ARTICLE OF OBSTETRICS PROBLEM

CORD PROLAPSE
Umbilical cord prolapse is where the umbilical cord descends through the
cervix, with (or before) the presenting part of the fetus. It affects 0.1 – 0.6% of
births.

Cord prolapse occurs in the presence of ruptured membranes, and is either

occult or overt:

 Occult (incomplete) cord prolapse – the umbilical cord descends alongside the
presenting part, but not beyond it.
 Overt (complete) cord prolapse – the umbilical cord descends past the
presenting part and is lower than the presenting part in the pelvis.
 Cord presentation – the presence of the umbilical cord between the presenting
part and the cervix. This can occur with or without intact membranes.

Although the incidence is relatively low, the mortality rate for such babies is high
(~91 per 1000). This is largely because cord prolapse occurs more frequently
in preterm babies, who are often breech, and who may also have
other congenital defects.

In this article, we shall look at the risk factors, clinical features and management
of cord prolapse.
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.

Risk Factors
The main risk factors for cord prolapse include:
 Breech presentation – in a footling breech, the cord can easily slip between and
past the fetal feet and into the pelvis.
 Unstable lie – this is where the presentation of the fetus changes between
transverse/oblique/breech and back.
o If >37 weeks gestation, consider inpatient admission until delivery due to risk of
cord prolapse
 Artificial rupture of membranes – particularly when the presenting part of the
fetus is high in the pelvis.
 Polyhydramnios – excessive amniotic fluid around the fetus
 Prematurity

Clinical Features and Differential Diagnosis

Cord prolapse should always be considered in the presence of a non-
reassuring fetal heart rate pattern and absent membranes. It can be confirmed
by external inspection or on digital vaginal examination. This is one of the
reasons that vaginal assessment, after abdominal examination, encompasses
a full assessment in the presence of a non-reassuring fetal heart rate pattern.

The fetal heart rate patterns can vary from subtle changes, such as
decelerations with some of the contractions, to more obvious signs of fetal
distress, such as a fetal bradycardia. The latter is strongly associated with
cord prolapse; relating to the mechanism of occlusion of the cord by the
presenting part.

An alternative diagnosis may be considered in the presence of bleeding per

vagina or heavily blood-stained liquor with ruptured membranes. This would
suggest placental abruption (the placenta starts to separate from the uterine
wall) or vasa praevia (fetal vessels running in the fetal membranes adjacent to
the internal os of the cervix).
Management
Firstly, call for help – umbilical cord prolapse is an obstetric emergency. It
should be managed as follows:

 Avoid handling the cord to reduce vasospasm.

 Manually elevate the presenting part by lifting the presenting part off the cord
by vaginal digital examination. Alternatively, if in the community, fill the maternal
bladder with 500ml of normal saline (warmed if possible) via a urinary catheter
and arrange immediate hospital transfer.
 Encourage into left lateral position with head down and pillow placed under left
hip OR knee-chest position. This will relieve pressure off the cord from the
presenting part.
 Consider tocolysis (e.g. terbutaline) – if delivery is not imminently available this
will relax the uterus and stop contractions, relieving pressure off the cord. It may
be sufficient to allow enough time for transfer to a location where delivery is
feasible (e.g. an operating theatre for a Caesarean section). This is a particularly
useful strategy if there are fetal heart rate abnormalities while preparing for a C-
section.
 Delivery is usually via emergency Caesarean section
o If fully dilated and vaginal delivery appears imminent, encourage pushing or
consider instrumental delivery.
o If at threshold for viability (23 + 0 weeks – 24 + 6 weeks) and extreme prematurity,
expectant management may be discussed due to significant maternal morbidity
with caesarean at this gestation and poor fetal outcomes.

PLACENTA PREVIA
Placenta Previa: Symptoms, Causes, and Treatment
Placenta Previa is a condition where the placenta lies low in the
uterus and partially or completely covers the cervix. The placenta
may separate from the uterine wall as the cervix begins to dilate
(open) during labor.
How Common Is Placenta Previa?
Placenta previa affects about 1 in 200 pregnant women in the third
trimester of pregnancy.
Placenta Previa is more common in women who have had one or
more of the following:
 More than one child
 A cesarean birth
 Surgery on the uterus
 Twins or triplets
What Are The Different Types Of Placenta Previa?
 Complete Previa: the cervical opening is completely covered
 Partial Previa: a portion of the cervix is covered by the placenta
 Marginal Previa: extends just to the edge of the cervix
What Are The Symptoms Of Placenta Previa?
 Signs and symptoms of placenta previa vary, but the most common
symptom is painless bleeding during the third trimester.
Other Reasons To Suspect Placenta Previa Would Be:
 Premature contractions
 Baby is breech, or in a transverse position
 Uterus measures larger than it should according to gestational age
What Is The Treatment For Placenta Previa?
Once diagnosed, placenta previa will usually require bed rest for the
mother and frequent hospital visits. Depending on the gestational
age, steroid shots may be given to help mature the baby’s lungs. If the
mother experiences bleeding that cannot be controlled, immediate
cesarean delivery is usually done regardless of the length of the
pregnancy. Some marginal previas can be delivered vaginally,
although complete or partial previas would require a cesarean
delivery.
Most physicians recommend women who are experiencing Placenta
Previa to:
 Avoid intercourse
 Limit traveling
 Avoid pelvic exams
What Causes Placenta Previa?
The exact cause of Placenta Previa is unknown.
However, the following can increase your risk:
 If over the age of 35
 Had more than four pregnancies
 Have a history of uterine surgery (regardless of incision type)
How Do I Cope With Placenta Previa?
With all the excitement and anticipation of a healthy delivery,
receiving the diagnosis of placenta previa can be a very shocking and
frustrating experience. There are support groups for bed
rest mothers and even some for mothers with placenta previa. They
are available to help you through this difficult time. Your
doctor, midwife, or doula should be able to assist you in finding
support groups or other women who have also had placenta previa.
 PREMATURE RUPTURE OF MEMBRANE

Premature rupture of membranes (PROM) is a rupture (breaking

open) of the membranes (amniotic sac) before labor begins. If
PROM occurs before 37 weeks of pregnancy, it is called preterm
premature rupture of membranes (PPROM).
PROM occurs in about 8 to 10 percent of all pregnancies. PPROM
(before 37 weeks) accounts for one fourth to one third of all preterm
births.
What causes premature rupture of membranes?
Rupture of the membranes near the end of pregnancy (term) may
be caused by a natural weakening of the membranes or from the
force of contractions. Before term, PPROM is often due to an
infection in the uterus. Other factors that may be linked to PROM
include the following:
 Low socioeconomic conditions (as women in lower socioeconomic
conditions are less likely to receive proper prenatal care)
 Sexually transmitted infections, such as chlamydia and gonorrhea
 Previous preterm birth
 Vaginal bleeding
 Cigarette smoking during pregnancy
 Unknown causes
Why is premature rupture of membranes a concern?
PROM is a complicating factor in as many as one third of premature
births. A significant risk of PPROM is that the baby is very likely to
be born within a few days of the membrane rupture. Another major
risk of PROM is development of a serious infection of the placental
tissues called chorioamnionitis, which can be very dangerous for
 mother and baby. Other complications that may occur with PROM
include placental abruption (early detachment of the placenta from
the uterus), compression of the umbilical cord, cesarean birth, and
postpartum (after delivery) infection.
What are the symptoms of PROM?
The following are the most common symptoms of PROM. However,
each woman may experience symptoms differently. Symptoms may
include:
 Leaking or a gush of watery fluid from the vagina
 Constant wetness in underwear
If you notice any symptoms of PROM, be sure to call your doctor as
soon as possible. The symptoms of PROM may resemble other
medical conditions. Consult your doctor for a diagnosis.
How is premature rupture of membranes diagnosed?
In addition to a complete medical history and physical
examination, PROM may be diagnosed in several ways, including
the following:
 An examination of the cervix (may show fluid leaking from the
cervical opening)
 Testing of the pH (acid or alkaline) of the fluid
 Looking at the dried fluid under a microscope (may show a
characteristic fern-like pattern)
 Ultrasound. A diagnostic imaging technique that uses high-
frequency sound waves and a computer to create images of blood
vessels, tissues, and organs. Ultrasounds are used to view internal
organs as they function, and to assess how much fluid is around the
baby.
Treatment for premature rupture of membranes
 Specific treatment for PROM will be determined by your doctor
based on:
 Your pregnancy, overall health, and medical history
 Extent of the condition
 Your tolerance for specific medications, procedures, or therapies
 Expectations for the course of the condition
 Your opinion or preference
Treatment for premature rupture of membranes may include:
 Hospitalization
 Expectant management (in very few cases of PPROM, the
membranes may seal over and the fluid may stop leaking without
treatment, although this is uncommon unless PROM was from a
procedure, such as amniocentesis, early in gestation)
 Monitoring for signs of infection, such as fever, pain, increased
fetal heart rate, and/or laboratory tests.
 Giving the mother medications called corticosteroids that may help
mature the lungs of the fetus (lung immaturity is a major problem
of premature babies). However, corticosteroids may mask an
infection in the uterus.
 Antibiotics (to prevent or treat infections)
 Tocolytics. Medications used to stop preterm labor.
 Women with PPROM usually deliver at 34 weeks if stable. If there
are signs of abruption, chorioamnionitis, or fetal compromise, then
early delivery would be necessary.)
Prevention of premature rupture of membranes
Unfortunately, there is no way to actively prevent PROM. However,
this condition does have a strong link with cigarette smoking and
mothers should stop smoking as soon as possible.

REFLECTION

CORD PROLAPSE
A delay in management of cord prolapse (where a loop of umbilical cord
is below the presenting part and the membranes are ruptured) is associated
with significant perinatal morbidity and mortality. It is acknowledged as
a serious obstetric emergency. The main aim of management is to relieve
pressure on the cord from the presenting part digitally and/or through the
technique of bladder filling.
Several risk factors are associated with cord prolapse :  Unengaged or
poorly applied presenting part  Obstetric interventions (eg. amniotomy,
vaginal manipulation of fetus, external cephalic version) 
Malpresentations (breech/shoulder/transverse or oblique lie/compound
presentation)  Prematurity and low birth weight  Polyhydramnios 
Second twin  Fetal congenital abnormalities (eg. anencephaly) 
Abnormal placentation  Multiparity.

PLACENTA PREVIA
Placenta previa is a pregnancy problem in which
the placenta blocks the cervix. The placenta is a round, flat organ
that forms on the inside wall of the uterus soon after conception.
During pregnancy, it gives the baby food and oxygen from the
mother.
In a normal pregnancy, the placenta is attached high up in the
uterus, away from the cervix. In placenta previa, the placenta
forms low in the uterus and covers all or part of the cervix.
If placenta previa is present during labor and delivery, it can cause
problems for both mother and baby.
 The mother may lose a lot of blood, which can be dangerous for
both her and her baby.
 The placenta may separate too early from the wall of the uterus.
This is called placenta abruptio, and it can cause serious
bleeding, too.
 The baby may be born too early (premature), at a low birth
weight, or with a birth defect.
PREMATURE RUPTURE OF MEMBRANE

Premature rupture of membranes (PROM) refers to a patient who

is beyond 37 weeks' gestation and has presented with rupture of
membranes (ROM) prior to the onset of labor. Preterm premature
rupture of membranes (PPROM) is ROM prior to 37 weeks'
gestation. Spontaneous preterm rupture of the membranes
(SPROM) is ROM after or with the onset of labor occurring prior to
37 weeks. Prolonged ROM is any ROM that persists for more than
24 hours and prior to the onset of labor.
At term, programmed cell death and activation of catabolic
enzymes, such as collagenase and mechanical forces, result in
ruptured membranes. Preterm PROM occurs probably due to the
same mechanisms and premature activation of these pathways.