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UMBILICAL CORD PROLAPSE

RCOG, 2008

Aboubakr Elnashar
Prof . Obs Gyn, Benha University Hospital
Aboubakr Elnashar

Cord prolapse:

Definition

cord through the cervix alongside (occult) or


past the presenting part (overt) in the presence of
ruptured membranes.

Cord presentation:
cord below presenting part with intact membranes

Aboubakr Elnashar

Aboubakr Elnashar

Incidence
Cord prolapse:
0.1% - 0.6%.

Breech presentation:
1%.

Aboubakr Elnashar

Perinatal mortality rate

91/1000.
Prematurity
congenital malformations
birth asphyxia
Asphyxia:
{cord compression and umbilical arterial vasospasm:
preventing venous and arterial blood flow to and from
the fetus}:
hypoxicischaemic encephalopathy and
cerebral palsy.

Aboubakr Elnashar

Risk factors
General
Multiparity
Low birth weight (<2.5 kg)
Prematurity (<37 w)
Fetal congenital anomalies
Breech presentation
Transverse, oblique and unstable
lie
Polyhydramnios
Low-lying placenta, other
abnormal placentation
Unengaged presenting part
Second twin

Procedure related 50%


ARM
Vaginal manipulation of
the fetus with ruptured
membranes
ECV (during procedure)
Internal podalic version
Stabilising induction of
labour
Insertion of uterine
pressure transducer

Aboubakr Elnashar

How:
1. Preventing close application of the presenting
part to the lower part of the uterus and/or pelvic
brim.
2. Rupture of membranes
3. Cord abnormalities: true knots or low content of
Whartons jelly: may alter the turgidity of the cord
4. Fetal hypoxiaacidosis may alter the turgidity of
the cord
Induction of labour with prostaglandins is not
associated with cord prolapse.

Aboubakr Elnashar

Detection of cord presentation antenatally


Routine US:
not sufficiently sensitive or specific:
should not be performed

Aboubakr Elnashar

Prevention of cord prolapse or its effects


1. Admission if
a. Transverse, oblique or unstable lie after 37+6 w
Refused: advise to present quickly if there are signs
of labour or suspicion of membrane rupture
{Inpatient care minimises delays in diagnosis and
management of cord prolapse.
Labour or ruptured membranes in the context of an
abnormal lie is an indication for CS} .
b. Noncephalic presentations and preterm
prelabour rupture of the membranes

Aboubakr Elnashar

3. Avoid ARM if
a. presenting part is mobile.
ARM necessary:
performed with arrangements for immediate CS.
Upward pressure on the presenting part should be
kept to a minimum .
b. cord is felt below the presenting part.
4. CS
When cord presentation in established labour

Aboubakr Elnashar

Suspicion of cord prolapse


Abnormal FHR pattern
bradycardia, variable decelerations, prolonged
deceleration
particularly after membrane rupture, spontaneously
or with amniotomy.

Aboubakr Elnashar

Speculum and/or digital vaginal examination should


be performed
1. At preterm gestations when cord prolapse is
suspected.
2. In labour:
after spontaneous rupture of membranes if
risk factors are present or if
CTG abnormalities commence soon thereafter.

No need:
With spontaneous rupture of membranes in the
presence of a normal FHR patterns and the
absence of risk factors for cord prolapse,
liquor is clear.
Aboubakr Elnashar

Do not handle cord too much.


Assess: cervical dilatation

pulsating or not?.
If non pulsating:

Check fetal heart sounds


US: assess heart activity

Aboubakr Elnashar

Initial management of cord prolapse in


hospital
1. Assistance should be immediately called
2. Preparations made for immediate delivery
Manual replacement of the prolapsed cord above
the presenting part to allow continuation of labour is
not recommended.
3. Prevent vasospasm:
minimal handling of loops of cord lying outside the
vagina.

Aboubakr Elnashar

4. Prevent cord compression:


presenting part be elevated either
manually or by
filling the urinary bladder.
kneechest position or
head-down tilt (preferably in left-lateral position).
5. Tocolysis
while preparing for CS if there are
persistent FHR abnormalities after attempts to
prevent compression mechanically and when the
delivery is likely to be delayed.

Aboubakr Elnashar

Aboubakr Elnashar

Swabs soaked in warm saline are wrapped


around the cord: unproven benefit.
Manual elevation:
By inserting a gloved hand or two fingers in the
vagina and pushing the presenting part upwards.
A variation is to remove the hand from the vagina
once the presenting part is above the pelvic brim
and apply continuous suprapubic pressure
upwards.
Excessive displacement may encourage more
cord to prolapse.

Aboubakr Elnashar

Bladder filling
If the decision-to-delivery interval is likely to be
prolonged, particularly if it involves ambulance
transfer
Moderate Trendelenburg position.
By inserting the end of a blood giving set into a
Foleys catheter. The catheter should be clamped
once 500750 ml has been instilled.
Empty the bladder again just before any delivery
attempt, be it vaginal or CS.

Aboubakr Elnashar

Tocolysis
{reduce contractions and abolish bradycardia}
Terbutaline: 0.25 mg SC

Aboubakr Elnashar

Mode of delivery with cord prolapse


1. CS
when vaginal delivery is not imminent
{prevent hypoxiaacidosis}.
2. Vaginal:
When vaginal birth is imminent {outcomes are
similar or better when compared with CS}.

Aboubakr Elnashar

CS:
Category 1:
Delivering within 30 min or less if there is
suspicious or pathological FHR
but without unduly risking maternal safety.
Verbal consent is satisfactory.
Category 2:
FHR is normal.
The outcome for emergency CS is not worse for
deliveries occurring up to 60 min from decision,
provided that the situation is not immediately lifethreatening for the fetus

Aboubakr Elnashar

Category 1=Emergency
Immediate threat to the life of a woman or fetus.
Category 2=Urgent
Maternal or fetal compromise but not immediately life
threatening.
Category 3=Scheduled
Needing early delivery but no maternal or fetal
compromise.
Category 4 =Elective
At a time to suit the woman and CS team.

Aboubakr Elnashar

Regional anaesthesia
may be considered in consultation with an

experienced anaesthetist. {With modern


techniques, the complications of general
anaesthesia are rare but still higher than for
regional anaesthesia.
The use of temporary measures, as described
above, can reduce cord compression, making
regional anaesthesia the technique of choice.}
Repeated attempts at regional anaesthesia
should be avoided.

Aboubakr Elnashar

Vaginal birth
Most cases operative
Very favourable characteristics:
full cervical dilatation
delivery would be accomplished quickly and safely.
Decision-to-delivery interval: 30 min or less.
Continuous CTG during labour
US: of F heart {audible heart tones and cord
pulsation may cease prior to delivery even though
the f remains alive}

Aboubakr Elnashar

Breech extraction:
Performed after internal podalic version for the
second twin.
Forceps or ventouse:
Depend on clinical circumstances and level of skill.
No difference in neonatal outcomes for fetal
distress

Aboubakr Elnashar

Neonatal care
Neonatologist should attend
Paired cord blood samples for pH and base
excess measurement
{strong predictive value of a normal paired cord
blood gas for the exclusion of intrapartum related
hypoxicischemic brain damage}

Aboubakr Elnashar

Management in community settings


1. Waiting for hospital transfer:
kneechest face-down position
2. During ambulance transfer:
left-lateral position
Elevate presenting part: manual or bladder filling
Prevent vasospasm: minimal handling of loops of
cord lying outside the vagina.

Aboubakr Elnashar

Management of cord prolapse before viability


Women should be counselled on both continuation and
termination of pregnancy
Expectant management
Gestational age at the limits of viability.
Uterine cord replacement may be attempted.
Prolongation of pregnancy at such gestational ages
creates a chance of survival but morbidity from prematurity
remains a frequent serious problem.
Delivery:
signs of severe fetal compromise
once viability has been reached or
gestational age associated with a reasonable neonatal
outcome is achieved.

,
Aboubakr Elnashar

Training

All staff involved in maternity care should receive at


least annual training in the management of
obstetric emergencies including the management
of cord prolapse.
Updates on the management of obstetric
emergencies (including the interpretation of fetal
heart rate patterns) are a proactive approach to
risk management.
All staff involved in maternity care should attend
annual multidisciplinary rehearsals (skill drills)
including the management of cord prolapse.

Aboubakr Elnashar

Clinical incident reporting


Clinical incident forms should be submitted for all
cases of cord prolapse.
Auditable standards
1. Proportion of staff receiving annual training in
cord prolapse.
2. Audit of the management of cord prolapse in
hospital settings.
3. Audit of the management of cord prolapse in
community settings.
4. Diagnosisdelivery interval for spontaneous and
assisted vaginal deliveries and CS in cases of cord
prolapse.
5. Critical analysis of adverse outcomes
(compliance with guidance).

Thanks

Aboubakr Elnashar