharton's jelly was assessed by measuring umbilical cord circumference. Mean bleeding times were significantly shorter in amniotic fluid compared with saline solution, but there was no consistent relationship between bleeding times and umbilical cord circumference. We conclude that properties of amniotic fluid facilitate coagulation at the site of umbilical vein puncture.

The site of the insertion of the umbilical cord into the placenta was determined in 940 consecutive term infants. No relation was found between birth weight and whether the cord was inserted centrally, eccentrically or marginally.

Ten fetuses underwent ultrasound scanning at 7-10 weeks gestational (postmenstrual) age. In all cases, an echogenic mass measuring 0.5-1.0 cm was demonstrated within the base of the umbilical cord at its insertion into the fetal abdomen. No area with echogenicity characteristic of the small bowel was identified within the lower part of the fetal abdomen. All fetuses were reexamined 4-12 weeks later, at which time the mass in the umbilical cord was no longer seen, and normal fetal bowel was visualized in the lower abdominal cavity of the fetus. This sequence of findings appears to represent the sonographic demonstration of normal fetal bowel migration early in gestation and should not be confused with defects of the abdominal wall such as omphalocele or gastroschisis.

The mechanisms of the development of knots in the umbilical cord are described. The different types of knots are enumerated. The causative factors for the development of a knot in the umbilical cord are discussed. This paper is based on a statistical evaluation of the deliveries of the Maternity Hospital of the University of Bonn from 1967-1970. These data have been adopted from the Author's M.D. Thesis of 1972. At the end of the paper the comparative anatomy of the umbilical cord complications is discussed.

The body weight of newborns, the weight of placenta, the length of umbilical cord and the content of urobilinogen, gulcose, protein, pH, keton body in amniotic fluid were investigated with samples from 16 litters of beagles. The mean body weight of newborn, weight of placenta and length of umbilical cord were 258.0 +/- 44.6 g (85 samples), 48.5 +/- 8.5 g (85 samples) and 11.0 +/- 2.7 cm (52 samples), respectively without any sex difference. The significant correlation were recognized between the weight of placenta and the body weight of newborn, between the length of umbilical cord and the body weight of newborn and between the weight of placenta and the length of umbical cord (P less than 0.01).

A series of 549 not selected placentas and umbilical cords were examined to show the influence of the different development of the umbilical cord structure on the umbilical cord perfusion and the course of parturition. For this purpose the quantity of Wharton's jelly, the spiraling of the umbilical vessels as well as the length of the cord are defined. At the same time anatomical pecularities and complications like umbilical cord torsions and true knots are considered. To judge the decisive condition of the newborn and with that the course of parturition, the pH-value of umbilical artery blood is determined. The analysis results that umbilical cords with much Wharton's jelly and with spiraling vessels are converted into an association with extremely better value than those with little jelly and less spiraling vessels. Short and rich jellied umbilical cords show a significantly lower incidence of loops around the fetal body. A similar trend can be demonstrated for umbilical cords with strong spiraling arteries. Rare phenomena like velamentous insertion, haematomas, edemas and true knots of the cords etc. proved to have no influence on the course of parturition in our relatively small examination series.

The present study is based on two previously stated theories: (1) that the umbilical cord length is influenced by fetal motor activity and (2) that the breech presentation is associated with low fetal motor activity. From this one would expect the mean cord length to be shorter in breech presentations as compared with vertex. This was indeed found to be the case. An already known difference between the sexes regarding cord length was also confirmed, and a difference in male:female ratio in the two presentations is shown. The results of the study thus seem to support the two stated theories.

In this study of the umbilical cord lengths of 602 Nigerian infants delivered at term, the mean, median and modal measurements were 57.48, 57.71 and 68.00 cm, respectively (range = 20-100 cm). There was a significant positive correlation between cord length and fetal weight (r = 0.2177, p less than 0.001) and also between cord length and placental weight (r = 0.2504, p less than 0.001). Other fetal and maternal variables studied did not correlate with cord length. Further investigations of the factors responsible for the growth of the umbilical vessels are needed.