Definition

Cord Presentation: Cord in front of presenting part before the rupture of membranes

Cord Prolapse: Cord in front of presenting part after rupture of

membranes

Cord presentation vs. Cord prolapse

Occult cord prolapse

• Cord lying alongside the presenting part• Occult vs. presentation vs. prolapsed cord

IncidencePrimigravida 0.45%Multigravida 0.66% (Risk ratio 2:3)Cephalic 0.3%Frank breech 0.9%Complete breech 5%Footling 10%Shoulder 15%Contracted pelvis 4-6 times

CausesMalpresentation - face, brow, breech and shoulderPrematurityPolyhydramniosMultiple pregnancyLong cord (90-100 cm)PROMCPDObstetric interventions - Amniotomy, Intrauterine

pressure catheter, scalp electrode, external cephalic version,

Dangers• Mortality rate as high as 50%• Hypoxia• Spasm of vessels• Operative trauma to suboxgenated

fetus

DiagnosisCord pulsations

CTG shows variable decelerations Fundal pressure causes bradycardiaMeconium stained liquor

US – cord loops Cord outside vulva

Prevention1. Do US for malpresentation and cord

presentation

2.FHR monitoring

3.Avoid ARM in an unengaged head

4.PV exam after ROM

ManagementLift presenting part off the cord Instruct patient NOT to push Position 1. Knee chest

2. Trendelenburg

3.Exaggerated position

Knee chest position

Trendelenburg position

Exaggerated sim’s position

Management (cont..)• Vulval pad• Replacement of cord• Tocolysis (ritodrine)Funic ReductionManual replacement of cord into uterusCord gently pushed above presenting

part while other cord decompression techniques are applied

Stage II Labor:

- Expedite delivery with episiotomy and vacuum extraction or forceps

Prepare for resuscitation of the newborn.

Fetal Mortality• Overall - 50%• 1st stage of labour - 70%• 2nd stage of labour -30%• Neonatal death - 4%• Perinatal mortality- 20%

Fetal Mortality

Fetal Mortality• More with vertex than breech

• More with anterior than posterior.

• More in prime than multi

• < 5 minutes, prognosis good, > 5 mins, damage and death.

•

Prognosis

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