Umbilical Cord prolapse

1. CORD PROLAPSE
Dr. massam
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2. Objectives
• Definition of Cord Prolapse
• Identify risk factors/causes of Cord Prolapse
• Describe pathogenesis of Cord Prolapse
• Describe clinical features and complications of Cord Prolapse
• Describe the differential diagnoses of Cord Prolapse
• Treat the patient according to guidelines of Cord Prolapse
• Describe preventive measures for Cord Prolapse
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3. Introduction
• Umbilical cord prolapse is when the umbilical cord comes out of the
uterus with or before the presenting part of the baby.
• The concern with cord prolapse is that pressure on the cord from the
baby will compromise blood flow to the baby.
• It usually occurs during labor but can occur anytime after the rupture
of membranes
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4. Introduction…
• Management focuses on quick delivery, usually by cesarean section
• Filling the bladder or pushing up the baby by hand is recommended
until this can take place.
• A knee-chest position or the Trendelenburg position in order to help
prevent further cord compression.
• Cord prolapse is one of the many causes of fresh stillbirth that needs
appropriate management
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5. Introduction…
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6. Introduction…
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7. Definition
• Cord prolapse is where the umbilical cord lies or falls in front of or
beside the presenting part in the presence of ruptured membranes,
into the birth canal.
OR
• Defined as a descent of the umbilical cord into the lower uterine
segment where it may lie adjacent to the presenting part or below
the presenting part, without intact fetal membranes.
NB: When the membranes are intact, it is called CORD PRESENTATION.
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8. Types
• Occult cord prolapse
• Cord is adjacent to the presenting part
• Cannot be palpated during pelvic examination.
• Might lead to variable decelerations or unexplained fetal distress, rupture of
membranes, and displacement of the cord through the vagina.
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9. Types…
• Funic (cord) presentation
• Prolapse of the umbilical cord below the level of the presenting part
before the rupture of fetal membranes
• Cord can often be easily palpated through the membranes
• Often the harbinger of cord prolapse
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10. Types…
•Overt cord prolapse
• Umbilical cord lies below the presenting part
• Associated with rupture of membranes, and displacement of the cord
through the vagina.
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11. Types…
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12. Epidemiology
• The incidence of occult cord prolapse is unknown because it can be
detected only by fetal heart rate changes characteristic of umbilical
cord compression.
• Overall Incidence of overt cord prolapse is between 0.1% to 0.6%,
where it is:-
• 0.5% in cephalic presentation
• 0.5% frank breech
• Complete breech 5%
• Footling breech 15%, and
• Transverse lie 20%
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13. Causes/Risk factors
• FETAL FACTORS
• Prematurity & IUGR
• Abnormal lies
• Malpresentation
• Fetal anomaly
• Multiple pregnancy
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14. Causes/Risk Factors Cont.….
• MATERNAL
• Rupture of membranes
• Spontaneous (including preterm ROM)
• Amniotomy (ARM)
• Pelvic tumors e.g cervical fibroid
• Pelvic contraction
• Preterm labour
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15. Causes/Risk Factors Cont.….
• PLACENTAL
• Polyhydramnios
• Minor degree of placenta previa
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16. Causes/Risk Factors Cont.….
• PROCEDURE- RELATED
• Amniotomy
• External Cephalic Version
• Internal Podalic Version
• Stabilizing Induction of labor
• Applying fetal scalp electrode
• Amnion infusion
• Placement of a cervical ripening balloon catheter
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17. Pathophysiology
• Umbilical cord prolapse is where the umbilical cord descends through
the cervix, with (or before) the presenting part of the fetus.
Subsequently, fetal hypoxia occurs via two main mechanisms:
• Occlusion – The presenting part of the fetus presses onto the
umbilical cord, occluding blood flow to the fetus.
• Arterial vasospasm – The exposure of the umbilical cord to the cold
atmosphere results in umbilical arterial vasospasm, reducing blood
flow to the fetus.
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18. Clinical Features
• Non-reassuring fetal heart rate pattern
• Absent membranes on presenting part (confirmed by external
inspection or on digital vaginal examination)
• Fetal bradycardia
• Bleeding per vagina or heavily blood-stained liquor with ruptured
membranes
• Fundal pressure causes bradycardia
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19. Clinical Features…
Cord Prolapse 19

20. Diagnosis
• Cord presentation and prolapse may occur without outward physical
signs and can only be suspected during clinical examinations
• An abnormal fetal heart rate pattern may suggest overt or occult cord
prolapse (bradycardia and marked variable decelerations )
• In the presence of ruptured membranes, particularly if such changes
occur soon after membrane rupture, spontaneously or with
amniotomy
• Confirmed by VAGINAL EXAMINATION
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21. Diagnosis…
• Sudden appearance of a loop of umbilical cord at the introitus, usually
just after membrane rupture
• May palpate cord during a vaginal examination in the absence of
intact membranes
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22. Diagnosis…
• NB: Cord (Funic) Presentation can also be diagnosed with USS before
the onset or during early labour but the USS is not sufficiently
sensitive or specific for identification of cord presentation ante-natally
and should not be performed routinely to predict cord prolapse
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23. Differential Diagnosis
• Cord presentation, sometimes felt below the presenting part when
membranes are intact.
• True Cord Knots
• An intertwining of a segment of umbilical cord,
• Circulation is usually not obstructed,
• commonly formed by the fetus slipping through a loop of the cord.
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24. Differential Diagnosis…
True Knot Presentation 24

25. Differential Diagnosis…
• Nuchal Cord
• The umbilical cord is wrapped around the neck of the fetus in utero or of the
baby as it is being born.
• It is usually possible to slip the loop or loops of cord gently over the child's
head.
• The condition occurs in more than 25% of deliveries, more often with long
cords than with short ones.
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26. Differential Diagnosis…
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27. Treatment and Management
Elevation of presenting part
Knee chest position.
Exaggerated Simms position-left lateral
supported with two pillows
Stop oxytocin
Reassure patient
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28. Treatment and Management…
OCCULT PROLAPSE
• Immediate vaginal examination to rule out cord prolapse
• Left lateral position
• Oxygen to the mother
• Discontinue oxytocin infusion if in place
• Allow labour to progress if foetal Heart rate returns to normal and no further
insult.
• Continuous foetal heart rate monitoring
• Amnioinfusion
• Caesarean Section if cord compression pattern continues prior to membrane
rupture
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29. Treatment and Management…
• If the baby is at term deliver by C/S prior to membrane rupture.
• If the baby is premature there is No consensus on management
• Hospitalize patient on bed rest in Sim’s position or Trendelenburg position
• Serial USS to ascertain cord position, presentation and GA
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30. Treatment and Management…
CORD PROLAPSE
The three components of management are:-
1. Prevent or relieve cord compression and vasospasm
2. Fetal assessment
3. Prompt delivery of the infant
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31. Treatment and Management…
1. Prevent/relieve cord compression and vasospasm
• Gently replace in the vagina if outside the vagina
• Adjust maternal position
• Manual replacement, Manual elevation and Funic reduction
N/B: There should be minimal handling of loops of cord lying outside
the vagina cover in surgical packs soaked in warm saline. Rough
handling of the cord, and colder temperature outside the vagina can
lead to vasospasm.
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32. Treatment and Management…
• It is essential to empty the bladder again just before any
delivery attempt, be it vaginal or CS.
• Physiologically inhibits uterine contraction. There may be
contractions but not strong enough for the presenting part to
effectively compress the cord. Tocolytics can also be used for this
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33. Treatment and Management…
• Maternal Position Adjustment
• Knee-chest position (Genu-pectoral)
• Gives maximum elevation of the presenting part.
• Provides good initial evaluation of the presenting part.
• A tiring posture to maintain.
• If any length of time is involved, move to the Sim’s lateral position
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34. Treatment and Management…
• Sim’s lateral position
• More relaxed and dignified for the patient.
• Elevate buttocks with pillow
• Trendelenburg position
• A head-down tilt.
• Very tiring
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35. 35

36. Treatment and Management…
• 2. FETAL ASSESSMENT
• IS THE BABY VIABLE?
• Interventions for fetal reasons are not necessary for:
• Already dead baby
• Too immature to survive (e.g. before age of fetal viability)
• Lethal fetal anomaly (e.g. anencephaly)
• In these cases, allow labor to progress and deliver vaginally unless there’s a
contraindication to vaginal delivery
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37. Treatment and Management…
• IF BABY IS ALIVE
• Quickest way to tell is by palpating the presence or absence of pulsations in
the cord.
• Beware of mistaking folds of membranes or tips of fetal fingers and toes for
the cord. Or clinician’s finger pulsation.
• Absent pulsations should be confirmed between contractions in case cord
compression is released and pulsations return.
• Fetal heart auscultation best determines whether or not the fetus is alive.
Electronic fetal heart monitoring using fetal scalp electrode may be useful.
• Real-time USS if available
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38. Treatment and Management…
• 3. PROMPT DELIVERY
• CERVIX FULLY DILATED
• Vaginal birth can be attempted at full dilatation if it is anticipated that
delivery would be accomplished within 20 minutes from diagnosis.
• Depending on the circumstances, this may involve delivery by forceps,
vacuum or breech extraction.
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39. Treatment and Management…
CERVIX NOT FULLY DILATED
• An immediate Caesarean Section (usually within 30 minutes) is the
recommended mode of delivery in cases of cord prolapse when
vaginal delivery is not imminent, in order to prevent hypoxia-acidosis.
• Some investigators have noted that the interval to delivery had little
effect on Apgar scores if they delivered within 30 minutes.
• The presenting part should be kept elevated during induction of
anesthesia and placement of sterile sheets.
• Remember to drain bladder and recheck for fetal hear rates before
incision.
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40. Treatment and Management…
• A practitioner competent in the resuscitation of the newborn, usually
a neonatologist, should attend all deliveries with cord prolapse.
• Neonates born after cord prolapse are at significant risk of needing
neonatal resuscitation, as evidenced by a high rate of low APGAR
scores (<7)
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41. Prognosis
• The prognosis is, however, related with the interval between its
detection and delivery of the baby and if the delivery is completed,
within 10–30 minutes the fetal mortality can be reduced to 5–10%.
The overall perinatal mortality is about 15–50%.
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42. Prevention
• Women with transverse, oblique or unstable lie should be offered
elective admission to hospital at 37 weeks of gestation, or sooner if
there are signs of labor or suspicion of ruptured membranes.
• Women with non-cephalic presentations and preterm pre-labour
rupture of the membranes should be offered admission.
• Labour or ruptured membranes of an abnormal lie is an indication for
caesarean section.
• Bradycardia or variable fetal heart rate decelerations have been
associated with cord prolapse and their presence should prompt
vaginal examination.
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43. Prevention…
• Artificial rupture of membranes should be avoided whenever possible
if the presenting part is unengaged and mobile.
• Mismanagement of abnormal fetal heart rate patterns is the
commonest feature of substandard care identified in perinatal death
associated with cord prolapse
• Speculum and/or a digital vaginal examination should be performed
when cord prolapse is suspected, regardless of gestation.
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44. Key Points
• Umbilical cord prolapse occurs when the cord descends through the
cervix and is alongside or below the presenting part of the fetus.
• It is an obstetric emergency, with a fetal mortality rate
• The diagnosis should be suspected in any patient with a non-
reassuring fetal heart trace and absent membranes.
• Manage by manually elevating the presenting part, and deliver via the
quickest mode (usually Caesarean section).
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45. Evaluation
1. What are the causes/risk factors for cord prolapse?
2. What are the difference between cord prolapse and cord
presentation?
3. What are the best lie position for a patient with cord prolapse?
4. How can you manage a patient with cord prolapse?
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46. Key Reference
i. Gynecology by Ten teachers
ii. Jones, D. (1992), Fundamentals of Obstetrics and Gynecology, 1sted, ELBS
iii. Massawe R, et al, Management of Obstetrics Emergencies and Obstetrics,
1984
iv. Myles, M. (1999), Textbook for Midwives, 13thed, Churchill Livingstone
v. Obstetrics and Gynecology by Dutta
vi. Obstetrics by Ten teachers
vii. MoHCDGEC/ NACTE (2016). Curriculum for Technician Certificate (NTA Level 5)
Curriculum, Dodoma.
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47. Self Study Assignment
• How does changing the patient position help in management of a
patient with cord prolapse?
• What are the complications of cord prolapse?
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