umbilical cord prolapse

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UMBILICAL CORD PROLAPSE RCOG, 2008 Aboubakr Elnashar Prof . Obs Gyn, Benha University Hospital Aboubakr Elnashar

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Umbilical cord prolapse

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Page 1: Umbilical Cord Prolapse

UMBILICAL CORD PROLAPSE

RCOG, 2008

Aboubakr Elnashar

Prof . Obs Gyn, Benha University Hospital Aboubakr Elnashar

Page 2: Umbilical Cord Prolapse

Definition

Cord prolapse: 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

Page 3: Umbilical Cord Prolapse

Aboubakr Elnashar

Page 4: Umbilical Cord Prolapse

Incidence Cord prolapse: 0.1% - 0.6%.

Breech presentation:

1%.

Aboubakr Elnashar

Page 5: Umbilical Cord Prolapse

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}:

hypoxic–ischaemic encephalopathy and

cerebral palsy.

Aboubakr Elnashar

Page 6: Umbilical Cord Prolapse

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

Risk factors

Aboubakr Elnashar

Page 7: Umbilical Cord Prolapse

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

Wharton’s jelly: may alter the turgidity of the cord

4. Fetal hypoxia–acidosis may alter the turgidity of

the cord

Induction of labour with prostaglandins is not

associated with cord prolapse.

Aboubakr Elnashar

Page 8: Umbilical Cord Prolapse

Detection of cord presentation antenatally Routine US:

not sufficiently sensitive or specific:

should not be performed

Aboubakr Elnashar

Page 9: Umbilical Cord Prolapse

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

Page 10: Umbilical Cord Prolapse

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

Page 11: Umbilical Cord Prolapse

Suspicion of cord prolapse Abnormal FHR pattern

bradycardia, variable decelerations, prolonged

deceleration

particularly after membrane rupture, spontaneously

or with amniotomy.

Aboubakr Elnashar

Page 12: Umbilical Cord Prolapse

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

Page 13: Umbilical Cord Prolapse

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

Page 14: Umbilical Cord Prolapse

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

Page 15: Umbilical Cord Prolapse

4. Prevent cord compression:

presenting part be elevated either

manually or by

filling the urinary bladder.

knee–chest 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

Page 16: Umbilical Cord Prolapse

Aboubakr Elnashar

Page 17: Umbilical Cord Prolapse

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

Page 18: Umbilical Cord Prolapse

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

Foley’s catheter. The catheter should be clamped

once 500–750 ml has been instilled.

Empty the bladder again just before any delivery

attempt, be it vaginal or CS.

Aboubakr Elnashar

Page 19: Umbilical Cord Prolapse

Tocolysis

{reduce contractions and abolish bradycardia}

Terbutaline: 0.25 mg SC

Aboubakr Elnashar

Page 20: Umbilical Cord Prolapse

Mode of delivery with cord prolapse

1. CS

when vaginal delivery is not imminent

{prevent hypoxia–acidosis}.

2. Vaginal:

When vaginal birth is imminent {outcomes are

similar or better when compared with CS}.

Aboubakr Elnashar

Page 21: Umbilical Cord Prolapse

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 life-

threatening for the fetus

Aboubakr Elnashar

Page 22: Umbilical Cord Prolapse

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

Page 23: Umbilical Cord Prolapse

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

Page 24: Umbilical Cord Prolapse

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

Page 25: Umbilical Cord Prolapse

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

Page 26: Umbilical Cord Prolapse

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

hypoxic–ischemic brain damage}

Aboubakr Elnashar

Page 27: Umbilical Cord Prolapse

Management in community settings

1. Waiting for hospital transfer:

knee–chest 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

Page 28: Umbilical Cord Prolapse

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

Page 29: Umbilical Cord Prolapse

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

Page 30: Umbilical Cord Prolapse

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. Diagnosis–delivery interval for spontaneous and

assisted vaginal deliveries and CS in cases of cord

prolapse.

5. Critical analysis of adverse outcomes

(compliance with guidance). Aboubakr Elnashar

Page 31: Umbilical Cord Prolapse

Thanks Aboubakr Elnashar