Cord Prolapse

1. Cord Prolapse

2. Presentation and Prolapse of Umbilical Cord
• A loop of cord is below the presenting part.
Occult Prolapsed : cord is placed by side of the presenting part and is not felt
by the fingers on internal examination.
Cord Presentation : cord is slipped down below the presenting part and is felt
lying in the intact bag of membranes.
Cord Prolapsed : cord is lying inside the vagina or outside the vulva following
rupture of the membranes.

4. Prolapsed Cord
• The umbilical cord lies in the birth canal below the fetal presenting part.
• The umbilical cord is visible at the vagina following rupture of the
membranes.

6. Risks of Cord Prolapse
• Cord is compressed between the presenting part and the pelvic inlet, cervix
and vaginal canal.
• Fetal circulation is compromised.
• This may lead to fetal hypoxia, brain damage and death.

7. Etiology
• Cord prolapse may occur when there is adequate room between the fetal
parts and the maternal pelvis.
• Anything which interferes with perfect adoptation of the presenting part to
the lower uterine segment, disturbing the ball valve action may favour cord
prolapse.

8. Predisposing Factors
• Rupture of membranes before the presenting is engaged in the pelvis.
• More common in abnormal fetal presentation such as shoulder, breech and
foot presentation.
• Transverse lie
• Prematurity
• Polyhydraminous
• Multiple gestation
• Abnormal long cord.
• Contracted pelvis
• Placental factor – minor degree placenta previa with marginal insertion of
the cord.
• Iatrogenic – low rupture of membrane, mannual rotation of head and
version.

9. Diagnosis
Occult prolpse
• Is difficult to diagnose.
• Possibility should be suspected if there is persistence of variable
deceleration of fetal heart rate pattern detected on continuous electronic
fetal monitoring

10. Variable decelerations
• Seen as a rapid fall in baseline rate with a variable recovery
phase
• Variable in their duration & may not have any relationship to
uterine contractions
• Most often seen during labour & in patients with reduced
amniotic fluid volume
• Usually caused by umbilical cord compression
• When pressure on the cord is reduced another acceleration
occurs & then the baseline rate returns
• Can sometimes resolve if the mother changes position
• The presence of persistent variable decelerations indicates the
need for close monitoring

12. Diagnosis
Cord Presentation
• Diagnosis is made by feeling the pulsation of the cord through the intact
membranes.
Cord Prolapse
• Cord is palpated directly by the fingers and its pulsation can be felt if the
contraction passes off.
• Loop of cord may be vesible
• Attempt to pull down the loop for visualization or unnecessary handling is
to be avoided to prevent vasospasm.
• Fetus may be alive even in the absence of the cord pulsation. So prompt
USG for cardiac movement or auscultation for FHS to be done before fetal
death is declared.

13. Management
• Principle of Management are:
• To relieve pressure on the cord
• To find out the fetus is alive or dead
• If alive, to deliver expeditiously
• If dead, and the pelvis and presentation are favourable, to wait
spontaneous delivery.

14. General Management
• If an oxytocin infusion is on, this should be stopped.
• Give oxygen at 4–6 L per minute by mask or nasal cannulae.
• Ensure continue fetal monotoring until in operation theater and
commencing caesarean section or until vaginal delivery.

15. Specific Management
PULSATING CORD
If the cord is pulsating, the fetus is alive.
• Diagnose stage of labour by an immediate vaginal examination
• If the woman is in the first stage of labour, in all cases:
– Wearing high-level disinfected or sterile gloves, insert a hand into the
vagina and push the presenting part up to decrease pressure on the cord
and dislodge the presenting part from the pelvis;
– Place the other hand on the abdomen in the suprapubic region to keep the
presenting part out of the pelvis;
– Once the presenting part is firmly held above the pelvic brim, remove the
other hand from the vagina. Keep the hand on the abdomen until
caesarean section;
– If available, give salbutamol 0.5 mg IV slowly over two minutes to
reduce contractions;
– Perform immediate caesarean section

16. If the woman is in the second stage of labour:
• Expedite delivery with episiotomy and vacuum extraction or forceps ;
• If breech presentation, perform breech extraction and apply Piper or
long forceps to the after-coming head ;
• Prepare for resuscitation of the newborn

17. Cord not Pulsating
• If the cord is not pulsating, the fetus is dead. Deliver in the manner that
is safest for the woman.

18. First aid management
• The aim is to minimise pressure on the cord till such time when the patient
is prepared for assisted delivery or is transferred to an equiped hospital.
• Bladder filling to raise the presenting part off the compressed cord.
• Bladder is filled with 400 – 750 ml of NS. Bladder is emptied before CS.
• Lifting the presenting part off the cord
• Postural treatment
• Replacing the cord into the vagina