cord prolapse 07
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Professor
Department of Obstetrics & Gynecology
King Khalid University
Abha, Saudi Arabia
UMBILICAL
CORD
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o provide information and practical guidance to
enable early diagnosis and efficient initiation ofemergency procedures to ensure the best
possible neonatal outcome
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Umbilical cord presentation! Presence of
cord in front of presenting part before therupture of membranes"
Umbilical cord prolapse! Descent of
umbilical cord follo#ing rupture of the
membranes, through the cervi$ so that it lieseither along side the fetal part or in front of
presenting part into the cervi$% and into or
out of vagina"
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Occult prolapse 'ord lies ad(acent to the
presenting part, but not beyond thepresenting part in the presence of intact or
#ithout intact membranes"
Overt prolapse cord #hich is visible or
palpable #ith na)ed eyes follo#ing ruptureof membranes"
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*dentify predisposing ris) factors
+nable prompt diagnosis and instituteimmediate action
*nitiate correct emergency procedures
aise a#areness of the neonatal implications
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Over all incidence -"./ -"0/
Primi gravida -"1 /
2ulti gravida -"0 /
'ephalic presentation -"3 /
4reech 5ran) -"6 /
'omplete 7 /
5ootling .- /
Shoulder presentation .7 /
'ontracted pelvis 10 times more"
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Non engagement of fetal head:
."Unengaged or poorly applied presenting part
8" 9igh parity #ea) muscles 3"
Unstable lie #ea) muscles
1" 2alpresentations
7" 4reech presentations
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Related to Uterine and Pelvic factors!
." Polyhydramnios
8" :ong umbilical cord 3"
:o# lying placenta
1" 'ontracted Pelvis
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Related to Fetal factors!
." Prematurity
8" :o# 4irth ;eight
3" Second t#in
1" 'ongenital malformations
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Related to clinical procedures!
." A2 in high presenting part
8" +$ternal cephalic version
3" Stabili
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Other causes
." PO2
8" 2ale fetuses
3" Anomalies of uterus
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Neonatal morbidity and Mortality as high
as 7- / due to." 9ypo$ia is due to cord compression by
the presenting part and also due to
vasospasm of umbilical vessels
8" Operative trauma 3"
Delay in transport
1" 'ongenital malformations
7" Prematurity
Maternal morbidity !
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Overt cord can be seen in the vagina or
outside the vagina feel pulsations =ariable deceleration and bradycardia on
'G follo#ing rupture of membranes"
5etal bradycardia follo#ing fundal pressure
2econium stained li>uor
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Ultrasound e$amination for malpresentation
and cord presentation" Avoid A2 in unengaged head
outinely doing P=+ follo#ing spontaneous
rupture of membranes"
'ontrolled A2 in poly hydramnios
Stabili
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Depends upon viability of the fetus and
absence of fetal malformations" ?uic) action should be ta)en to e$pedite the
delivery"
Survival of fetus depends on s#ift action
Prepare for +mergency interventions li)e
'esarean section and or *nstrumentaldelivery"
2ultidisciplinary approach or eam #or) is
re>uired
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Discontinue *= o$ytocin infusion
O$ygen by mas) .7 lits% mt
'OD ' call for help
O organi
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Avoid presenting part pressure over cord by
digital or manual pressure" *nstruct the patient to not to e$ert pressure
or pushing"
4ladder filling #ith 7-- @-- ml of saline"
ocolysis *n("erbutaline 87- microgams S'ly
Positioning of the patient!." Knee chest position
8" rendelenburg position
3" +$aggerated Sims or lateral position
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Do's
eplace the cord into the vagina to preventfrom vasospasm #ith saline soa)ed pad
'ontinuous monitoring of 59
*nform the patient
2inimal handling of cord
Don'ts
eplace inside the uterus
+$cessive handling of the cord"
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Knee chest face do#n position
4ladder filling #ith saline
*n Ambulance left lateral position
2anual elevation if a nurse or family
physician there
Urgent transfer to center #ith cesarean
facilities and neonatal care"
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!tage " of #abor
Prepare for +mergency 'esarean section *nform the senior pediatrician
Delivery should be done #ithin 3- minutes
*f fetal death occurs, try for vaginal delivery"
!tage "" #abor !
+$pedite delivery #ith liberal episiotomy andinstrumental delivery"
*f there is fetal heart disturbance and not infavor of vaginal delivery plan for +mergency'esarean section"
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$%treme prematurity &ith cord prolapse:
." elo& or around () &ee*s counsel thepatient"
*f she #ishes to continue pregnancy if 59 is
normal and patient #illing for up to 3 #ee)s
*f patient does not agree allo# for vaginal
delivery #ith or #ithout o$ytocin infusion
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Overall 7- /
5irst stage of labor @7 /
Second stage 7- /
Beonatal death 1 /
Perinatal mortality 8- /
Asphy$ia 9ypo$ic ischaemic encaephlopathy
'erebral palsy
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Good #ith verte$ presentation than 4reech"
Good in Primigravida than in multi"
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2+D:*B+ and B9S databases
'OG Green op Guidelines
;omenCs 9ospitals Australasia
:in 2G 8--0E" Umbilical cord prolapse" Obstetrical and Gynecological Survey
0.1E!806@@"
2app 8--7E" 5eelings and fears post obstetric emergencies8" British Journal of
Midwifery .3.E!301-"
2app , 9udson K 8--7E" 5eelings and fears during obstetric emergencies." British
Journal of Midwifery .3.E!3-7"
2urphy DF, 2acKen
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Press
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Afolabi 44, :esi 5+, 2era BA 8--0E" egional versus general anaesthesia for caesarean
section" Cochrane atabase of Systematic !eviews, issue 1"
4oyle FF, Kat< =: 8--7E" Umbilical cord prolapse in current obstetric practice" Journal
of !eproductive Medicine 7-7E!3-30"
'linical Begligence and Other is)s Scheme 'BO*S 8--6E" http!%%###"cnoris"com
IAccessed 80 2arch 8-.-J"
'rofts F5, +llis D, Draycott F et al 8--@E" 'hange in )no#ledge of mid#ives and
obstetricians follo#ing obstetric emergency training! a randomised controlled trial of
local hospital, simulation centre and team#or) training" BJOG: "n International Journal
of Obstetrics and Gynaecology ..1 .8E!.7311."
Draycott , ;inter ', 'rofts F, et al# eds 8--HE" 2odule H" 'ord prolapse in! $!OM$%:
$ractical Obstetric Multi$rofessional %raining Course Manual " :ondon! 'OG Press!..@81"
Gos#ami K 8--@E" Umbilical cord prolapse" *n! Grady K, 9o#ell ', 'o$ ' eds"
Managing Obstetric &mergencies and %rauma' %he MO&% course manual 8nd ed"
:ondon! 'OG Press! 833@"
9oughton G 8--0E" 4ladder filling! an effective techni>ue for managing cord prolapse"
British Journal of Midwifery .18E!HH6"
Kat< , Shoham , :ancet 2 et al .6HHE" 2anagement of labor #ith umbilical cord
prolapse! a 7year study" Obstetrics and Gynecology @88E!8@HH."
Koonings PP, Paul 9, 'ampbell K .66-E" Umbilical cord prolapse" A contemporary
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loo)" Journal of !eproductive Medicine 37@E!06-8"
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+han* ,ouCORD PROLAPSECord prolapse has been defned as thedescent o the umbilical cord through
the cervix alongside (occult) or pastthe presenting part (overt) in thepresence o ruptured membranes.Cord presentation is the presence othe umbilical cord between the etalpresenting part and the cervix, with or
without membrane rupture. Theoverall incidence o cord prolapseranges rom 0.1 to 0.!. "n the caseo breech presentation, the incidenceis slightl# higher than 1. "t has beenreported that male etuses appear to
be predisposed to cord prolapse. Theincidence is in$uenced b# populationcharacteristics and is higher where
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there is a large percentage o multiplegestations.
Cases o cord prolapse appearconsistentl# in perinatal mortalit#en%uiries, and one large stud# ounda perinatal mortalit# rate o &1'1000.rematurit# and congenitalmalormations account or themaorit# o adverse outcomesassociated with cord prolapse inhospital settings1 but birth asph#xia isalso associated with cord prolapse.erinatal death has been describedwith normall# ormed term babies,particularl# with planned home birth.*ela# in transer to hospital appearsto be an important contributing actor.+sph#xia ma# also result in h#poxicischaemic encephalopath# andcerebral pals#.
The principal causes o asph#xia inthis context are thought to be cordcompression and umbilical arterial
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vasospasm preventing venous andarterial blood $ow to and rom theetus. There is a paucit# o long-termollow-up data o babies born aliveater cord prolapse in both hospitaland communit# settings.
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"n general, these actors predispose tocord prolapse b# preventing closeapplication o the presenting part tothe lower part o the uterus and'orpelvic brim. upture o membranes insuch circumstances compounds theris/ o prolapse.
ome authorities have also speculatedthat cord abnormalities (such as true/nots or low content o harton2s
ell#) and etal h#poxiaacidosis ma#alter the turgidit# o the cord andpredispose to prolapse. "nterventionscan result in cord prolapse with about30 o cases being preceded b#obstetric manipulation.
The manipulation o the etus with orwithout prior membrane rupture(external cephalic version, internalpodalic version o the second twin,manual rotation, placement ointrauterine pressure catheters) andplanned artifcial rupture o
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membranes, particularl# with anunengaged presenting part, are theinterventions that most re%uentl#precede cord prolapse.
Can cord presentation bedetected antenatally?
outine ultrasound examination is notsu4cientl# sensitive or specifc oridentifcation o cord presentationantenatall# and should not beperormed to predict increasedprobabilit# o cord prolapse, unless inthe context o a research setting.
Can cord prolapse or its efects beavoided?
ith transverse, obli%ue or unstablelie, elective admission to hospital ater567! wee/s o gestation should bediscussed and women should beadvised to present %uic/l# i there are
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signs o labour or suspicion omembrane rupture. omen withnoncephalic presentations andpreterm prelabour rupture o themembranes should be o8eredadmission.
+rtifcial membrane rupture shouldbe avoided whenever possible i thepresenting part is mobile. " itbecomes necessar# to rupture themembranes, this should be perormedwith arrangements in place orimmediate caesarean deliver#.
9aginal examination and obstetricintervention in the context o rupturedmembranes and a high presentingpart carr# the ris/ o upwarddisplacement and cord prolapse.:pward pressure on thepresenting part should be /ept to aminimum in such women.
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upture o membranes should beavoided i, on vaginal examination, thecord is elt below the presenting part.hen cord presentation is diagnosedin established labour, caesareansection is usuall# indicated.
When should cord prolapse besuspected? Cord presentation and prolapse ma#occur without outward ph#sical signsand with a normal etal heart ratepattern. The cord should be examinedor at ever# vaginal examination inlabour and ater spontaneous ruptureo membranes i ris/ actors arepresent or i cardiotocographicabnormalities commence soonthereater.
ith spontaneous rupture omembranes in the presence o anormal etal heart rate patterns andthe absence o ris/ actors or cord
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prolapse, routine vaginal examinationis not indicated i the li%uor is clear.
Cord prolapse should be suspectedwhere there is an abnormal etal heartrate pattern (brad#cardia, variabledecelerations etc), particularl# i suchchanges commence soon atermembrane rupture, spontaneousl# orwith amniotom#. peculum and'ordigital vaginal examination should beperormed at preterm gestations whencord prolapse is suspected.
What is the optimal initialmanagement o cord prolapse inhospital settings?
hen cord prolapse is diagnosedbeore ull dilatation, assistanceshould be immediatel# called and
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preparations made or immediatedeliver# in theatre. There areinsu4cient data to evaluate manualreplacement o the prolapsed cordabove the presenting part to allowcontinuation o labour. This practice isnot recommended.
To prevent vasospasm, there shouldbe minimal handling o loops o cordl#ing outside the vagina. To preventcord compression, it is recommendedthat the presenting part be elevatedeither manuall# or b# flling theurinar# bladder. Cord compression canbe urther reduced b# the motheradopting the /neechest position orhead-down tilt (preerabl# in let-lateral position).
Tocol#sis can be considered whilepreparing or caesarean section ithere are persistent etal heart rateabnormalities ater attempts to
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prevent compression mechanicall#and when the deliver# is li/el# to bedela#ed.+lthough the measures describedabove are potentiall# useul duringpreparation or deliver#, the# must notresult in unnecessar# dela#.
What is the optimal mode odelivery with cord prolapse?
+ caesarean section is therecommended mode o deliver# incases o cord prolapse when vaginaldeliver# is not imminent, to preventh#poxiaacidosis.
+ categor# 1 caesarean section shouldbe perormed with the aim odelivering within 50 minutes or less ithere is cord prolapse associated witha suspicious or pathological etal heartrate pattern but without undul# ris/ingmaternal saet#. 9erbal consent issatisactor#.
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Categor# ; caesarean section isappropriate or women in whom theetal heart rate pattern is normal.egional anaesthesia ma# beconsidered in consultation with anexperienced anaesthetist.
What is the optimal managementin community settings?
omen should be advised, over thetelephone i necessar#, to assume the/neechest ace-down position whilewaiting or hospital transer. *uringemergenc# ambulance transer, the/neechest is potentiall# unsae andthe let-lateral position should beused.
+ll women with cord prolapse shouldbe advised to be transerred to thenearest consultant-led unit ordeliver#, unless an immediate vaginal
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examination b# a competentproessional reveals that aspontaneous vaginal deliver# isimminent. reparations or transershould still be made.
The presenting part should beelevated during transer b# eithermanual or bladder flling methods. "t isrecommended that communit#midwives carr# a
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What is the optimal managemento cord prolapse beore viability?
>xpectant management should bediscussed or cord prolapsecomplicating pregnancies withgestational age at the limits oviabilit#.:terine cord replacement ma# beattempted. omen should becounselled on both continuation andtermination o pregnanc# ollowingcord prolapse at the threshold oviabilit#.
Clinical governance
Debriengostnatal debriefng should be o8ered toever# woman with cord prolapse. +ter
severe obstetric emergencies, womenmight be ps#chologicall# a8ected withpostnatal depression, post-traumaticstress disorder or ear o urther childbirth.omen with cord prolapse
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who undergo urgent transer to hospitalmight be particularl# vulnerable toemotional problems.
*ebriefng is an important part omaternit# care and should be o8ered b# aproessional competent in counselling
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