Definition
| Prolapse | Presentation |
| · Descent of umbilical cord through cervix
· alongside(occult) or past (overt) presenting part · In the presence of ruptured membranes |
· Presence of umbilical cord between fetal presenting part and cervix
· With/without intact membranes · Cervix not dilated
|
- Mortality by
- UC compress between maternal pelvis & presenting part ,greater in cephalic presentation —hypoxia
- Expose to cold environment outside vagina
- venous obstruction,
- arterial vasospasm,
- asphyxia–HIE
- if cord compression > 10 min — cerebral damage
>20 min –fetal death
- prematurity, Fetal anomaly, also contributes to mortality
Incidence
- 1-0.6%,
- breech 1%
- Mortality 1%
Risk factors
| Spontaneous | Iatrogenic (50%) |
| Fetal
1. Malpresentation /Abnormal lie a. breech b. oblique/transverse c. unstable 2. Unengaged presenting part 3. Polyhydramnios 4. second twin 5. Prematurity ( <37)/ a. PTL b. LBW(2.5kg) 6. Congenital anomalies 7. 2nd twin Maternal 1. Multiparity 2. Uterine anomaly Placenta 1. Lower lying placenta-prevent HE |
1. Manipulation
a. ECV b. Internal podalic version c. Vaginal manipulation
2. IOL a. Large balloon catheter induction >180ml b. ARM with high presenting part
3. Procedure a. Uterine pressure transducers b. Fetal scalp blood sampling
|
| No increased risk | Uncertain risk |
| 1. ARM to SOL
2. PG induction |
1.Amnio infusion
2.Cord Anomalies-knots, less wartson jelly, single umbilical artery |
Diagnosis
By VE (Digital or speculum) in cord prolapse
In cord presentation –VE , USS + doppler
| FHR
Cord prolapse should be suspected when abnormal FHR pattern (especially after membrane rupture)
Heart rate abnormalities are · variable decelerations · persistent Bradycardia · prolonged deceleration > 1 minute
However, Some cases have normal FHR –prolapse only detected at VE
SE/VE should be done
|
Screening
- USS -unselected population 12% sensitivity, not recommended
- Term Breech-can use selectively
Prevention and early detection
- SROM with normal FHR- routine VE to detect cord prolapse is not indicated.
| prevention | Early detection |
| a. USS screening
a. Avoid ARM for high presenting part b. Avoid ARM if cord presentation c. Stabilizing induction Start oxytocin> contractions >stabilize the presenting part >do ARM d. Avoid upward pressure on presenting part in VE e. Footling breech – casarean delivery f. If high risk avoids straining till head applies |
a. Advice – early to hospital if pains, dribbling
b. Admit -high risk pt c. Do SE/VE after PROM/ARM d. Monitor FHS after ROM e. Close FHS monitoring of labour f. Checking for prolapse routinely at VE |
In Cord presentation à cord may revert to a normal position prior to onset of labour
Fetal viability – hand held doppler, visualize heart beat in USS
CTG time consuming , pulse in cord not reliable
Peripheral:
- consider transfer, Mortality x 10
- Relieve measures-while in transport/LL better than knee chest
- Expedite delivery
- Until fetus is delivered
- Relieve compression
- Digital elevation – when immediate CS
middle & index fingers
Hand should in vagina until incision made in LS
- Filling the bladder – catheter – 500ml NS
Do if there is a delay in CS only
Empty before entering in to abdominal cavity
- Position the mother
- Knee chest position – AW
- Exaggerated sims position- while transport
- Head low left lateral
- Tocolytics
Stop oxytocin infusion
If delay in CS , abnormal FHR à consider tocolytics
- IU resuscitation methods
O2 , IVF
- Relieve vasospasm
If prolapsed outside uterus à place in to vagina carefully with minimal handling
Insert moist gauze in to vagina below the cord
Excessive handling à vasospasm
Replace above presenting part (funic reduction ) à not recommended
| Call help | If Vaginal birth is imminent | If Vaginal birth is not imminent | CS |
| · MDT
· Obs · NN · Aneasthesist
Asses for delivery · FHS · VE dilatation
FHS ( absent -IUD -VD)
If FHS present VE ( dilatation)
|
If Fully dilated
if confident- Instrument VD Special 2nd of twin IPV and Breech extraction
– CS
|
Good FHS-Cat 2 CS SA
Abnormal FHS-Cat 1 CS GA
Relieve till delivery Till delivery If VD not imminent,
· O2 · W/H oxytocin · Wet gauze, gently keep cord in · Manual elevation of presenting part +suprapubic pressure · Knee chest( ward)/L.Lateral ( ambulance)with pillow · Bladder fill 500ml · Tocolytics : SC terbutaline 0.25 |
· Cannula
· Blood for Ix-FBC/DT · Inform NN/CA · Unclamp catheter before · Anaesthesia : According to competency. Post partum Baby · Consider early cord clamping · Cord blood PH · NN resuscitation
Debrief, Document,
Clinical governance · Risk management · Incident reporting · Training/drills |
| Delayed cord clamping |
| Benefits up to 180 sec( recommend for all delivery at least 60 sec)
ü fewer blood transfusions for anemia, ü better circulatory stability, ü fewer IVH (all grades) ü lower risk of NEC considered if baby stable resuscitation is priority over delayed clamping |
Cord prolapse at threshold of viability
- (23+0 to 24+6 weeks) discuss expectant Mx
- no evidence to support replacement of the cord at this age
- patient explained on termination, conservative
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