CORD PROLAPSE

UMBILICAL CORD PROLAPSE AND

SURGICAL SITE INFECTION
CASE VIGNETTE
A 39 year old Gravida 7 Para 6 presented at 37 weeks of gestation
with transverse lie and uterine contractions of 2:10 minutes lasting
35 seconds. The fetal heart rate was 146/minute
On vaginal examination, the cervix was fully effaced, cervical
dilatation 4cm dilated. The membranes were bulging. The umbilical
cord had prolapsed through the cervix.
An urgent caesarean section was done and a healthy baby boy
were delivered.
Post-operatively, she developed surgical site infection which
required further treatment and prolonged hospital stay. She
recovered without the need for surgical suturing.

INSTRUCTION TO
CANDIDATE
She attends the postnatal clinic with
her partner
She wants to know more as to why a
caesarean section was done
She wants further clarification as to
why her surgical wound had become
infected
Counsel the patient appropriately

The candidate is expected to:

Be tactful in handing complaints and
complications following surgery
Demonstrate managerial skills in
handling complaints
Explains the reasons for surgical site
infection
Inform patients about strategies
hospitals adopt to reduce surgical
site onfection

ITEM

MARKS
ALLOTE
D

Professionalism
Greet patient and partner
Sits at consultation table at a reasonable
distance from clients
Invites both partner and patient and makes
them comfortable
Has all documents and Bed Head ticket of
patient regarding the Obstetric Emergency
(cord presentation) and abnormal lie
Also has details of intrapartum and course of
postnatal care
States purpose of consultation and reviews her
obstetric problem and complication

ITEM

MARK
ALLOT
ED

Clarifies risk factors and states reasons for

caesarean section
Grandmultiparity at 37 weeks of gestation in
established labour as evidenced by uterine
contractions and cervical dilatation of 4 cm. the
fetus was in transverse lie and hence high risk of
cord prolapse. This is evident in the case as the
cord ids prolapses and the membranes are bulging.
The diagnosis was CORD PRESENTATION and the
fetus is alive
Caesarean section was the best option under the
circumstances

Reiterates processes that would have been

carried prior to operation:
Informed consent
Plain language used
Explanation about CS and type of anesthesia
Reassures that routines of preoperative care and
urgent CS were strictly followed

ITEM

MARK
ALLOTE
D

Willing to clarify further, asks if patient needs more

information
Maintain eye contact and also invites partner into
the consultation
Pauses and waits for response and ensures that
patients is satisfied with explanation
Discuss possible reasons for surgical site
infection
2-5% surgical site infection is seen in busy hospital
practice
Higher incidence in emergency surgery vs elective
Prophylactic antibiotics (preoperative) is normally
given
Nosocomial infection is a known issue but steps to
lower the incidence is in place in this hospital
Volunteers to give information about next pregnacy
and if vaginal birth after caesarean section is possible;
possibility of repeat caesarean section is increased as

ITEM

MARK
ALLOTE
D

Wraps up having clarified all issues and cleared

any doubts; again ensures that explanation
given are acceptable to both patient and
partner. Also informs that management
strategies are in place to prevent surgical site
infection via:
Infection control committee
Surgical site infection audit
Prophylactic antibiotics in CS
Informed consent and consent taking
Role of communication as part of doctorpatient relationship
Open channels for investigation of complaits

CTG INTERPRETATION IN UMBILICAL

CORD PROLAPSE
Case Scenario
A 36 year old G5P4 at term present with
the fetus in longitudinal lie. The fetal
head is 5/5th above the pelvic brim. The
pregnancy is uncomplicated.
An artificial rupture of the membranes is
done as she has weak contractions
The Bishop score is 6/10

INSTRUCTION TO
CANDIDATE
The cardiotocography done on the
patient after artificial ruptere of
membrane is shown below.
Study the CTG and answer the
questions

QUESTIONS
1. What do the TWO graphs in the CTG indicate?
The upper graph is a record of the fetal heart
rate and this is obtained using an ultrasound
(transducer placed over the point where the feta
heart is best heard)
The lower graph is obtained using a tranducer
which records the contractions of the uterus. It is
an indirect indication of intrauterine pressure

QUESTIONS
2. Describe the abnormality seen in CTG
Baseline fetal HR is about 150 bpm
The variability is <5 bpm
Variable decelerations from the baseline
are seen with variable recovery
Shouldering is clearly seen
Uterine contractions are occuring 1:3 in a
10 minute interval

QUESTIONS
3. What is the probable diagnosis
Considering the history of ARM in
patient where the fetal head is not
engaged, the most probable diagnosis
is PROLAPSE OF THE UMBILICAL CORD

QUESTIONS
4. How would you manage this patient?
i. Alert senior members of the team and keep patient nil
orally
ii. Set up iv access line and sent off blood for FBC and group
and X-match for possible urgent caesarean delivery
iii. Since the fetal heart is present one is assured the fetal is
alive
iv. Perform a pelvic examination taking aseptic measures
and confirm if the cord has prolapse
Also feel for cord pulsation and reassess the dilatation of
the cervical os

The execute the measures advocated for management of

cord prolapse which include:
Filling the urinary bladder and distending it as to take
pressure off the cord during contraction
Informing the patient about mode of delivery and getting
informed consent
If the delivery is remote from second stage and cord
prolapse is confirmed an urgent CS is done to save the
baby
If the cervical dilatation is beyond 8 cm dilated an
instrumented delivery is not contraindicated, the bladder is
emptied and delivery expedited with either vacuum
extraction or forceps
The baby is evaluated for hypoxia by the paediatric team
The patient is kept informed of outcome and reasons for
obstetric complication

THANK YOU