cord prolapse 07

8/17/2019 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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cord prolapse 07

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