Definition
The term ‘cord prolapse’ refers to the descent of the
umbilical cord, following rupture of the membranes,
throu...
of operative births (caesarean sections) and a more
proactive approach to the intrapartum management of
preterm births (Pa...
Obstetric emergencies Umbilical Cord Prolapse
Obstetric emergencies / Umbilical Cord Prolapse 03
First line management
In ...
Obstetric emergencies Umbilical Cord Prolapse
G Where the woman is continuing to have uterine
contractions, this may effec...
Obstetric emergencies Umbilical Cord Prolapse
Obstetric emergencies / Umbilical Cord Prolapse 05
G Handling of umbilical c...
Obstetric emergencies Umbilical Cord Prolapse
Obstetric emergencies / Umbilical Cord Prolapse 06
NHS Litigation Authority ...
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Midirs Cord Prolapse

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Midirs Cord Prolapse

  1. 1. Definition The term ‘cord prolapse’ refers to the descent of the umbilical cord, following rupture of the membranes, through the cervix so that it lies either alongside the fetal presenting part or descends beyond it (Murphy & MacKenzie 1995, Lin 2006, Siassakos et al 2008) (Fig 1). Where the forewaters are still intact, this is defined as a ‘cord presentation’ (Tiran 2006, Siassakos et al 2008). In normal circumstances, the well flexed fetal head moves down into the maternal pelvis during the latter weeks of pregnancy or in early labour, which prevents the descent of the umbilical cord. There are two types of cord prolapse: G Overt prolapse - there is protrusion of the umbilical cord beyond the fetal presenting part. The membranes are invariably ruptured and the cord is either visible or palpable on vaginal examination. G Occult prolapse – the cord descends alongside, but not beyond the presenting part in the presence of intact or ruptured membranes. Definitive diagnosis is difficult, but clinical features of fetal compromise may be indicative of cord prolapse (Siassakos et al 2008). Cord prolapse is usually diagnosed at vaginal examination; however, it may also be suspected in pregnancies considered at increased risk of cord prolapse, and/or where there are abnormal changes in the fetal heart rate pattern, eg variable fetal heart rate decelerations or fetal bradycardia (Koonings et al 1990). It is a life-threatening obstetric emergency because blood flow through the umbilical vessels is often compromised by the compression of the umbilical cord against the fetal presenting part, the cervix and uterus, and the female bony pelvis, which can lead to intrapartum hypoxia, long term morbidity and death (Siassakos et al 2008). Incidence Cord prolapse is not common and the incidence is considered to range from 0.1% to 0.6% of births (Lin 2006, Siassakos et al 2008). However, where cord prolapse occurs in the presence of a breech presentation, this rate increases further to just over 1% of births (Panter & Hannah 1996). Background Cord prolapse is a true obstetric emergency associated with maternal morbidity and perinatal morbidity and mortality. The perinatal mortality rate associated with cord prolapse remains high at around 9%, although the rate has fallen in past decades (Murphy & MacKenzie 1995). This is believed to be due to modern obstetric practices which may have influenced the natural history of cord prolapse (Boyle & Katz 2005). These include the more rapid and frequent use Obstetric emergencies Umbilical Cord Prolapse Obstetric emergencies / Umbilical Cord Prolapse 01 Fig. 1 Prolapsed umbilical cord Fetus Uterus Umbilical cord Cervix
  2. 2. of operative births (caesarean sections) and a more proactive approach to the intrapartum management of preterm births (Panter & Hannah 1996). In unfortunate cases where infant death does occur, this is now more likely to be associated with complications relating to the prematurity of the fetus or its low birth weight, rather than as a result of intrapartum asphyxia (Murphy and MacKenzie 1995, Siassakos et al 2008). The research evidence indicates that the time interval between the diagnosis of cord prolapse and the delivery of the infant is significantly related to fetal outcome and the incidence of stillbirth and neonatal death. Therefore, where a cord prolapse occurs within the community setting, delay in transfer to hospital appears to be a significant factor in fetal prognosis (Murphy & MacKenzie 1995). The anticipation of cord prolapse, its early diagnosis and the effective monitoring of fetal well-being are therefore all crucial aspects of intrapartum care (Koonings et al 1990, Draycott et al 2008). Risk factors linked with cord prolapse The possibility of a cord prolapse occurring should be anticipated where the membranes (forewaters) rupture in any situation and the presenting part is either not fully engaged, or not well applied to the cervix/lower uterine segment. Therefore, the presence of any of the following factors could predispose to cord prolapse: General Related to engagement of the presenting part G Unengaged or poorly applied presenting part G Multiparity – the presenting part may not be engaged G Malpresentation - eg shoulder/compound presentation G High parity/unstable lie – where weakened muscles allow unrestricted movement and the long axis of the fetus is constantly changing eg oblique/transverse lie G Breech presentation – particularly with a footling or complete breech Related to uterine/pelvic factors G Polyhydramnios (also referred to as hydramnios) – an excessive amount of amniotic fluid in pregnancy, means the cord can easily slip down in the ‘gush’ following spontaneous rupture of the membranes (SRM) G Unusually long umbilical cord G Low lying placenta (placenta praevia) or other abnormal implantation of the placenta G Malformation/contracture of the pelvis Related to fetal factors G Prematurity - where the gestation is < 37 completed weeks of pregnancy ie the smaller size of the fetus is significant in relation to the size of the maternal pelvis and malpresentation is more common G Low birth weight/small for gestational age where the birth weight is <2.5 kg (as before) G Second twin – where malpresentation is more commonplace G Fetal congenital malformation Related to clinical procedures It is suggested that around 50% of cord prolapses are preceded by obstetric intervention/manipulation (Usta et al 1999). G Planned artificial rupture of the membranes in the presence of a high presenting part G External cephalic version (ECV) G Manual rotation of the fetus (eg internal rotation of occipito-posterior (OP) position) G Stabilising induction of labour G Application of fetal scalp electrode (FSE) G Internal podalic version of the second twin G Rotational instrumental delivery (Draycott et al 2008, Siassakos et al 2008) Obstetric emergencies / Umbilical Cord Prolapse 02 Obstetric emergencies Umbilical Cord Prolapse
  3. 3. Obstetric emergencies Umbilical Cord Prolapse Obstetric emergencies / Umbilical Cord Prolapse 03 First line management In hospital Where cord prolapse is suspected, the practitioner should perform a vaginal examination without delay and where it is diagnosed, immediately instigate the following measures: G The practitioner needs to remain calm, so that the woman and her partner do not panic/ become distressed. Always endeavour to give explanations of your findings and the emergency measures that might be required. While it can be more difficult in true emergency situations to keep the woman and her partner informed of all events, it is important to gain their informed consent/cooperation for any interventions/ procedures needed. G Use the emergency call bell to summon urgent assistance. The delivery suite coordinator will need to summon the obstetric registrar, anaesthetist, theatre team (for caesarean section) and neonatal paediatrician. G If an intravenous infusion of oxytocin is in progress, this should be discontinued immediately. G Maternal oxygen via non-rebreathing facemask at a rate of 15 litres/min may be given to help increase Po2 levels in the hypoxic fetus. G The practitioner who has diagnosed the cord prolapse should make every effort to try and keep the umbilical cord from being compressed between the presenting part and the woman’s bony pelvis. With their consent, the woman should be assisted into the knee chest position (ie the baby gravitates away from the lower uterine segment) (Fig 2), or helped to lie down in the left lateral with a pillow or make-shift wedge positioned under her left hip (exaggerated Sims position) (Fig 3). The head of the bed may also be lowered (ie Trendelenburg position) to help relieve cord compression. G The practitioner should perform a vaginal examination and, keeping their fingers/gloved hand in the woman’s vagina, make every effort to manually elevate the presenting part and reduce any compression against the umbilical cord. Where SRM occurs at the time of vaginal examination, elevation of the presenting part should be instigated and maintained. This is particularly important during uterine contractions and elevation should continue until delivery (Vago 1970). G Excessive handling of the umbilical cord should be avoided, as this can induce the vessels in the cord to go into spasm. Any handling of the umbilical cord must therefore be kept to an absolute minimum. G Where the cord is presenting outside the woman’s vagina, there is a risk that it can become cooled and dehydrated, and spasm of the cord vessels (vasoconstriction) is more likely to arise. Where possible, the cord should be gently replaced into the woman’s vagina; alternatively it can be kept moistened by gently applying sterile gauze that has been soaked in warmed saline solution (Goswami 2007), although there is little evidence to support this practice (Draycott et al 2008). Fig. 2 Fig. 3
  4. 4. Obstetric emergencies Umbilical Cord Prolapse G Where the woman is continuing to have uterine contractions, this may effect the obstetric plan of care and subsequent management. G Where immediate delivery is not possible (eg during transfer in from the community), insertion of a self-retaining Foley catheter into the bladder and the instillation of 500-750mls of sterile normal saline can help to enlarge the bladder sufficiently, so that it pushes the presenting part above the ischial spines and relieves any compression against the cord (Katz et al 1988, Houghton 2006). NB. The holes at the end of a Foley catheter are small, so attaching an intravenous bag of normal saline to a blood giving set and squeezing the bag of saline, can help to expedite this process. Fetal well-being should be continuously monitored throughout this procedure to help gauge the effectiveness of the intervention. The woman’s bladder will need to be drained immediately before delivery whether this is in theatre prior to caesarean section, or at assisted vaginal birth. G The obstetrician may elect to give a tocolytic to reduce contractions and help alleviate bradycardia where there is a foreseeable delay before delivery. The administration of Terbutaline 0.25mg subcutaneously is suggested (NCCWCH 2007, Draycott et al 2008). G Fetal well-being should be continuously assessed by auscultation of the fetal heart rate using CTG or ultrasound scan. G With maternal consent, two wide bore cannulae (one in each arm) should be inserted and blood obtained for full blood count (FBC), Group & Save (G&S) and cross-match (X match) – if a Jehovah’s Witness, practitioners may need to consider the use of cell saver. G The obstetric registrar will determine the urgency of delivery and the most appropriate mode of delivery: (i) If the cervix is fully dilated and it is considered delivery can be accomplished safely and quickly, then assisted vaginal delivery may be attempted. (ii) Where the baby’s condition is not giving any cause for concern and there is no umbilical cord compression, it may be possible to achieve a regional (spinal) anaesthesia prior to a Category 2 caesarean section. (iii) Where the cord is compressed and/or the fetal heart rate pattern is abnormal, the baby needs to be delivered urgently. In this situation the woman would be advised to undergo a Category 1 caesarean section, with the aim of delivering within 30 minutes. Applying the aforementioned temporary measures to reduce cord compression can enable the use of regional anaesthesia, which is preferable to general anaesthesia (GA) (Afolabi et al 2006). However, the elected method of anaesthesia will ultimately depend on the baby’s condition. (iv) In the event of fetal death, it is usual practice to cease intervention and allow labour to continue to the birth of the baby. G A practitioner who is competent in neonatal resuscitation should attend the delivery, as the need for resuscitation is known to be high (Murphy & MacKenzie 1995). A neonatalogist should be present. G Once the baby has been delivered, paired (arterial and venous) cord bloods should be obtained for blood gas analysis, pH and base excess measurement (NCCWCH 2007, Draycott et al 2008). In the community G Where cord prolapse occurs in the community and the woman is alone, she should be advised over the phone to adopt the knee-chest position while awaiting paramedic assistance. G Where the midwife diagnoses cord prolapse in the woman’s home, they should call 999 for immediate paramedic assistance and prepare the woman for urgent transfer by ambulance into the nearest consultant led maternity unit. G Women being transferred into hospital by ambulance will need to lie in the left lateral position as they will need to be strapped into the ambulance stretcher. G Elevation of the presenting part (whether manually or by bladder filling) should be maintained during transfer. It is recommended that community-based midwives carry a Foley catheter and a giving set for this purpose (Siassakos et al 2008). Obstetric emergencies / Umbilical Cord Prolapse 04
  5. 5. Obstetric emergencies Umbilical Cord Prolapse Obstetric emergencies / Umbilical Cord Prolapse 05 G Handling of umbilical cord presenting outside the woman’s vagina should be kept to an absolute minimum. Implications for practice G In the presence of known risk factors, practitioners should always anticipate the potential for cord prolapse occurring. G Practitioners need to be aware of the maternal morbidity and perinatal morbidity and mortality associated with cord prolapse. G The practitioner diagnosing a cord prolapse should summon emergency assistance immediately. Where this is in hospital, the obstetric registrar and delivery suite coordinator should be in attendance. If the cervix is not fully dilated, arrangements should be made for urgent delivery by caesarean section. G If a fetal heart rate is not present and the umbilical cord is not pulsating (non pulsatile), prompt ultrasound assessment for viability should be undertaken. G Following delivery, umbilical arterial and venous cord blood should be obtained for blood gas analysis, pH and base excess measurement (NCCWCH 2007, Siassakos et al 2008). G Contemporaneous and accurate documentation of events, including the relevant times, names of practitioners present and their designation, care/interventions/obstetric manipulations undertaken, clinical decisions made and outcomes should be completed in accordance with Nursing and Midwifery Council (NMC) best practice guidance for record keeping (NMC 2009). G A clinical incident AIMS (Accident and Incident Management System) form should be completed for the attention of the Maternity Risk Manager. G Practitioners should be aware that because cord prolapse requires a rapid, often operative birth, the woman and her partner can sustain psychological trauma that might affect their ability to bond with their baby, cause postnatal depression (PND) or leave them with a fear of childbirth. Debriefing and support from a practitioner competent in counselling should always be offered (Mapp 2005, Mapp & Hudson 2005). G Debriefing can also be helpful for the maternity staff involved. G The safe management of cord prolapse demands a high level of clinical and interpersonal skills from all practitioners involved. G On-site, annual multiprofessional (practical) obstetric emergency training has been found to enhance skills and knowledge retention, clinical performance, team communication and improve perinatal outcomes (Draycott et al 2006, Crofts et al 2007, Siassakos et al 2009a, Siassakos et al 2009b). G Cord prolapse guidelines are mandated by the Clinical Negligence Scheme for Trusts (CNST) Maternity Risk Management Standards (NHSLA 2009), Welsh Risk Pool (Welsh Risk Pool 2005), and Clinical Negligence and Other Risks Scheme (CNORIS 2009). References 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. 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 umbili- cal 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.
  6. 6. Obstetric emergencies Umbilical Cord Prolapse Obstetric emergencies / Umbilical Cord Prolapse 06 NHS Litigation Authority (2009). Clinical Negligence Scheme for Trusts maternity clinical risk management standards. Version 2. 2009/10. London: NHS Ligitation Authority. Nursing and Midwifery Council (2009). Record keeping: guidance for nurses and midwives. London: NMC Panter KR, Hannah ME (1996). Umbilical cord prolapse: so far so good? Lancet 347(8994):74. Siassakos D, Fox R, Draycott TJ (2008). Umbilical Cord Prolapse [Green-top Guideline No. 50]. London: RCOG Press. Siassakos D, Crofts JF, Winter C et al (2009a). The active components of effective training in obstetric emergencies. BJOG: An International Journal of Obstetrics and Gynaecology 116 (8):1028-32. Siassakos D, Hasafa Z, Sibanda T et al (2009b). Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG: An International Journal of Obstetrics and Gynaecology 116 (8):1089-96. Tiran D (2006). Baillière’s Midwives’ Dictionary. 10th ed. London: Baillière Tindall: 264. Usta IM, Mercer BM, Sibai BM et al (1999). Current obstetrical practice and umbilical cord prolapse. American Journal of Perinatology 16 (9):479-84. Vago T (1970). Prolapse of the umbilical cord. A method of management. American Journal of Obstetrics and Gynecology 107:967-9. Welsh Risk Pool (2005). Standard 15: Maternity, Version 3. Suggested additional reading Fraser DM, Cooper MA eds (2009). Myles textbook for midwives. 15th ed. Edinburgh: Churchill Livingstone: 627-9. Kinsella SM, Scrutton MJL (2009). Assessment of a modified four-category classification of urgency of caesarean section. Journal of Obstetrics and Gynaecology 29(2):110-13. McGeown P (2001). Practice recommendations for obstetric emergencies. British Journal of Midwifery 9 (2):71-3. Patterson C (2005). Managing cord prolapse at a home birth. Practising Midwife 8(9):34-5. Rogers C, Schiavone N (2008). Cord prolapse audit: recognition, management and outcome. British Journal of Midwifery 16(5):315-18. Thurlow JA, Kinsella SM (2002). Intrauterine resuscitation: active management of fetal distress. International Journal of Obstetric Anesthesia 11(2):105-16. Weston R (2001). When birth goes wrong. Practising Midwife 4(8):10-12. Useful resources Practical Obstetric Multiprofessional Training (PROMPT) and associated resources, includes a downloadable cord prolapse proforma: http://www.prompt-course.org/home.htm

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