EDITORIAL COMMENT: We accepted this paper for publication because cord problems should interest readers and it is generally accepted, as the author notes, that a true knot is seldom a cause of death before the onset of labour in contradistinction to entanglement of the cord around the baby’s limbs and body. As far as the Editor is aware, diminished or absence of fetal movements has never been shown cardiotocographically to be caused by a true knot with successful delivery of the fetus although one can imagine that this could occur. It is interesting to speculate, as the author has done, concerning how a true knot tightens when the umbilical cord is of normal length. In Chew’s (A) paper the cardiotocographic findings were analyzed in 2,601 women who reported diminished fetal movements and there was no example of a knotted cord in any of the 21 perinatal deaths or in any of the 24 infants who had loss of baseline variation and type 2 decelerations, which was regarded as evidence of critical fetal reserve. A Medline search identified a case where a sinusoidal fetal heart rate pattern and moderate fetal hypoxia was associated with a true knot of the cord (B). Another study of 12 pregnancies in which fetal distress and death resulted from umbilical cord abnormalities included 8 where the patients had a history of decreased fetal movements, and where nonstress cardiotocography was abnormal (C). These authors concluded that antepartum fetal deaths due to umbilical cord abnormalities are still difficult to prevent, as it is often impossible to detect distress in time for appropriate intervention. Prompt action to deliver the baby after an abnormal cardiotocograph appears to be a necessary step to prevent such deaths, yet even this failed in Case 2 reported in this paper. These 2 cases may inspire us to keep looking. One can imagine that the fetus may have been saved in Case 1 had the patient reported change in fetal movements earlier.
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