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Cord prolapse


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Cord prolapse

  1. 1. Umbilical cord prolapse and presentation Definition The umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby, where it may lie adjacent to the presenting part (occult cord prolapse) or below the presenting part (overt cord prolapse).
  2. 2. Cord prolapse – It is associated with rupture of membranes •In occult prolapse, the umbilical cord cannot be palpated during pelvic examination, whereas •Overt cord prolapse is displacement of the umbilical cord into the vagina, often through the introitus. Cord or Funic presentation, which is characterized by prolapse of the umbilical cord below the level of the presenting part before the rupture of membranes occurs, the cord often can be easily palpated through the membranes.
  3. 3. ETIOLOGY Premature delivery of the baby Multiple gestation (twins, triplets, etc.) Multiparity Excessive amniotic fluid (polyhydramnios) Fetal malpresentation(Breech delivery) Long umbilical cord: Premature rupture of the amniotic sac Consequences- Loss of oxygen to the fetus, brain damage, and Stillbirth.
  4. 4. Clinical Findings Occult prolapse: ois rarely palpated during pelvic examination. oThis condition can be inferred only if fetal heart rate changes - Bradycardia (a heart rate of less than 120 beats per minute). Overt cord prolapse : ocan be diagnosed simply by visualizing the cord protruding from the introitus or by palpating loops of cord in the vaginal canal by fingers. Funic presentation ois made by pelvic examination if loops of cord are palpated through the membranes.
  5. 5. Prevention •Patients at risk for umbilical cord prolapse should be treated as high-risk patients. Patients with mal-presentations or poorly applied cephalic presentations should be considered for ultrasonographic examination at the onset of labor to determine fetal lie and cord position within the uterine cavity. •Because most prolapses occur during labor as the cervix dilates, patients at risk for cord prolapse should be continuously monitored to detect abnormalities of the fetal heart rate. •Artificial rupture of membranes should be avoided until the presenting part is well applied to the cervix.
  6. 6. • At the time of spontaneous membrane rupture, a prompt, careful pelvic examination should be performed to rule out cord prolapse. • Should amniotomy be required and the presenting part remains unengaged, careful needling of the membranes and slow release of the amniotic fluid can be performed until the presenting part settles against the cervix.
  7. 7. Management Overt Cord Prolapse •The diagnosis of overt cord prolapse demands immediate action to preserve the life of the fetus. •An immediate pelvic examination should be performed to determine cervical effacement and dilatation, station of the presenting part, and strength and frequency of pulsations within the cord vessels •If the fetus is viable, the patient should be placed in the knee– chest position, and the examiner should apply continuous upward pressure against the presenting part to lift and maintain the fetus away from the prolapsed cord until preparations for cesarean delivery are complete.
  8. 8. • Alternatively, 400–700 mL of saline can be instilled into the bladder in order to elevate the presenting part. • Oxygen should be given to the mother until the anesthesiologist is prepared to administer a rapid-acting inhalation anesthetic for delivery. • If heart rate changes, should not delay preparation for cesarean delivery and a pediatric team should be on standby in the event immediate resuscitation of the newborn is necessary.
  9. 9. Occult Cord Prolapse •If occult cord prolapse is suspected, the patient should be placed in the lateral Sims or trendelenburg position in an attempt to alleviate cord compression. •If the fetal heart rate returns to normal, labor can be allowed to continue, provided no further fetal insult occurs. •Oxygen should be administered to the mother, and the fetal heart rate should be continuously monitored electronically. •If the cord compression pattern persists or recurs to the point of fetal jeopardy (moderate to severe variable decelerations or bradycardia), a rapid cesarean section should be accomplished
  10. 10. lateral Sims or trendelenburg position
  11. 11. Funic Presentation •The patient at term with funic presentation should be delivered by cesarean section prior to membrane rupture. •However, there is no consensus on management if the fetus is premature. •The most conservative approach is to hospitalize the patient on bed rest in the Sims or Trendelenburg position in an attempt to reposition the cord within the uterine cavity. •Serial ultrasonographic examinations should be performed to ascertain cord position, presentation, and gestational age.
  12. 12. Route of Delivery •Vaginal delivery can be successfully accomplished in cases of overt or occult cord prolapse if, at the time of prolapse, the cervix is fully dilated, cephalopelvic disproportion is not anticipated, and an experienced physician determines that delivery is imminent. •Cesarean delivery is the preferred route of delivery in most cases. Vaginal delivery is the route of choice for the previable or dead fetus. 14
  13. 13. Prognosis Maternal • Maternal complications include those related to anesthesia, blood loss, and infection following cesarean section or operative vaginal delivery. Maternal recovery is generally complete Neonatal • If the diagnosis is made early and the duration of complete cord occlusion is less than 5 minutes, the prognosis is good. • If complete cord occlusion has occurred for longer than 5 minutes or if intermittent partial cord occlusion has occurred over a prolonged period of time, fetal damage or death may occur. 15