CORD PROLAPSE

DR NUR AMIRAH BINTI ZULWARDI

O&G HOSPITAL KEMAMAN
 Associated with significant
perinatal morbidity and
Introduction mortality
•  Birth asphyxia can occur as a result
of cord compression or vasospasm

Often associated with

prematurity, breech and
abnormal lie
Goals:
• To be skilled in early diagnosis of cord prolapse.
• To manage cord prolapse promptly as a multi – professional team.
• To provide safe transfer of cord prolapse if facilities are inadequate.
 Cord prolapse has been defined as the descent of
Definitions the umbilical cord through the cervix alongside
(occult) or past (overt) the presenting part in the
presence of ruptured membranes
Cord Presentation

Cord presentation is the presence of the umbilical cord between the

fetal presenting part and the cervix, with or without intact
membranes.
AJOG 2021
 Maternal factors
• Multiparity
• Contracted pelvis
Fetal factors
• Pelvic tumor/mass

• Prematurity Others
• Multiple gestation • Polyhydramnios
Risk factors • Fetal anomaly eg: • Spontaneous ruptures of
anencephaly membrane/ARM
• Malpresentation • ECV
• Fetal scalp eclectrode
• Long umbilical cord placement/fetal blood
sampling
 Diagnosis

• Umbilical cord visible/ protruding from vagina

• Cord palpable on vaginal examination
• Abnormal FHR on auscultation or CTG (bradycardia, decelerations,
prolonged deceleration) in the presence of ruptured membranes
• Prompt vaginal examination is the most important aspect of diagnosis
Can cord prolapse or its effects be avoided?
• With transverse, oblique or unstable lie, elective admission to hospital after
37+0 weeks of gestation should be discussed and women in the community
should be advised to present urgently if there are signs of labour or suspicion
of membrane rupture
• Women with non-cephalic presentations and preterm prelabour rupture of
membranes should be recommended inpatient care.

• Artificial membrane rupture should be avoided whenever possible if the

presenting part is mobile and/or high. If it becomes necessary to rupture the
membranes with a high presenting part, this should be performed with
arrangements in place for immediate caesarean section.
RCOG 2014
• Upward pressure on the presenting part should be kept to a minimum in
women during vaginal examination and other obstetric interventions in the
context of ruptured membranes because of the risk of upward
displacement of the presenting part and cord prolapse.

• Rupture of membranes should be avoided if on vaginal examination the

cord is felt below the presenting part. When cord presentation is diagnosed
in established labour, caesarean section is usually indicated

RCOG 2014
Management
of
cord prolapse
C – call for help

O – organize delivery

R – relieve pressure on the cord

D – deliver
 DOs:
If fetus is alive
1. Initiate RED alert
2. Call for help (obstetrician, anesthetist and paediatrician).
3. Arrange operating theatre (OT) for category 1 caesarean section.
4. Monitor fetal heart rate continuously.
5. Measures to relieve cord compression until delivery of fetus.
6. Measures to prevent umbilical cord vasospasm.
7. Arrange for immediate delivery
• Os not fully dilated/delivery not imminent – delivered via cat 1
caesarean section
• Os fully dllated & delivery imminent – trial of vaginal delivery
with/without instrumental delivery.
8. Deflate bladder before peritoneal entry during caesarean section.
9. Where resources are limited, arrange for immediate transfer while
maintaining decompression of the cord. Communicate effectively with
receiving centre.
In the event of stillbirth
• Aim for vaginal birth with augmentation.
• If the lie is unfavourable and
augmentation fails, consider caesarean
section.
Optimal management of cord prolapse at the
threshold of viability?

Expectant management
Women should be counselled
should be discussed for cord
on both continuation and
prolapse complicating
termination of pregnancy
pregnancies with a gestational
following cord prolapse at the
age at the threshold of
threshold of viability
viability (23+0 to 24+6 weeks).

RCOG 2014
Optimal mode of birth with cord prolapse
Caesarean section is the recommended mode of delivery in cases of cord
prolapse when vaginal birth is not imminent in order to prevent hypoxic
acidosis.

A category 1 caesarean section should be performed with the aim of achieving

birth within 30 minutes or less if the cord prolapse is associated with a
suspicious or pathological fetal heart rate pattern but without compromising
maternal safety.
Optimal mode of birth with cord prolapse
• Category 2 caesarean birth can be considered for women in whom the fetal
heart rate pattern is normal, but continuous assessment of the fetal heart trace
is essential. If the cardiotocograph (CTG) becomes abnormal, re-categorisation
to category 1 birth should immediately be considered

• Vaginal birth, in most cases operative, can be attempted at full dilatation if it is

anticipated that birth would be accomplished quickly and safely, using standard
techniques and taking care to avoid impingement of the cord when possible.

• Breech extraction is appropriate under some circumstances, for example, after

internal podalic version for a second twin
 • Midwives should assess the risk of cord prolapse for
women requesting birth in centres without facilities for
immediate caesarean section and at the start of labour in
the community
• During emergency ambulance transfer, the knee–chest
What is the position is potentially unsafe and the exaggerated Sims
position (left lateral with pillow under hip) should be
optimal used.
management • All women with cord prolapse should be advised to be
transferred to the nearest consultant-led unit for birth,
in community unless an immediate vaginal examination by a competent
settings? professional reveals that a spontaneous vaginal birth is
imminent.
• The presenting part should be elevated during transfer
either manually or by using bladder distension.
• To prevent vasospasm, there should be minimal handling
of loops of cord lying outside the vagina
RCOG 2014
AJOG 2021
 Measures to relieves cord compression

1. Elevate maternal buttocks with 2 pillows/Tredenlenburg

position/knee-chest position/sims position(left lateral with a pillow
under the hip).
2. Gently push fetal head upwards, away from maternal pelvis. Use
other hand to apply suprapubic pressure to keep fetus away from
pelvis.
3. Inflate maternal bladder with 500cc of saline via Foley’s catheter.
Exaggerated sim position

Knee chest position

 Measures to prevent umbilical cord vasospasm

1. Discontinue oxytocin (where applicable).

2. Administer tololytic agents (i.e. s/c Terbutaline 0.25mcg STAT) if
evidence of fetal bradycardia.
3. Minimize excessive handling of umbilical cord.
4. If umbilical cord is outside, gently wrap the exposed cord with warm
gauze.
Deliver the fetus in quickest and safest mode possible

1. Aim for decision to delivery interval within 30minutes.

2. Instrumental delivery if favourable or if handled by an experienced
professional.
3. Breech extraction if favourable and conducted by an experienced
professional.
DONTs:
1. Replacing the cord into uterus (funic reduction) should be avoided as it can
cause vasospasm and fetal hypoxia
2. Avoid excessive upward displacement of presenting part during amniotomy
3. Don’t remove the examining fingers once diagnosis is made as the upward
pressure prevent cord compression
4. Avoid transfer to another centre with mother in knee-chest position as
prolonged knee-chest position may compromise lower limb blood circulation
5. Avoid delay in caesarean section by trying to achieve vaginal birth
6. Use of Doppler ultrasound to detect occult cord presentation is not reliable.
THANK YOU