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Received: 10 July 2020    Revised: 20 August 2020    Accepted: 20 August 2020
DOI: 10.1111/aogs.13985
ORIGINAL RESEARCH ARTICLE
Bradycardia-to-delivery interval and fetal outcomes in
umbilical cord prolapse
Lo Wong | Wing T. Tse | Chit Y. Lai | Annie S. Y. Hui | Piya Chaemsaithong |
Daljit S. Sahota | Liona C. Poon | Tak Y. Leung
Department of Obstetrics and Gynecology,
The Chinese University of Hong Kong, Hong
Kong, Hong Kong
Correspondence
Tak Y. Leung, Department of Obstetrics
and Gynecology, Prince of Wales Hospital,
Shatin, Hong Kong.
Email: tyleung@cuhk.edu.hk
Abbreviations: IQR, interquartile range.
© 2020 Nordic Federation of Societies of Obstetrics and Gynecology (NFOG). Published by John Wiley & Sons Ltd
Acta Obstet Gynecol Scand. 2020;00:1–8. 
Abstract
Introduction: Umbilical cord prolapse is a major obstetric emergency associated with
significant perinatal complications. However, there is no consensus on the optimal
decision-to-delivery interval, as many previous studies have shown poor correlation
between the interval and umbilical cord arterial blood gas or perinatal outcomes. We
aim to investigate whether bradycardia-to-delivery or decision-to-delivery interval
was related to poor cord arterial pH or adverse perinatal outcome in umbilical cord
prolapse.
Material and methods: This was a retrospective study conducted at a university ter-
tiary obstetric unit in Hong Kong. All women with singleton pregnancy complicated
by cord prolapse during labor between 1995 and 2018 were included. Women were
categorized into three groups. Group 1: persistent bradycardia; Group 2: any type of
decelerations without bradycardia; and Group 3: normal fetal heart rate. The main
outcome was cord arterial blood gas results of the newborns in different groups.
Maternal demographic data and perinatal outcomes were reviewed. Correlation anal-
ysis between cord arterial blood gas result and time intervals including bradycardia-
to-delivery, deceleration-to-delivery, and decision-to-delivery were performed for
the different groups with Spearman test.
Results: There were 34, 30, and 50 women in Groups 1, 2, and 3, respectively. Cord
arterial pH and base excess did not correlate with decision-to-delivery interval in any
of the groups, but they were inversely correlated with bradycardia-to-delivery inter-
val in Group 1 (Spearman’s ρ = −.349; P = .043 and Spearman's ρ = −.558; P = .001,
respectively). The cord arterial pH drops at 0.009 per minute with bradycardia-
to-delivery interval in Group 1 (95% CI 0.0180-0.0003). The risk of significant aci-
dosis (pH < 7) was 80% when bradycardia-to-delivery interval was >20 minutes, and
17.2% when the interval was <20 minutes.
Conclusions: There is significant correlation between bradycardia-to-delivery inter-
val and cord arterial pH in umbilical cord prolapse with fetal bradycardia but not in
cases with decelerations or normal heart rate. The drop of cord arterial pH is rapid
and urgent delivery is essential in such situations.
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KEYWORDS
bradycardia-to-delivery interval, cord arterial pH, decision-to-delivery interval, fetal
bradycardia, umbilical cord prolapse
1 |  I NTRO D U C TI O N
Umbilical cord prolapse is an unpredictable obstetric emergency
with an incidence ranging from 1 to 6 per 1000 pregnancies.1-5
However, it remains to be a significant cause of perinatal com-
plications, with reported perinatal mortality rates ranging from
1,6-8
6% to 10% in developed countries, and 23% to 27% in some
developing countries in Africa.9,10 Prematurity and birth asphyxia
account for the majority of adverse perinatal outcomes in umbili-
cal cord prolapse. The diagnosis of cord prolapse is made when the
membranes have ruptured and the cord is found below or beside
the fetal presenting part on vaginal examination.11 Cord compres-
sion by the fetal presenting part and umbilical arterial vasospasm
are the two main mechanisms leading to fetal hypoxia and birth
asphyxia. Hence, rapid delivery is generally accepted as an impor-
tant life-saving intervention, and for reducing the risk of hypoxic
11
brain injury and subsequent cerebral palsy. However, there is
no consensus on the optimal decision (or diagnosis)-to-delivery
interval, as many previous studies have shown poor correlation
between decision-to-delivery interval and umbilical cord arterial
12-15
blood gas or perinatal outcomes. A paradoxical result of im-
proved Apgar scores with longer decision-to-delivery interval has
also been reported.16
The lack of correlation between decision-to-delivery inter-
val and umbilical cord arterial blood gas or perinatal outcomes
in these studies could be explained partly by their small sample
size, and partly by the fact that the decision-to-delivery inter-
val is not the actual duration of fetal hypoxia. The occurrence of
cord prolapse and the onset of fetal hypoxia might have occurred
sometime before the diagnosis or decision for delivery was made.
Hence, it has been proposed that bradycardia-to-delivery inter-
val is a more accurate predictor of perinatal outcomes.17 We have
previously shown that the cord arterial pH and base excess dete-
riorate rapidly with bradycardia-to-delivery interval and do not
correlate with decision-to-delivery interval, in cases where fetal
distress was due to a group of irreversible pathologies, including
placental abruption, uterine rupture, cord prolapse, preeclampsia,
and failed instrumental delivery.18 Yet, the number of cases with
cord prolapse in the previous study was limited. Further, there
is a paucity of literature reporting on the relationship between
the perinatal outcomes and fetal heart rate patterns other than
bradycardia in the event of cord prolapse. This study focused spe-
cifically on cord prolapse, with the aims of investigating the dif-
ferent presentation of fetal heart rate abnormalities during cord
prolapse, and whether bradycardia-to-delivery interval or deci-
sion-to-delivery interval was related to poor cord pH or adverse
perinatal outcome.
Key message
In case of cord prolapse resulting with fetal bradycardia,
cord arterial pH deteriorates at 0.009 per minute of brad-
ycardia-to-delivery interval. The risk of severe acidosis
(pH  <  7) was 80% when this is ≥20  minutes, and 17.2%
when it is <20 minutes.
2 | M ATE R I A L A N D M E TH O DS
This was a retrospective study conducted in a university tertiary re-
ferral obstetric unit from 1 January 1995 to 31 December 2018. The
study unit had an annual delivery rate of approximately 6000-7000
during the study period.19 All women who had delivery in the study
unit had routine continuous intrapartum cardiotocogram monitor-
ing, which was interpreted according to the guidelines of the Royal
College of Obstetricians and Gynaecologists. 20
All singleton pregnancies complicated by umbilical cord pro-
lapse during delivery were identified from the hospital Obstetric
Specialty Clinical Information System, which is a clinical database
recording maternal and perinatal outcome information for all
women delivering at the obstetric unit. 21,22 Umbilical cord prolapse
was diagnosed with the descent of the umbilical cord through the
cervix alongside (occult) or past (overt) the fetal presenting part
in the presence of ruptured membranes.11 Other inclusion criteria
were low-risk pregnancies with normal fetal heart rate before onset
of labor or at the start of labor. Women with cord presentation, de-
fined as the presence of umbilical cord between the fetal present-
ing part and the cervix with or without ruptured membrane,11 cord
prolapse in multiple pregnancies, and cases with other co-existing
causes of fetal hypoxia (such as placental abruption, intrauterine
infection, fetal growth, or structural abnormalities) were excluded
from the study.
Once umbilical cord prolapse was diagnosed, treatment was
prompt delivery; the mode of delivery depended on the fetal pre-
sentation and degree of cervical dilatation at diagnosis. Two operat-
ing theatres for immediate delivery were available continuously with
on-site 24-hour emergency anesthetic support. Every emergency
cesarean section with fetal distress was attended by neonatologists.
Umbilical cord arterial and venous blood samples were collected at
the time of delivery for blood gas analysis routinely in the study unit
as described previously. 23,24 The timings of all major events, includ-
ing the onset of fetal heart rate abnormalities, decision of delivery,
and birth, were clearly documented in the medical notes.
WONG et al.
Maternal demographic data, including maternal age, ethnicity,
height, body weight, and previous obstetric history, which were col-
lected at the booking visits, were retrieved from the clinical data-
base. Perinatal outcomes including gestational age at delivery, mode
of delivery, fetal presentation, birthweight, Apgar scores, and cord
arterial blood gas results were also retrieved. Medical notes of all
eligible cases were reviewed by an experienced obstetrician to ob-
tain details of the cardiotocogram tracing and the time of diagnosis
of cord prolapse, as well as decision for crash cesarean delivery, the
degree of cervical dilatation at decision making, maneuvers used to
reduce cord compression after diagnosis, the time of birth, and um-
bilical cord arterial blood gas result.
The cardiotocogram tracing of each case was reviewed and cat-
egorized into three different groups according to the fetal heart
rate pattern at the initial assessment and diagnosis of umbilical
cord prolapse, regardless of possible subsequent deterioration or
improvement with different maneuvers: Group 1: persistent brady-
cardia defined as fetal heart rate <110 beats per minute for 5 min-
utes; Group 2: any type of deceleration but without bradycardia;
and Group 3: normal. In all three groups, decision-to-delivery inter-
val was defined as the period from decision of delivery to delivery.
In Group 1, bradycardia-to-delivery interval was the period from
the onset of bradycardia-to-delivery; and in Group 2, decelera-
tion-to-delivery interval from the onset of decelerations to delivery.
2.1 | Statistical analyses
Correlation analysis between cord arterial blood gas results and
bradycardia-to-delivery interval, deceleration-to-delivery interval,
and decision-to-delivery interval were performed for the different
groups using the Spearman test. Comparisons were made between
groups with regard to maternal demographics, delivery intervals, ma-
neuvers applied for the umbilical cord prolapse, and perinatal out-
comes using Kruskal-Wallis test for continuous variables and Pearson
chi-squared test for categorical variables. The rate of drop of pH with
bradycardia-to-delivery in Group 1 was estimated by linear regres-
sion analysis. The level of significance was set at a two-sided P < .05.
Data analysis was performed with SPSS version 22.0 (SPSS).
2.2 | Ethical approval
Ethical approval was obtained from the Joint Chinese University of
Hong Kong—New Territories East Cluster Clinical Research Ethics
Committee (reference 2019.637) on 20 December 2019.
3 | R E S U LT S
In total, 132 women with umbilical cord prolapse were identified
during the study period; during this time there were 153 363 births,
giving an incidence of 0.1%. Thirteen women with twin pregnancies
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were excluded from the study. Cord blood gases were not available
in three cases because of insufficient sampling or machine failure
and cardiotocogram tracing was not performed in two cases, leaving
114 women for final analysis. The arterial cord pH and base excess
of these 114 women were all validated.
The median maternal age of the study cohort was 33 (interquar-
tile range [IQR] 27-35) and 47 (41.2%) women were nulliparous. The
median gestational age at delivery was 38 weeks (IQR 37-40) and 22
(19.3%) women delivered before 37 weeks of gestation. The median
birthweight was 3160 g (IQR 2700-3468 g). There was malpresenta-
tion in 32 women (28.1%) and 112 (98.2%) women were delivered by
cesarean delivery with 103 (90.4%) under general anesthesia while
the rest were under spinal anesthesia. The overall median deci-
sion-to-delivery interval for the study cohort was 11.0 minutes (IQR
9.0-14.0  minutes). The overall median cord arterial pH was 7.217
(IQR 7.089-7.261) and it was less than 7 in 14 cases (12.3%).
The cases were then classified according to the initial cardioto-
cogram tracing as stated in our method. Thirty-four (29.8%) and 30
(26.3%) women presented with sudden and persistent fetal bradycar-
dia (Group 1), and deceleration of fetal heart rate (Group 2), respec-
tively. Fifty (43.9%) women presented with a normal fetal heart rate
tracing, when cord prolapse was found during vaginal examination or
following rupture of membranes (Group 3). Table  1 summarizes the
demographic characteristics of all women with umbilical cord prolapse
in the three groups. There was no statistically significant difference
between groups in terms of parity, maternal age, cervical dilatation
at time of diagnosis, cesarean delivery rate, the use of general anes-
thesia, and birthweight. However, Group 3 had a higher frequency of
non-cephalic pregnancies (11.8% vs 10.0% vs 50.0%; P  <  .001) and
lower gestational age at delivery (39 vs 39 vs 38 weeks; P = .028).
The median bradycardia-to-delivery interval of Group 1 was
significantly shorter than the median deceleration-to-delivery inter-
val in Group 2 (15.0  minutes; IQR 12.0-17.0  minutes vs 23.0  min-
utes; IQR 15.0-51.3 minutes; P < .001). In Group 1, cord arterial pH
and base excess were significantly inversely correlated with bra-
dycardia-to-delivery interval (Spearman’s ρ  =  −.349; P  =  .043 and
Spearman’s ρ = −.558; P = .001, respectively; Table 2). The rate of
drop of pH with bradycardia-to-delivery interval in Group 1 esti-
mated by linear regression analysis was 0.009 per minute (95% CI
0.0180-0.0003). The bradycardia-to-delivery interval was <20 min-
utes in 29 cases and 5 of the 29 cases (17.2%) had severe acidosis
(cord arterial pH  <  7). Only five cases had bradycardia-to-delivery
interval ≥20  minutes, all but one case (80%) had severe acidosis.
The number of newborns with severe acidosis was significantly
higher compared with cases with bradycardia-to-delivery interval
<20 minutes (P = .003). In Group 2, neither the cord arterial pH nor
base excess was correlated with deceleration-to-delivery interval
(Table  2). The changes of pH with bradycardia-to-delivery interval
and deceleration-to-delivery interval are shown in Figure 1. Hence,
the incidence of cord arterial pH < 7 was highest in Group 1 (26.5%)
when compared with Group 2 (16.7%) and Group 3 (0%; P = .001)
even though cases in Group 1 were delivered in a shorter decision-
to-delivery interval. The median decision-to-delivery interval was
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4       WONG et al.

TA B L E 1   Maternal demographics,
Group 1 (n = 34) Group 2 (n = 30) Group 3 (n = 50) P-value
delivery intervals and perinatal outcomes
Nulliparity 18 (52.9) 13 (43.3) 16 (32) .154a  in different groups of umbilical cord
Maternal age (y) 32 [27-36] 33 [29-34] 32 [28-37] .574b  prolapse (Group 1: persistent bradycardia;
Group 2: recurrent decelerations; Group
Gestation at 39 [38-40] 39 [38-40] 38 [34-40] .028b 
3: normal fetal heart rate)
delivery (wk)
Non-cephalic 4 (11.8) 3 (10) 25 (50.0) <.001a 
presentation
Cervical dilation 3 (2-5) 3 (2-4) 2 (2-3) .178
(cm)
Birthweight (g) 3298 [2978-3503] 3195 [2783-3500] 2950 [2360-3306] .066b 
Cesarean delivery 32 (94.1) 30 (100) 50 (100) .091a 
General 32 (100) 28 (93.3) 43 (86.0) .071a 
anesthesia
Bradycardia/ 5.0 [3.0-7.0] 10.0 [3.8-40.0] NA .012b 
deceleration-to-
decision interval
(min)
Decision-to- 10.0 [9.0-11.0] 12.5 [9.0-15.0] 12.5 [10.0-17.0] .010 b 
delivery interval
(min)
Bradycardia/ 15.0 [12.0-17.0] 23.0 [15.0-51.3] NA <.001b 
deceleration-to-
delivery interval
(min)
Cord arterial pH 7.111 7.201 7.245 [7.190-7.283] <.001b 
[6.990-7.213] [7.040-7.243]
Cord arterial 9 (26.5) 5 (16.7) 0 (0) .001a 
pH < 7
Cord arterial base −10.05 [−13.3 to −6.80 [−11.0 to −6.00 [−9.6 to .040 b 
excess (mmol/L) −7.3] −4.0] −4.0]
Apgar score at 9 [5-9] 8 [7-9] 8 [7-9] .471b 
1 min
Apgar score at 9 [9-10] 10 [8-10] 10 [8-10] .450 b 
5 min
Neonatal death 2 (5.9) 0 (0) 1 (2.0) .318a 

Note: Data are n (%) or median [interquartile range].

a
Pearson chi-squared test.
b
Kruskal-Wallis H test.

also shortest in Group 1 (10.0 minutes; IQR 9.0-11.0 minutes) when
compared with Groups 2 and 3 (12.5  minutes for both; P  =  .010).
There was no correlation between decision-to-delivery interval and
pH or base excess in any of the three groups, except that pH was
positively correlated with decision-to-delivery interval in Group 2.
In 92 cases (80.7%), application of different maneuvers was docu-
mented to reduce cord compression, as shown in Table  3. Manual el-
evation of the fetal presenting parts (94.6%) was the most commonly
performed maneuver, followed by Trendelenburg position (44.6%), knee-
chest position (5.4%), and wrapping the prolapsed cord with warm packs
(3.3%). Filling of the urinary bladder was not performed in our cohort.
There was no major maternal postoperative complication. There
were three cases of neonatal death (2.6%), which were associated with
extreme premature gestational age at 24, 25, and 26  weeks of ges-
tation. The 24- and 26-week cases presented with fetal bradycardia
(Group 1). The 24-week infant was delivered by assisted vaginal breech
delivery with bradycardia-to-delivery interval of 10  minutes. The
cord arterial pH was 7.150 and the infant died on day 12 of life. The
26-week infant was delivered by crash lower segment cesarean deliv-
ery with bradycardia-to-delivery interval of 19 minutes and the cord ar-
terial pH was 7.280; the infant died on day 3 of life. The 25-week infant
had normal cardiotocogram (Group 3) and was delivered by emergency
classical cesarean delivery with decision-to-delivery interval of 29 min-
utes. The cord arterial pH was 7.334 and the infant died on day 12 of
life. The causes of death were related to complications from extreme
prematurity rather than as a direct result of the umbilical cord prolapse.
Long-term follow-up data of the infants were available in 13 of
14 cases with significant acidosis (pH < 7), and in 89 cases of the 111
alive cases (80.2%) of the whole cohort. Only one case developed
cerebral palsy and died at the age of 2 years. The case presented
WONG et al. |
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TA B L E 2   Correlation between umbilical cord blood gas parameters with various delivery intervals in different groups of umbilical cord
prolapse (Group 1: persistent bradycardia; Group 2: recurrent decelerations; Group 3: normal fetal heart rate) using Spearman's ρ test
(ρ = Correlation Coefficient)

Group 1 Group 3
All (n = 114) (n = 34) Group 2 (n = 30) (n = 50)

pH vs decision-to-delivery interval Spearman's ρ (P-value) .318 (.001) −.049 (.785) .389 (.034) .292 (.055)
pH vs bradycardia/deceleration-to-delivery Spearman's ρ (P-value) NA NA −.349 (.043) .112 (.554) NA
interval
Base excess vs decision-to-delivery interval Spearman's ρ (P-value) .115 (.241) −.330 (.057) .215 (.254) .100 (.515)
Base excess vs bradycardia/deceleration-to- Spearman's ρ (P-value) NA NA −.558 (.001) .055 (.772) NA
delivery interval

Note: Data are Spearman's ρ (P-value).

F I G U R E 1   A, Change of cord arterial pH with bradycardia-to-delivery interval in Group 1 umbilical cord prolapse. B, Change of cord
arterial pH with deceleration-to-delivery interval in Group 2 umbilical cord prolapse

TA B L E 3   Different maneuvers applied

Group 1 Group 2 Group 3 P-
in in different groups of umbilical cord
All (n = 114) (n = 34) (n = 30) (n = 50) value
prolapse (Group 1: persistent bradycardia;
Group 2: recurrent decelerations; Group Maneuvers not 22 5 6 11 —
3: normal fetal heart rate) to relieve cord recorded
compression Maneuvers recorded 92 29 24 39 —
Manual elevation of 83 (90.2) 26 (89.7) 23 (95.8) 34 (87.2) .749a 
fetal presenting part
Trendelenburg 43 (46.7) 14 (48.3) 14 (58.3) 15 (38.5) .557a 
position
Knee-chest position 5 (5.4) 1 (3.4) 0 (0) 4 (10.3) .390a 
Wrapping with warm 2 (2.2) 1 (3.4) 1 (4.2) 0 (0) .801a 
packs
Filling of urinary 0 (0) 0 (0) 0 (0) 0 (0) —
bladder

Note: Data are presented as n (% per cases with maneuvers documented in the medical notes).
a
Kruskal-Wallis H test.
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6       WONG et al.
with fetal bradycardia with the infant in oblique cephalic presenta-
tion and emergency cesarean section was performed at 40 weeks
of gestation with bradycardia-to-delivery interval of 30  minutes.
The cord arterial pH was 6.940 and base excess was −23 at birth.
4 |  D I S CU S S I O N
Our study has shown that when cord prolapse occurs, there are three
categories of fetal heart rate patterns including bradycardia, recur-
rent decelerations, and normal. In the first scenario, cord arterial pH
deteriorates rapidly at 0.009 per minute from the onset of brady-
cardia. In the case of recurrent decelerations and normal fetal heart
rate, there is no significant correlation between cord blood gas and
deceleration-to-delivery interval or decision-to-delivery interval.
Our study is distinguished from previous studies on umbilical cord
prolapse, which focused only on decision-to-delivery interval and
12-15
could not demonstrate any correlation with perinatal outcome.
Tan et al could not demonstrate any association between cord arte-
rial pH and decision-to-delivery interval in their small cohort of 34
cases.12 Murphy et al reported that prolonged decision-to-delivery
interval (>30  minutes) was associated with a low Apgar score (<7)
at 5  minutes, but not with a low cord pH (<7), the latter being an
essential criterion for establishing a causal relationship between in-
trapartum fetal distress and cerebral palsy. 2,25,26 A Ugandan study
demonstrated a higher perinatal mortality rate of 53.5% after 30 min-
utes of decision-to-delivery interval, compared with 12.1% when de-
cision-to-delivery interval was within 30  minutes.9 However, such
high perinatal mortality rates may be related to a prolonged period
of fetal hypoxia before the patients were transferred to the hospitals
for decision of delivery, and hence their result may not be applicable
to developed countries.1,4,7 Faiz et al demonstrated a contradictory
result of improved Apgar score at 5 minutes when decision-to-deliv-
16
ery interval was longer than 20 minutes. This paradoxical phenom-
enon was also demonstrated in Group 2, and likely resulted from a
selection bias, in which the severe cases with poorer outcome were
delivered urgently, whereas mild cases with good outcome tended to
17,18
be delivered less urgently. Only when we analyzed according to
different fetal heart rate patterns and defined the time period from
the onset of bradycardia, was the correlation revealed.
We recognized that in umbilical cord prolapse, the fetal heart
may present with persistent bradycardia (29.8%) or recurrent de-
celerations (26.3%), or it may be normal (43.9%). Recurrent decel-
erations can be explained by intermittent cord compression during
uterine contractions, resulting in variable or late decelerations or a
combination of both. During uterine relaxation, the fetal heart rate
will return to normal. On the other hand, there are multiple path-
omechanisms for persistent bradycardia. In addition to cord com-
pression, there may be umbilical vasospasm,11 possibly stimulated by
27
cooling or drying of the umbilical cord in the ex utero environment.
Therefore, the fetal heart rate would not recover even if the cord
compression was relieved. These findings have strong implications
on acute management. In simple cord compression with recurrent
decelerations, the mainstay of management is to avoid further cord
compression and expulsion. Trendelenburg, knee-chest position, and
acute tocolysis serve both of these purposes. With Trendelenburg
and knee-chest positions, the direction of cord expulsion is opposite
to gravity. Tocolytics may reduce intrauterine pressure, which may
push the umbilical cord outwards. 28 On the other hand, although
urinary bladder filling may help to disengage the fetal head and re-
duce cord compression, 29 it alone cannot prevent cord expulsion.
A normal fetus can usually tolerate transient and intermittent hy-
poxia. As long as the fetal heart rate is continuously monitored and
there is no subsequent deterioration, a decision-to-delivery interval
within 30 minutes is acceptable, according to the Royal College of
Obstetricians and Gynaecologists guideline on umbilical cord pro-
lapse and classification of urgency of cesarean section.11,30 Quick
delivery is desirable in all cases of umbilical cord prolapse but the
risks of an urgent delivery should be balanced against the risk of
worsening hypoxemia. The risks are not as high in cases with normal
fetal heart rate or decelerations only without bradycardia. Spinal an-
esthesia is an option as general anesthesia usually carries a higher
risk of maternal complications in an emergent setting.31-33
On the other hand, once vasospasm has occurred resulting in per-
sistent bradycardia, delivery in a short time is critical to prevent ad-
verse perinatal outcome. Cord arterial pH drops at 0.009 per minute,
which is similar to our previously reported rate of 0.011 per minute in
other irreversible causes such as abruptio placentae and shoulder dys-
tocia.18,34 Hence, a decision-to-delivery interval of less than 15 min-
utes (or bradycardia-to-delivery interval of less than 20  minutes)
should be achieved to minimize the chance of significant fetal acidosis.
While arranging crash cesarean delivery, simple and quick maneuvers
like Trendelenburg or knee-chest position should still be applied to re-
lieve cord compression, though they are not very effective in reversing
vasospasm. Urinary bladder filling is time consuming and emptying of
the bladder is required before cesarean delivery; hence it is not a good
option in such scenarios.29,35 In our setting, it has a limited role as the
transfer of women to the operation theatre is usually fast, reflected by
the median decision-to-delivery interval of 11 minutes.
To shorten bradycardia-to-delivery interval or decision-to-deliv-
ery interval, adequate training is essential but may not be sufficient.36
Siassakos et al showed that after training for umbilical cord prolapse
management, the median decision-to-delivery interval drops signifi-
cantly from 25 to 14.5  minutes.37 Copson et al7 showed that the
decision-to-delivery interval before and after training remain at
16 minutes, being similar to the post-training decision-to-delivery in-
terval of Siassakos et al In our cohort, we achieved an overall median
decision-to-delivery interval of 11 minutes, which is consistent with
our previous report,18 and is significantly shorter than the above two
studies. This may be related to the availability of two operation the-
atres inside our labor ward, and an on-site obstetric anesthetist is
available anytime. These variations in reported decision-to-delivery
interval imply, while training may enhance human factor in improv-
ing and maintaining a relatively short decision-to-delivery interval of
around 15 minutes, as shown in the studies by Siassakos et al37 and
Copson et al,7 the efficiency of staff may be limited by the availability
WONG et al.
of facilities. Resources to enhance facilities are needed to obtain a
breakthrough in shortening decision-to-delivery interval.
The major strength of our study is a large cohort of 114 cases,
which had complete results for cord blood gases and well-defined
onset of abnormal fetal heart rate pattern. Therefore, it allowed us to
analyze based on three different fetal heart rate patterns. However,
the smaller number in Group 2 may fail to reveal a significant correla-
tion between drop of pH and deceleration-to-deliver interval. The
limitation of our study is its retrospective nature. To reduce bias,
we had excluded from our cohort any cases with other co-existing
causes of fetal hypoxia. The maternal characteristics, such as parity,
gestational age, and the mode of delivery, were also similar across
the three groups, except that Group 3 consisted of more non-cephal-
ic-presenting pregnancies; although this is unlikely to cause any bias
towards the finding of correlation between bradycardia-to-delivery
interval and poor outcome in Group 1. Although our cohort consists
of cases over past 20 years, the acute management of cord prolapse
had not changed, and our reported decision-to-delivery interval is as
short as we reported 12 years ago.18 As it is not feasible to conduct
a randomized controlled trial or prospective study in such an unpre-
dictable emergency, the results from our large retrospective cohort
are valuable to guide clinical management.
5 | CO N C LU S I O N
When umbilical cord prolapse occurs, fetuses may present with per-
sistent bradycardia, or recurrent decelerations, or normal heart rate.
Cord arterial pH does not drop significantly with decision-to-delivery
interval. In cases of fetal bradycardia, cord arterial pH deteriorates sig-
nificantly with bradycardia-to-delivery interval, with a rapid drop of
0.009 per minute. The risk of significant acidosis (pH < 7) was 80%
when bradycardia-delivery interval was >20 minutes; but only 17.2%
when the interval was <20 minutes. Urgent delivery is essential in such
situations. In cases with recurrent decelerations, cord arterial pH does
not change significantly with the deceleration-to-delivery interval.
C O N FL I C T O F I N T E R E S T
The authors have stated explicitly that there are no conflicts of inter-
est in connection with this article.
ORCID
Tak Y. Leung  https://orcid.org/0000-0002-9153-0343
REFERENCES
1. Gibbons C, O’Herlihy C, Murphy JF. Umbilical cord prolapse—
changing patterns and improved outcomes: a retrospective cohort
study. BJOG. 2014;121:1705-1708.
2. Murphy DJ, MacKenzie IZ. The mortality and morbidity as-
sociated with umbilical cord prolapse. Br J Obstet Gynaecol.
1995;102:826-830.
3. Uygur D, Kiş S, Tuncer R, Ozcan FS, Erkaya S. Risk factors and infant
outcomes associated with umbilical cord prolapse. Int J Gynaecol
Obstet. 2002;78:127-130.
|
      7
4. Kahana B, Sheiner E, Levy A, Lazer S, Mazor M. Umbilical
cord prolapse and perinatal outcomes. Int J Gynaecol Obstet.
2004;84:127-132.
5. Dilbaz B, Ozturkoglu E, Dilbaz S, Ozturk N, Sivaslioglu AA, Haberal
A. Risk factors and perinatal outcomes associated with umbilical
cord prolapse. Arch Gynecol Obstet. 2006;274:104-107.
6. Lagrew DC, Bush MC, McKeown AM, Lagrew NG. Emergent (crash)
cesarean delivery: indications and outcomes. Am J Obstet Gynecol.
2006;194:1638-1643.
7. Copson S, Calvert K, Raman P, Nathan E, Epee M. The effect of a
multidisciplinary obstetric emergency team training program, the
In Time course, on diagnosis to delivery interval following umbili-
cal cord prolapse—a retrospective cohort study. Aust N Z J Obstet
Gynaecol. 2017;57:327-333.
8. Critchlow CW, Leet TL, Benedetti TJ, Daling JR. Risk factors and
infant outcomes associated with umbilical cord prolapse: a popu-
lation-based case-control study among births in Washington State.
Am J Obstet Gynecol. 1994;170:613-618.
9. Wasswa EW, Nakubulwa S, Mutyaba T. Fetal demise and associ-
ated factors following umbilical cord prolapse in Mulago hospital,
Uganda: a retrospective study. Reprod Health. 2014;11:12.
10. Bako B, Chama C, Audu BM. Emergency obstetrics care in a Nigerian
tertiary hospital: a 20 year review of umbilical cord prolapse. Niger
J Clin Pract. 2009;12:232-236.
11. Royal College of Obstetricians and Gynecologists. Green-top
Guideline No. 50 Umbilical cord prolapse 2014. https://www.
rcog.org.uk/en/guide​l ines​- resea​r ch-servi​c es/guide​l ines/​g tg50/.
Accessed July 8, 2020
12. Tan WC, Tan LK, Tan HK, Tan AS. Audit of 'crash' emergency cae-
sarean sections due to cord prolapse in terms of response time and
perinatal outcome. Ann Acad Med Singapore. 2003;32:638-641.
13. Khan RS, Naru T, Nizami F. Umbilical cord prolapse—a review of di-
agnosis to delivery interval on perinatal and maternal outcome. Pak
Med Assoc. 2007;57:487-491.
14. Gabbay-Benziv R, Maman M, Wiznitzer A, Linder N, Yogev Y.
Umbilical cord prolapse during delivery—risk factors and pregnancy
outcome: a single center experience. J Matern Fetal Neonatal Med.
2014;27:14-17.
15. Katz Z, Shoham Z, Lancet M, Blickstein I, Mogilner BM, Zalel Y.
Management of labor with umbilical cord prolapse: a 5-year study.
Obstet Gynecol. 1988;72:278-281.
16. Faiz SA, Habib FA, Sporrong BG, Khalil NA. Results of delivery in
umbilical cord prolapse. Saudi Med J. 2003;24:754-757.
17. Leung TY, Lao TT. Timing of caesarean section according to ur-
gency. Best Pract Res Clin Obstet Gynaecol. 2013;27:251-267.
18. Leung TY, Chung PW, Rogers MS, Sahota DS, Lao TT, Hung Chung
TK. Urgent cesarean delivery for fetal bradycardia. Obstet Gynecol.
2009;114:1023-1028.
19. Cheng YK, Lao TT, Sahota DS, Leung VK, Leung TY. Use of birth
weight threshold for macrosomia to identify fetuses at risk of shoul-
der dystocia among Chinese populations. Int J Gynaecol Obstet.
2013;120:249-253.
20. Royal College of Obstetricians and Gynaecologists. NICE guideline
on intrapartum care for healthy women and babies 2014. https://
www.nice.org.uk/guida​nce/cg190. Accessed July 8, 2020
21. Leung TY, Leung TN, Sahota DS, et al. Trends in maternal obesity
and associated risks of adverse pregnancy outcomes in a population
of Chinese women. BJOG. 2008;115:1529-1537.
22. Leung TY, Stuart O, Suen S, Sahota D, Lau TK, Lao T. Comparison
of perinatal outcomes of shoulder dystocia alleviated by different
type and sequence of manoeuvres: a retrospective review. BJOG.
2011;118:985-990.
23. Leung TY, Lok I, Tam WH, Leung TN, Lau TK. Deterioration in
cord blood gas status during the second stage of labour is more
 |
8       WONG et al.
rapid in the second twin than in the first twin. Br J Obstet Gynaecol.
2004;111:546-549.
24. Leung TY, Tam WH, Leung TN, Lok I, Lau TK. Effect of twin-to-twin
delivery interval on umbilical cord blood gas in the second twins.
BJOG. 2002;109:63-67.
25. American College of Obstetricians and Gynecologists. Neonatal en-
cephalopathy and cerebral palsy: defining the pathogenesis and patho-
physiology, 1st edn. Washington, DCACOG; 2003.
26. Kelly R, Ramaiah SM, Sheridan H, et al. Dose-dependent relation-
ship between acidosis at birth and likelihood of death or cerebral
palsy. Arch Dis Child Fetal Neonatal Ed. 2018;103:F567-F572.
27. Barrett JM. Funic reduction for the management of umbilical cord
prolapse. Am J Obstet Gynecol. 1991;165:654-657.
28. Katz Z, Lancet M, Borenstein R. Management of labor with umbili-
cal cord prolapse. Am J Obstet Gynecol. 1982;142:239-241.
29. Vago T. Prolapse of the umbilical cord: a method of management.
Am J Obstet Gynecol. 1970;107:967-969.
3 0. Royal College of Obstetricians and Gynecologists. Classification of
Urgency of Caesarean Section—a Continuum of Risk. Good Practice
No.11. 2010. https://www.rcog.org.uk/en/guide​lines​-resea​rch-
servi​ces/guide​lines/​good-pract​ice-11/. Accessed July 8, 2020
31. Bloom SL, Spong CY, Weiner SJ, et al. National Institute of Child
Health and Human Development Maternal-Fetal Medicine Units
Network. Complications of anesthesia for cesarean delivery. Obstet
Gynecol. 2005;106:281-287.
32. Afolabi BB, Lesi FE. Regional versus general anaesthesia for caesar-
ean section. Cochrane Database Syst Rev. 2012;10:CD004350.
33. Moroz L, DiNapoli M, D'Alton M, Gyamfi-Bannerman C. Surgical
speed and risk for maternal operative morbidity in emergent repeat
cesarean delivery. Am J Obstet Gynecol. 2015;213(4):584.e1-584.
e6.
3 4. Leung TY, Stuart O, Sahota DS, Suen SS, Lau TK, Lao TT. Head-
to-body delivery interval and risk of fetal acidosis and hypoxic isch-
aemic encephalopathy in shoulder dystocia: a retrospective review.
BJOG. 2011;118:474-479.
35. Caspi E, Lotan Y, Schreyer P. Prolapse of the cord: reduction of
perinatal mortality by bladder instillation and cesarean section. Isr J
Med Sci. 1983;19:541-545.
36. Weiner E, Bar J, Fainstein N, et al. The effect of a program to
shorten the decision-to-delivery interval for emergent cesarean
section on maternal and neonatal outcome. Am J Obstet Gynecol.
2014;210(3):224.e1-224.e6.
37. Siassakos D, Hasafa Z, Sibanda T, et al. Retrospective cohort study
of diagnosis-delivery interval with umbilical cord prolapse: the ef-
fect of team training. BJOG. 2009;116:1089-1096.
How to cite this article: Wong L, Tse WT, Lai CY, et al.
Bradycardia-to-delivery interval and fetal outcomes in
umbilical cord prolapse. Acta Obstet Gynecol Scand.
2020;00:1–8. https://doi.org/10.1111/aogs.13985