UMBILICAL CORD

PROLAPSEDr.Suresh Babu Chaduvula

Professor

Department of Obstetrics & Gynecology

King Khalid University

Abha, Saudi Arabia

AIM To provide information and practical

guidance to enable early diagnosis and efficient initiation of emergency procedures to ensure the best possible neonatal outcome

TERMINOLOGIES Umbilical cord presentation:

Presence of cord in front of presenting part before the rupture of membranes.

Umbilical cord prolapse: Descent of umbilical cord following rupture of the membranes, through the cervix so that it lies either along side the fetal part or in front of presenting part into the cervix/ and into or out of vagina.

TERMINOLOGIES Occult prolapse – Cord lies adjacent to

the presenting part, but not beyond the presenting part in the presence of intact or without intact membranes.

Overt prolapse – cord which is visible or palpable with naked eyes following rupture of membranes.

OBJECTIVES: Identify predisposing risk factors Enable prompt diagnosis and institute

immediate action Initiate correct emergency procedures Raise awareness of the neonatal

implications

INCIDENCE Over all incidence – 0.1% -0.6% Primi gravida – 0.4 % Multi gravida – 0.6 % Cephalic presentation – 0.3 % Breech - Frank – 0.9 % - Complete – 5 % - Footling – 10 % Shoulder presentation – 15 % Contracted pelvis – 4-6 times more.

ETIOLOGY OR RISK FACTORS - 1 Non engagement of fetal head: 1.Unengaged or poorly applied presenting part 2. High parity - weak muscles 3. Unstable lie – weak muscles 4. Malpresentations 5. Breech presentations

ETIOLOGY OR RISK FACTORS -2 Related to Uterine and Pelvic

factors: 1. Polyhydramnios 2. Long umbilical cord 3. Low lying placenta 4. Contracted Pelvis

ETIOLOGY OR RISK FACTORS -3 Related to Fetal factors: 1. Prematurity 2. Low Birth Weight 3. Second twin 4. Congenital malformations

ETIOLOGY OR RISK FACTORS -4 Related to clinical procedures: 1. ARM in high presenting part 2. External cephalic version 3. Stabilizing induction of labor 4. Manual rotation of fetal head in OP position 5. Application of fetal scalp electrode 6. Internal podalic version of second twin

ETIOLOGY OR RISK FACTORS -5 Other causes 1. PROM 2. Male fetuses 3. Anomalies of uterus

COMPLICATIONS: Neonatal morbidity and Mortality –

as high as 50 % due to 1. Hypoxia - is due to cord compression by the presenting part and also due to vasospasm of umbilical vessels 2. Operative trauma 3. Delay in transport 4. Congenital malformations 5. Prematurity Maternal morbidity :

DIAGNOSIS Overt cord can be seen in the vagina or

outside the vagina- feel pulsations Variable deceleration and bradycardia

on CTG following rupture of membranes. Fetal bradycardia – following fundal

pressure Meconium stained liquor

PREVENTION Ultrasound examination for

malpresentation and cord presentation. Avoid ARM in unengaged head Routinely doing PVE following

spontaneous rupture of membranes. Controlled ARM in poly hydramnios –

Stabilizing induction. Bradycardia and variable decelerations

- do either vaginal examination or speculum examination

MANAGEMENT Depends upon viability of the fetus and

absence of fetal malformations. Quick action should be taken to

expedite the delivery. Survival of fetus depends on swift action Prepare for Emergency interventions like Cesarean section and or Instrumental delivery. Multidisciplinary approach or Team work

is required

MANAGEMENT Discontinue IV oxytocin infusion

Oxygen by mask – 15 lits/ mt

CORD – C – call for help - O – organize for delivery - R – Relieve pressure - D – Delivery Funic repositioning: with soaked warm saline reposition into vagina

ELEVATING THE PRESENTING PART Avoid presenting part pressure over cord

by digital or manual pressure. Instruct the patient to not to exert

pressure or pushing. Bladder filling with 500 700 ml of

saline. Tocolysis? Inj.Terbutaline 250 microgams

SCly Positioning of the patient:1. Knee chest position2. Trendelenburg position3. Exaggerated Sims or lateral position

TRENDELENBURG POSITION

EXAGGERATED SIM’S POSITION

DO’S AND DON’TS Do’s – Replace the cord into the vagina to

prevent from vasospasm with saline soaked pad

Continuous monitoring of FHR Inform the patient Minimal handling of cord Don'ts – Replace inside the uterus Excessive handling of the cord.

COMMUNITY LEVEL Knee chest face down position Bladder filling with saline In Ambulance – left lateral position Manual elevation – if a nurse or family

physician there Urgent transfer to center with cesarean

facilities and neonatal care.

Stage I of Labor Prepare for Emergency Cesarean section Inform the senior pediatrician Delivery should be done within 30 minutes If fetal death occurs, try for vaginal delivery. Stage II Labor: Expedite delivery with liberal episiotomy

and instrumental delivery. If there is fetal heart disturbance and not in

favor of vaginal delivery plan for Emergency Cesarean section.

Extreme prematurity with cord prolapse:

1. Below or around 24 weeks – counsel the patient.

If she wishes to continue pregnancy if FHR is normal and patient willing for up to 3 weeks

If patient does not agree allow for vaginal delivery with or without oxytocin infusion

FETAL MORTALITY Overall – 50 % First stage of labor – 75 % Second stage – 50 % Neonatal death – 4 % Perinatal mortality – 20 % Asphyxia – Hypoxic ischaemic

encaephlopathy - Cerebral palsy

PROGNOSIS Good with vertex presentation than

Breech. Good in Primigravida than in multi.

RESOURCES - 1 MEDLINE and NHS databases

RCOG Green Top Guidelines

Women’s Hospitals Australasia

Lin MG (2006). Umbilical cord prolapse. Obstetrical and Gynecological Survey 61(4):269-77. Mapp T (2005). Feelings and fears post obstetric emergencies-2. British Journal of Midwifery 13(1):36-40. Mapp T, Hudson K (2005). Feelings and fears during obstetric emergencies-1.

British Journal of Midwifery 13(1):30-5. Murphy DJ, MacKenzie IZ (1995). The mortality and morbidity associated with

umbilical cord prolapse. British Journal of Obstetrics and Gynaecology. 102(10):826-30. National Collaborating Centre for Women’s and Children’s Health (2007).

Intrapartum care: care of healthy women and their babies during childbirth. London: RCOG

Press

RESOURCES - 2 Afolabi BB, Lesi FE, Mera NA (2006). Regional versus general anaesthesia for

caesarean section. Cochrane Database of Systematic Reviews, issue 4. Boyle JJ, Katz VL (2005). Umbilical cord prolapse in current obstetric practice. Journal of Reproductive Medicine 50(5):303-6. Clinical Negligence and Other Risks Scheme (CNORIS 2009). http://www.cnoris.com [Accessed 26 March 2010]. Crofts JF, Ellis D, Draycott TJ et al (2007). Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG: An International Journal of Obstetrics and Gynaecology 114 (12):1534-41. Draycott T, Winter C, Crofts J, et al, eds (2008). Module 8. Cord prolapse in: PROMPT: Practical Obstetric MultiProfessional Training Course Manual. London: RCOG Press:117-

24. Goswami K (2007). Umbilical cord prolapse. In: Grady K, Howell C, Cox C eds. Managing Obstetric Emergencies and Trauma. The MOET course manual 2nd ed. London: RCOG Press: 233-7. Houghton G (2006). Bladder filling: an effective technique for managing cord prolapse. British Journal of Midwifery 14(2):88-9. Katz Z, Shoham Z, Lancet M et al (1988). Management of labor with umbilical cord prolapse: a 5-year study. Obstetrics and Gynecology 72(2):278-81. Koonings PP, Paul RH, Campbell K (1990). Umbilical cord prolapse. A contemporary look. Journal of Reproductive Medicine 35(7):690-2.

Thank You