Cord Prolapse

Question 1

What is cord presentation and cord prolapse?

Answer 1

• cord presentation —> a loop of cord lies below the presenting part when the membranes are intact
• cord prolapse —> a loop of cord lies below the presenting part when the membranes have ruptured, this can be occult (alongside) or overt (past) the pp

Question 2

What is the incidence of cord prolapse?

Answer 2

• 0.1-0.6% of all births

- 1.7 per 1000 live births

Question 3

What are some of the risk factors for cord prolapse?

Answer 3

• multiparity
• polyhydramnios
• breech
• unstable lie
• oblique or transverse lie
• low-lying placenta
• ECV
• expectant management of PROM
• previous cord prolapse
• amniotomy (ARM) especially with a high presenting part
• prematurity
• internal podalic version
• second twin (multiple pregnancy)
• disimpaction of fetal head during rotational assisted delivery
• FSE application
• congenital abnormalities

Question 4

What are the complications associated with cord prolapse?

Answer 4

• once the position of the cord becomes compromised, and especially when put of the vagina, the fetal blood supply is obstructed
• this is either because of the drop in temperature and spasm of the vessels, or compression between the bony pelvis and the presenting part
• this restricted blood flow will cause fetal hypoxia and asphyxia and may be followed by fetal or neonatal death dependent on the time scale
• perinatal mortality rate remains between 3-9%

Question 5

How is it diagnosed?

Answer 5

• early recognition is important
• cord presentation is usually diagnosed on vaginal examination when the cord is felt behind intact membranes, it may also be seen on ultrasound
• cord prolapse may be diagnosed when there is an obvious loop of cord protruding through the vulva, however it may not always be apparent and may only be found on vaginal examination
• cord prolapse should always be suspected when there is an abnormal fetal heart rate pattern e.g. bradycardia in the presence of ruptured membranes, particularly if such changes commence soon after membrane rupture

Question 6

How should cord prolapse be managed?

Answer 6

• RECOGNISE
  —> umbilical cord visible/ protruding from vagina
  —> cord palpable on VE
  —> abnormal fetal heart rate on auscultation/CTG
• CALL FOR HELP
  —> emergency buzzer (SOAPS, theatre team)
  —> relieve pressure on the cord
  —> prepare for immediate birth (theatre checklist, ranitidine etc)
  —> secure IV access/ take bloods (FBS, group and X match)
  —> CTG monitoring
  —> consider pulse oximetry to confirm maternal HR and fetal HR are differentiated
• METHODS TO RELIEVE PRESSURE ON THE CORD
  —> manually elevate presenting part
  —> position woman (exaggerate sims position, move woman into eft-lateral position with head down and pillow placed under left hip OR knee-chest position
  —> consider bladder filling if delay is anticipated and apply a dry pad to try to keep the cord inside the vagina
  —> consider tocolysis with subcutaneous terbutaline 0.25 mg/ stop oxytocin infusion
• PLAN FOR BIRTH
  —> transfer to LW/hospital
  —>assess and assist birth by quickest means
  —> urgency dependent on FHR and gestational age
  —> consider delayed cord clamping if infant is uncompromised
• POST BIRTH
  —> umbilical cord gases
  —> documentation and datix
  —> debrief mother and relatives

Question 7

Should the cord be replaced?

Answer 7

• current evidence does not recommend attempting to replace the cord or wrapping warm swabs around the prolapsed cord
• may cause the cord to go into vasospasm

Question 8

How is the bladder filled?

Answer 8

• a Foley catheter is placed into the bladder
• empty urine
• the bladder is then filled via the catheter with sterile 0.9% saline using an IV giving set
• the catheter should be clamped once 500-750 ml has been stilled
• it is essential to empty the bladder just before any method of birth is attempted