Umbilical cord prolapsed and

presentation
INTRODUCTION
• Cord prolapse is one of the many causes of fresh
stillbirth.
• It is one of the obstetric emergencies seen in
maternity units in obstetrics and timely delivery is
the good clinical management.
• In many developing countries like ours,
mobilizing the theatre for emergency CS may
pose a challenge and patients with cord prolapse
with partially dilated cervix may have to travel
long distances before reaching a hospital
equipped for CS. This usually results in fetal
deaths.
CORD PROLAPSE
• Defined as descent of the umbilical cord into the
lower uterine segment where it may lie adjacent
to the presenting part or below the presenting
part, without intact fetal membranes.
• When the membranes are intact, it is called
CORD PRESENTATION.
Umbilical cord prolapse and presentation
• Definition
 The umbilical cord drops (prolapses) through
the open cervix into the vagina ahead of the
baby, where it may lie adjacent to the presenting
part (occult- hidden cord prolapse) or below the
presenting part (overt cord prolapse).
1. Occult cord prolapse
• Cord is adjacent to the presenting part
• Cannot be palpated during pelvic examination.
• Might lead to variable slow or unexplained fetal
distress.
2. Funic (cord) presentation
• Prolapse of the umbilical cord below the level of
the presenting part before the rupture of fetal
membranes
• Cord can often be easily palpated through the
membranes
• Often the signal of cord prolapse
 3. Overt cord prolapse
• Umbilical cord lies below the presenting part
•Associated with rupture of membranes, and
displacement of the cord through the vagina.
 INCIDENCE
• The incidence of occult cord prolapse is unknown
because it can be detected only by fetal heart rate
changes characteristic of umbilical cord compression.
• Overall Incidence of overt cord prolapse is between
0.1% to 0.6%1
• 0.5% in cephalic presentation
• 0.5% frank breech
• complete breech 5%
• footling breech 15%,
• transverse lie 20%
• MANAGEMENT OF OVERT CORD PROLAPSE
The three components of management are:
1. Prevent or relieve cord compression and
vasospasm
2. Fetal assessment
3. Prompt delivery of the infant
1. Prevent/relieve cord compression and
vasospasm
 Manual replacement
• Wearing high level disinfected or sterile gloves.
• Insert a hand into vagina and push the presenting part up
decrease pressure on the cord and dislodge the presenting part
from the pelvis.
• It should be replaced gently to maintain temperature and
minimize vasospasm due to irritation
• 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 cesarean section.
Bladder filling
 Adjust maternal position
Bladder filling
• Alternatively, 400–700 mL of saline can be
instilled into the bladder in order to elevate the
presenting part.
• It is essential to empty the bladder again just
before any delivery attempt, be it vaginal or CS.
• Physiologically inhibits uterine contraction.
There may be contractions but not strong
enough for the presenting part to effectively
compress the cord.
• Tocolytics can also be used to achieve this
Maternal Position Adjustment
 Knee-chest position
• Gives maximum elevation of the presenting
part.
• Provides good initial evaluation of the
presenting part.
• A tiring posture to maintain. • If any length of
time is involved, move to the Sim’s lateral
position
 Sim’s lateral position
• More relaxed and dignified for the patient.
• Elevate buttocks with pillow
Trendelenburg position
• A head-down tilt.
• Very tiring
2. FETAL ASSESSMENT IS THE BABY VIABLE?
Interventions for fetal reasons are not necessary
for:
• Already dead baby
• Too immature to survive (e.g. before age of fetal
viability)
• Lethal fetal anomaly (e.g. anencephaly)
• In these cases, allow labour to progress and
deliver vaginally unless there’s a contraindication
to vaginal delivery
 IF BABY IS ALIVE
Quickest way to tell is by palpating the presence or
absence of pulsations in the cord. If the cord is pulsating,
the fetus is alive.
Beware of mistaking folds of membranes or tips of fetal
fingers and toes for the cord. Or clinician’s finger
pulsation.
Diagnosis stages of labour by immediate vaginal
examination.
Call for immediate assistance
Explain to the mother and family the findings and
measures that will be needed.
If any oxytocin is on, this should be stopped.
• Intravenous fluid is given.
• Give oxygen 4-6 L , per min by mask or nasal
cannula.
• Ensure continuous fetal monitoring until in
vaginal delivery birth or cesarean section.
3. PROMPT DELIVERY
CERVIX FULLY DILATED
 Vaginal birth can be attempted at full dilatation if
it is anticipated that delivery would be
accomplished within 20 minutes from diagnosis.
 Depending on the circumstances, this may
involve delivery by forceps, vacuum or breech
extraction.
• CERVIX NOT FULLY DILATED
 An immediate Caesarean Section (usually within
30 minutes) is the recommended mode of
delivery in cases of cord prolapse when vaginal
delivery is not imminent, in order to prevent
hypoxia-acidosis.
 The 30-minute decision-to-delivery interval
(DDI) is the target for CS.
 Oxygen should be given to the mother until the
anesthesiologist is prepared to administer a rapid-
acting inhalation anesthetic for delivery
• The presenting part should be kept elevated during
induction of anaesthesia and placement of sterile
sheets.
• Remember to drain bladder before incision.
• Recheck fetal heart before incision.
• A practitioner competent in the resuscitation of the
newborn, usually a neonatologist, should attend all
deliveries with cord prolapse.
• Neonates born after cord prolapse are at significant
risk of needing neonatal resuscitation, as evidenced
by a high rate of low APGAR scores (<7)