Figure 3: Type B loop: a nuchal loop that encircles the neck in a locked manner. Should this fetus be delivered breech, the loop will get tighter around the neck of the fetus.
The recognition of a single loop relies on the observation of a section of cord between the head and shoulder in a sagittal section, and the demonstration of a complete loop in an axial section of the neck. This is often difficult because of shadowing, and a compound image is often required. In an axial section, cord that is simply draped over the neck can be excluded. Color Doppler is the easiest mean to assess the cord in the axial view. Multiple loops are detected in the same manner, but the number of loops can only be counted in the sagittal section. Again, color Doppler is the easiest modality to count multiple loops. The assessment of the type (locking versus freely sliding) requires the demonstration of the crossing of one of the ends under the other end. This is easier in higher order looping since the cord is more taught, but if the crossing occurs behind the fetus, the diagnosis cannot be made.
Prognosis versus number of loops
Despite the good prognosis in most of the cases, some studies demonstrate that the presence of a nuchal cord is associated with variable fetal heart rate deceleration3, , , , decreased fetal movement, umbilical arterial metabolic acidemia 7,, neonatal anemia, and, in extreme situations, intrauterine fetal demise10. 
In 1995, Larson, studying intrapartum complications associated with multiple nuchal cord entanglement, concluded that the group with four or more loops involved had significantly lower birth weight, more episodes of severe variable and late decelerations, meconium, and a higher incidence of operative delivery5.
Multiple nuchal cord is probably the most common of abnormal umbilical cord findings. Variable decelerations commonly occur during the first and second periods of labor. When episodes of cord compression are sufficiently spaced, the fetus can clear the increased CO2 and maintain the oxygenation by using the oxygen reserve. However, if signs of fetal discomfort, such as decreased fetal movement or persistent fetal heart variable decelerations, or even signs of fetal distress like repeated late decelerations are present, operative intervention is recommended .
We speculate that, in the present case, the good Apgar scores and outcome at the nursery are attributed to the prompt intervention on the ultrasound findings.
Although the presence of a single nuchal cord does not require changes on the management of the pregnancy, the prenatal detection of multiple loops may alter the management and improve the outcome of these fetuses.
Our experience and the literature show that most cases of four or more nuchal loops are at high risk to develop complications in labor and delivery; thus, these cases demand caution and are more likely to end in an operative intervention.
 Gould, G.M., Pyle, W. L.(1896). Prenatal anomalies. Anomalies and curiosities of medicine. The Julian Press, Inc., New York, p95
 Hippocrates: De Octimestri Partu
 Pritchard J. A., Macdonald P. C., Gant N.F.(1985). Conduct of normal labor and delivery. Williams Obstetrics.17th edition. Norwalk,CT, Appleton-Century Crofts , p340
Larson, J.D., Rayburn, W.F., Harlan, V.L.(1997). Nuchal cord entanglement and gestational age. Am J Perinatol. 14(9): 555-557
 Larson, J.D., Rayburn, W.F., Crosby, S., Thurnau, G.R.(1995). Multiple nuchal entanglements and intrapartum complications. Am J Obstet Gynecol 173(4): 1228-1231
 Giacomello F: (1988) Ultrasound determination of nuchal cord breech presentation. Am J Obstet Gynecol 159:531-2
 Hankins, G.D.V., Snyder, R.R., Hauth ,J.C., Gilstrap III, L. C., Hammond, T.(1987). Nuchal cords and neonatal outcome. Obstet. Gynecol. 70(5): 687 - 691
 Anyaegbunam, A., Brustman, L., Divon, M., Langer, O.(1986). The significance of antepartum variable decelerations. Am J Obstet Gynecol 155: 707-710
 Tejani N.A., Mann, L.I., Sanghavi, M., Bhakthavathsalan A., Weiss, R.(1977). The association of umbilical cord complications and variable decelerations with acid-base findings. Obstet Gynecol 49: 159-162
 Steinfeld, J.D., Ludmir, J., Eife, S., Robbins, D., Samuels, P.(1992). Prenatal detection and management of quadruple nuchal cord. J Reprod Med 37(12): 989-991
 Stembera Z.K., Horska, S.(1972). The influence of coiling of the umbillical cord around the neck of the fetus on its gas metabolism and acid-base balance. Biol Neonate 20: 214
 Collins, J.H.(1993). Two cases of multiple umbilical abnormalities resulting in stillbirth: prenatal observation with ultrasonography and fetal heart rates. Am J Obstet Gynecol 168(1): 125-128
 Feinstein, S.J., Lodeiro, J.G., Vintzileos, A.M., Weinhaum, P.J., Cambell, W.A., Nochimson, D.J.(1985). Intrapartum ultrasound diagnosis of nuchal cord as a decisive factor in management. Am J Obstet Gynecol 153(3): 308-309