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Umbilical cord prolapse - Dr.Suresh Babu Chaduvula
 

Umbilical cord prolapse - Dr.Suresh Babu Chaduvula

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    Umbilical cord prolapse - Dr.Suresh Babu Chaduvula Umbilical cord prolapse - Dr.Suresh Babu Chaduvula Presentation Transcript

    • Dr.Suresh Babu Chaduvula Professor 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
    •  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.
    •  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.
    •  Identify predisposing risk factors  Enable prompt diagnosis and institute immediate action  Initiate correct emergency procedures  Raise awareness of the neonatal implications
    •  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.
    •  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
    •  Related 1. 2. 3. 4. to Uterine and Pelvic factors: Polyhydramnios Long umbilical cord Low lying placenta Contracted Pelvis
    •  Related to Fetal factors: 1. Prematurity 2. Low Birth Weight 3. Second twin 4. Congenital malformations
    •  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
    •  Other causes 1. PROM 2. Male fetuses 3. Anomalies of uterus
    •  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 :
    •  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
    •  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
    •  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
    •  Discontinue  Oxygen  CORD 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
    •  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 position 2. Trendelenburg position 3. Exaggerated Sims or lateral position
    • 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.
    •  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
    •  Overall – 50 %  First stage of labor – 75 %  Second stage – 50 %  Neonatal death – 4 %  Perinatal mortality – 20 %  Asphyxia – Hypoxic ischaemic encaephlopathy - Cerebral palsy
    •  Good with vertex presentation than Breech.  Good in Primigravida than in multi.
    •  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         
    •                      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