Obstetrical patient at 36 weeks and she's not measuring as much as I would expect. I think it may be because the baby is transverse instead of head down, but I'm not sure. I order an ultrasound to help sort this out and thankfully by the time this is done the baby has assumed the correct position and the baby's growth is appropriate. That's all I really wanted to know. But wait. There's more. The ultrasound is so clear, the radiologist can see the umbilical cord looped around the baby's neck.
Now what do I do with that? At delivery at least 1/3 of babies will have what's referred to as a nuchal cord, or a cord around it's neck. At times it is thought this may cause some concerning decelerations in the baby's heart rate during labor, but labor management does not change and good outcomes are still the rule.
Of women who come into labor and delivery at or near term with a fetal demise probably the most common identifiable cause is what's referred to as a cord accident (the most common cause of term fetal demises is unknown). In a cord accident blood flow to the baby is somehow completely cut off asphyxiating the fetus. Occasionally a true knot will be found in an umbilical cord for example.
So what do I do with this piece of information that I wasn't looking for anyway? The odds are so remote that this will lead to anything disastrous, most would not change their management of this pregnancy and move to early delivery which poses a greater likelihood of risks to the baby. On the other hand, am I obligated to tell her about this, so I can at least say I told her? I think the radiologist most likely included it in his report, for that reason. If anything goes wrong for whatever reason, he is absolved. He can at least say, "I told you the cord was there."
In the end I did tell my patient, though I am still obviously conflicted over it. I told her to monitor baby's movement closely and we talked about kick counts. In the back of my mind, however, I know there's little evidence these practices are effective and my patient lives far enough away from the hospital that should a cord accident take place and she does detect the lack of fetal movement the chance of intervening successfully is incredibly remote.
Have I just passed the buck and given her something to worry about which is unlikely to happen and that she has absolutely no control over anyway?