Umbilical Cord Prolapse 6

8/17/2019 Umbilical Cord Prolapse 6

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Cases o cord prolapse appear consistentl# in perinatal

mortalit# en%uiries, and one large stud# ound a

perinatal mortalit# rate o &1'1000. rematurit# andcongenital malormations account or the maorit# o

adverse outcomes associated with cord prolapse in

hospital settings1 but birth asph#xia is also associated

with cord prolapse. erinatal death has beendescribed with normall# ormed term babies,

particularl# with planned home birth. *ela# in transer

to hospital appears to be an important contributing

actor. +sph#xia ma# also result in h#poxicischaemic

encephalopath# and cerebral pals#.

The principal causes o asph#xia in this context are

thought to be cord compression and umbilical arterial


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vasospasm preventing venous and arterial blood $ow

to and rom the etus. There is a paucit# o long-term

ollow-up data o babies born alive ater cord prolapse

in both hospital and communit# settings.


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"n

general,

these

actors


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predispose to cord prolapse b# preventing close

application o the presenting part to the lower part o

the uterus and'or pelvic brim. upture o membranes

in such circumstances compounds the ris/ o prolapse.

ome authorities have also speculated that cord

abnormalities (such as true /nots or low content o

harton2s ell#) and etal h#poxiaacidosis ma# alterthe turgidit# o the cord and predispose to prolapse.

"nterventions can result in cord prolapse with about

30 o cases being preceded b# obstetric

manipulation.

The manipulation o the etus with or without prior

membrane rupture (external cephalic version, internal

podalic version o the second twin, manual rotation,


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placement o intrauterine pressure catheters) and

planned artifcial rupture o membranes, particularl#

with an unengaged presenting part, are the

interventions that most re%uentl# precede cordprolapse.

Can cord presentation be detected antenatally?

outine ultrasound examination is not su4cientl#

sensitive or specifc or identifcation o cordpresentation antenatall# and should not be perormed

to predict increased probabilit# o cord prolapse,

unless in the context o a research setting.


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Can cord prolapse or its efects be avoided?

ith transverse, obli%ue or unstable lie, elective

admission to hospital ater 567! wee/s o gestation

should be discussed and women should be advised to

present %uic/l# i there are signs o labour or suspicion

o membrane rupture. omen with noncephalic

presentations and preterm prelabour rupture o themembranes should be o8ered admission.

+rtifcial membrane rupture should be avoided

whenever possible i the presenting part is mobile. " it

becomes necessar# to rupture the membranes, this

should be perormed with arrangements in place or

immediate caesarean deliver#.


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9aginal examination and obstetric intervention in the

context o ruptured membranes and a high presenting

part carr# the ris/ o upward displacement and cordprolapse. :pward pressure on the

presenting part should be /ept to a minimum in such

women.

upture o membranes should be avoided i, on

vaginal examination, the cord is elt below the

presenting part. hen cord presentation is diagnosed

in established labour, caesarean section is usuall#

indicated.

When should cord prolapse be suspected?


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Cord presentation and prolapse ma# occur without

outward ph#sical signs and with a normal etal heart

rate pattern. The cord should be examined or at ever#

vaginal examination in labour and ater spontaneous

rupture o membranes i ris/ actors are present or i

cardiotocographic abnormalities commence soon

thereater.

ith spontaneous rupture o membranes in the

presence o a normal etal heart rate patterns and the

absence o ris/ actors or cord prolapse, routinevaginal examination is not indicated i the li%uor is

clear.


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Cord prolapse should be suspected where there is

an abnormal etal heart rate pattern (brad#cardia,

variable decelerations etc), particularl# i such

changes commence soon ater membrane rupture,spontaneousl# or with amniotom#. peculum and'or

digital vaginal examination should be perormed at

preterm gestations when cord prolapse is suspected.

What is the optimal initial management o cord

prolapse in hospital settings?


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hen cord prolapse is diagnosed beore ull dilatation,

assistance should be immediatel# called and

preparations made or immediate deliver# in theatre.

There are insu4cient data to evaluate manualreplacement o the prolapsed cord above the

presenting part to allow continuation o labour. This

practice is not recommended.

To prevent vasospasm, there should be minimal

handling o loops o cord l#ing outside the vagina. To

prevent cord compression, it is recommended that the

presenting part be elevated either manuall# or b#flling the urinar# bladder. Cord compression can be

urther reduced b# the mother adopting the /nee

chest position or head-down tilt (preerabl# in let-

lateral position).


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Tocol#sis can be considered while preparing or

caesarean section i there are persistent etal heart

rate abnormalities ater attempts to prevent

compression mechanicall# and when the deliver# is

li/el# to be dela#ed.

+lthough the measures described above are

potentiall# useul during preparation or deliver#, the#

must not result in unnecessar# dela#.

What is the optimal mode o delivery with cord

prolapse?


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+ caesarean section is the recommended mode o

deliver# in cases o cord prolapse when vaginal

deliver# is not imminent, to prevent h#poxiaacidosis.

+ categor# 1 caesarean section should be perormed

with the aim o delivering within 50 minutes or less i

there is cord prolapse associated with a suspicious or

pathological etal heart rate pattern but withoutundul# ris/ing maternal saet#. 9erbal consent is

satisactor#.

Categor# ; caesarean section is appropriate or

women in whom the etal heart rate pattern is normal.

egional anaesthesia ma# be considered in

consultation with an experienced anaesthetist.


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What is the optimal management in community

settings?

omen should be advised, over the telephone i

necessar#, to assume the /neechest ace-downposition while waiting or hospital transer. *uring

emergenc# ambulance transer, the /neechest is

potentiall# unsae and the let-lateral position should

be used.

+ll women with cord prolapse should be advised to be

transerred to the nearest consultant-led unit or

deliver#, unless an immediate vaginal examination b#


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a competent proessional reveals that a spontaneous

vaginal deliver# is imminent. reparations or transer

should still be made.

The presenting part should be elevated during transer

b# either manual or bladder flling methods. "t is

recommended that communit# midwives carr# a


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with prolapse occurring inside the hospital. =eonatal

morbidit# is also increased in this circumstance

What is the optimal management o cord

prolapse beore viability?

>xpectant management should be discussed or cord

prolapse complicating pregnancies with gestational

age at the limits o viabilit#.

:terine cord replacement ma# be attempted. omen

should be counselled on both continuation and

termination o pregnanc# ollowing cord prolapse at

the threshold o viabilit#.


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Clinical governance

Debrieng

ostnatal debriefng should be o8ered to ever# woman with

cord prolapse. +ter severe obstetric emergencies, women

might be ps#chologicall# a8ected with postnatal depression,

post-traumatic stress disorder or ear o urther childbirth.

omen with cord prolapsewho undergo urgent transer to hospital might be

particularl# vulnerable to emotional problems.

*ebriefng is an important part o maternit# care and should

be o8ered b# a proessional competent in counselling


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:mbilical Cord

rolapse? is/ pidemiolog#Presentati

on

9e

rtex


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apid esponseto rolapse

?ecognie non-reassuring tracing

?9isuall# inspect'palpatecord to diagnose

?+ssess etal status(


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revention o

rolapse

? "denti# ris/ actors- @alpresentation, highpresentation

- atient education reF membrane

rupture

at home

? =o +G@ when station


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high

- @a# HneedleH membranes underdouble

set-up


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praevia, D, operativedeliver#

? *i#gosit# (raternal) K;'5

- "ncreases with age, parit#,

amilialactors

? @ono#gosit# (identical) K

1'5????????


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*

i

a

g

n

o

s

is o @ultiple

IestationGvulation induction

arl# "D>levated @+


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ol#h#dramnios

?????

+ssociated

Complicationsrematurit#

Congenital anomaliesregnanc#-induced

h#pertension

lacenta praevia


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< etal deathF 0.3 - !.B


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*elivering Twin

M

? +ttempt internal podalicversion? Mreech deliver# is reasonable

choicewhenF

- >xternal version unsuccessul or

not


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ummar

#

? ix t#pes o

malpresentations

? *iagnosis b# ph#sical exam

andimaging

? Me alert to etiologicassociation


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? Me alert to potential

complications ? 9aginal deliver#ma# be consideredor G, breech, ace andcompoundpresentation

Umbilical Cord Prolapse 6

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