Dr.Suresh Babu Chaduvula
Department of Obstetrics & Gynecology
King Khalid University
Abha, Saudi Arabia
To provide information and practical guidance to
enable early diagnosis and efficient initiation of
emergency procedures to ensure the best
possible neonatal outcome
cord presentation: Presence of
cord in front of presenting part before the
rupture of membranes.
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.
prolapse – Cord lies adjacent to the
presenting part, but not beyond the
presenting part in the presence of intact or
without intact membranes.
prolapse – cord which is visible or
palpable with naked eyes following rupture
predisposing risk factors
Enable prompt diagnosis and institute
Initiate correct emergency procedures
Raise awareness of the neonatal implications
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.
engagement of fetal head:
1.Unengaged or poorly applied presenting part
2. High parity - weak muscles
3. Unstable lie – weak muscles
5. Breech presentations
to Uterine and Pelvic factors:
Long umbilical cord
Low lying placenta
to Fetal factors:
2. Low Birth Weight
3. Second twin
4. Congenital malformations
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
2. Male fetuses
3. Anomalies of uterus
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
Maternal morbidity :
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
examination for malpresentation
and cord presentation.
Avoid ARM in unengaged head
Routinely doing PVE following spontaneous
rupture of membranes.
Controlled ARM in poly hydramnios –
Bradycardia and variable decelerations - do
either vaginal examination or speculum
upon viability of the fetus and
absence of fetal malformations.
Quick action should be taken to expedite the
Survival of fetus depends on swift action
Prepare for Emergency interventions like
Cesarean section and or Instrumental
Multidisciplinary approach or Team work is
IV oxytocin infusion
by mask – 15 lits/ mt
– C – call for help
- O – organize for delivery
- R – Relieve pressure
- D – Delivery
Funic repositioning: with soaked warm saline
reposition into vagina
presenting part pressure over cord by
digital or manual pressure.
Instruct the patient to not to exert pressure
Bladder filling with 500 700 ml of saline.
Tocolysis? Inj.Terbutaline 250 microgams SCly
Positioning of the patient:
1. Knee chest position
2. Trendelenburg position
3. Exaggerated Sims or lateral position
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
Replace inside the uterus
Excessive handling of the cord.
chest face down position
Bladder filling with saline
In Ambulance – left lateral position
Manual elevation – if a nurse or family
Urgent transfer to center with cesarean
facilities and neonatal care.
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
If there is fetal heart disturbance and not in
favor of vaginal delivery plan for Emergency
prematurity with cord prolapse:
1. Below or around 24 weeks – counsel the
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
– 50 %
First stage of labor – 75 %
Second stage – 50 %
Neonatal death – 4 %
Perinatal mortality – 20 %
Asphyxia – Hypoxic ischaemic encaephlopathy
- Cerebral palsy
with vertex presentation than Breech.
Good in Primigravida than in multi.
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