UMBILICAL CORD ACCIDENTS

DR PADMASRI R
PROF & HOD, DEPT OF OBSTETRICS &
GYNAECOLOGY
SAPTHAGIRI INSTITUTE OF MEDICAL SCIENCES

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• “Cord accident,” defined by obstruction
of fetal blood flow through the umbilical
cord, is a common ante- or perinatal
occurrence.
• Obstruction can be either acute, as in
cases of cord prolapse during delivery, or
sub acute to-chronic, as in cases of
grossly abnormal umbilical cords
Placental findings in cord accidents. Mana M Parast
From Stillbirth Summit 2011, Minneapolis, USA 2
 TYPES
Acute events Sub Acute on Chronic
• Umbilical Cord Prolapse • Loops
• Knots
• Vasa Praevia • Entanglements
• Coiling
• Torsion
• Rupture
• Haematomas, thrombosis
• Cysts, tumours
• Nuchal Cord
• Insertion - velamentous cord
CORD COMPRESSION – SUDDEN
IUD’s

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CORD COMPRESSION

2 Principles of asphyxia are:

a. Cord compression -preventing venous return
to the fetus
b. Umbilical vasospasm -preventing venous and
arterial blood flow to and from the fetus due
to exposure to external environment.

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 Recovery time from compression
• 1min, 1 time 100% compression – 5 mins to
recover- oxygen levels decrease by 50%
• 5 mins comp – 30 mins to recover
• Continued 5 min compressions every 30 mins
causes fetal decompensation
RISK FACTORS FOR CORD PROLAPSE
GENERAL PROCEDURE RELATED
Artificial rupture of membranes with high
Multiparity
presenting part
Vaginal manipulation of the fetus with ruptured
Low birthweight (< 2.5 kg)
membranes
Preterm labour (< 37+0
External cephalic version (during procedure)
weeks)
Fetal congenital anomalies Internal podalic version
Breech presentation Stabilising induction of labour
Transverse, oblique and
Insertion of intrauterine pressure transducer
unstable lie*
Second twin Large balloon catheter induction of labour
Polyhydramnios
Unengaged presenting part
Low-lying placenta

RCOG Green-top Guideline No. 50, 2014 6

 MANAGEMENT
• Call for help • Expedite the birth of the baby. At full
• Counsel the woman and dilatation, vaginal birth may be an
her birth partner option depending on parity and
• Move the woman into the engagement of head
knee-chest or exaggerated • Transport the woman to the operating
Sims’ position theatre, if required
• Stop oxytocin augmentation • Tocolysis can be considered while
if in progress preparing for caesarean section if
• Elevate the presenting part there are persistent fetal heart rate
digitally or by bladder filling abnormalities after attempts to
prevent compression mechanically or
• To prevent vasospasm, when the delivery is likely to be
there should be minimal delayed.
handling of loops of cord Tocolysis may allow time for regional
lying outside the vagina anaesthesia to be administered.
• Continue to assess fetal
heart rate

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 VASA PRAEVIA
• Vasa praevia is a rare but potentially
serious condition in which blood vessels
carrying blood between the placenta and
the baby cross over the cervix.
• These vessels may bleed if the woman
goes into labour, if the waters break, or if
the cervix opens

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 TYPES
Type 1 vasa praevia occurs with
velamentous insertion of the
umbilical cord into the placenta
Type II vasa praevia occurs with a
velementous fetal vessel connecting
the placenta to a succinuriate
placental lobe.
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 PRESENTATION – CLASSICAL TRIAD
MEMBRANE RUPTURE

PAINLESS FETAL
VAGINAL BLEEDING BRADYCARDIA/DEATH
(BENCKISER’S HEMORRHAGE)

• The mortality rate in this situation is around 60%.

• If detected antenatally improved survival rates of up to 97%
have been reported.

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 Vasa previa management
Caeserean section

Antenatally confirmed Unconfirmed,

Vasa previa Detected during labour

Preterm contractions/ No risk factors

Don’t wait for
Short cervix/ confirmation
Low lying placenta
May consider conservative
management on OP basis
Fetal exsanguination
Prophylactic hospitalization
(from 30-32 weeks)
Emergency
Antenatal corticosteroids Caeserean section

Neonatal resuscitation
Elective LSCS between 35-37 weeks 11
O Rh –ve Blood
 CONCLUSION
• Vasa previa is an uncommon but
potentially life threatening condition for
the fetus /neonate.
• Perinatal outcomes improve significantly
when antenatal diagnosis enables
planned management that includes
elective Caesarean section by 35 weeks
gestation before the onset of labour.

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NUCHAL CORD – NOOSE OR NECKLACE?
• NUCHAL CORD - Cord round the neck, 360 deg
• Two types of cord around foetal neck.
• TYPE A- umbilical cord encircles the fetal neck in a sliding
manner (less dangerous)
• TYPE B- Nuchal cord encircles the neck in a locking manner
(very dangerous)

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ULTRASOUND DIAGNOSIS OF NC
2 Views
• They should be identified by presence of the cord in the
transverse and sagittal planes of the neck and lying around at
least three of the four sides of the neck
• On sagittal view –NC seen as dimples at the posterior neck of
the fetus
• Although there appears to be a linear increase over gestation in
the presence of both single and multiple loops, NC keeps
appearing and disappearing over time.
• The difficulty encountered in visualizing the NC at term and
prior to induction of labor is due to fetal crowding, low position
of the fetal head or reduced amniotic fluid volume .
• Generally, the sensitivity of diagnosis is higher with color
Doppler imaging, and it may have a particular advantage in the
presence of ruptured membranes

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 UMBILICAL CORD COILING
• Whether an umbilical cord is normal, hypercoiled or
hypocoiled is dependent on the number of coils present in
the cord – this is known as the umbilical coiling index (UCI).
• Sonographic umbilical coiling index is defined as number of
vascular coil in a given cord.
• Usually 1 coil / 5 cm of umbilical cord length and may coil as
many as 40 times.
• < 10th percentile
– hypocoiled.
• 10th – 90th percentile
– normocoiled .
• >90th percentile
– hypercoiled.
 Summary
• UCA can be acute event or acute on chronic
• Training and CP guidebook / box should be in
place for quick action
• Diagnose VP antenatally in 2nd trimester to
reduce perinatal mortality to nil
• Be wary of Type B Nuchal Cord which can be
dangerous to the fetus
• Look for UCI to rule out hypo/hypercoiling of
cord