CORD PROLAPSE AND PRESENTATION-OBSTETRIC EMERGENCIES

OBJECTIVES

To define cord presentation and cord prolapsed

To identify the associated risk factors

To discuss management of cord prolapse /cord presentation, Clinical responsibilities and postnatal care

➡️ CORD PRESENTATION

Definition:

Cord presentation: defined as Cord presenting at the cervix before the presenting part with intact membranes.Felt on vaginal examination

soft pulsating- no ARM

Seen during speculum examination

or,

Cord presentation :

is the presence of one or more loops of umbilical cord between the fetal presenting part and the cervix, without membrane rupture.

➡️ CORD PROLAPSE

Definition

Cord prolapse: defined as descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes.

Background

-The overall incidence of cord prolapsed ranges from 0.1 to 6 %.

-Male fetuses seem to be predisposed.

-The incidence is higher in multiple gestations.

Incidence

(i) Vertex – 0.2 – 0.5%

(ii) Frank Breech – 0.5%

Legs flexed at hip and extended at knee

(iii) Complete breech – 4-6%

Hips and knees are flexed, feet presenting in pelvis

(iv) Multiple pregnancy 4%

(v) Preterm labour & birth 5-10%

🔴 Cases of cord prolapse appear consistently

in perinatal mortality enquiries, and one

large study found a perinatal mortality

rate of 91 per 1000.

Prematurity

Asphyxia may also result in hypoxic-ischaemic encephalopathy and cerebral palsy.

Asphyxia is due to:

*Cord compression preventing venous return to the fetus .

*Umbilical arterial vasospasm secondary to exposure to vaginal fluids and/or air.

📶 RISK FACTORS FOR CORD PROLAPSE

What are the risk factors for cord prolapse?

Malpresentations
Rupture of membranes
Cord abnormalities (such as true knots or low content of Wharton’s jelly) and Fetal hypoxia-acidosis may alter the turgidity of the cord and predispose to prolapse.
The manipulation of the fetus in the presence of membrane rupture (external cephalic version, internal podalic version of the second twin, manual rotation, placement of intrauterine pressure catheters) or
The artificial rupture of membranes

Summary of predisposing factors:

- Multiparty

- Low birth weight , 2.5kg prematurity< <37 weeks

- Fetal congenital anomalies

- Breech presentation

- Transverse, oblique and unstable lie.

- Second twin.

- Polyhydramnious

- Unengaged presenting part.

- Low placenta, other abnormal presentation.

- Fetus of male gender.

Procedure related to cord presentation /prolapsed :

Artificial of rupture membranes.

Vaginal manipulation.

External cephalic version.

Internal podalic version.

➡️ HOW TO PREVENT CORD PRESENTATION AND CORD PROLAPSE

1. Women with transverse, oblique or unstable lie, non cephalic and preterm should be offered elective admission to hospital at 37+6 weeks of gestation,

2.Speculum and/or a digital vaginal examination should be performed when cord prolapse is suspected, regardless of gestation regardless it is preterm.

3.Artificial rupture of membranes should be avoided whenever possible if the presenting part is unengaged and mobile.

4. Rupture of membranes should be avoided if on vaginal examination the cord is felt below the presenting part in labour (Cord presentation)

Diagnosis of cord presentation and prolapse:

Cord presentation and prolapse may occur without outward physical signs.

-The cord should be felt for at every vaginal examination and after spontaneous rupture of membranes in labour.

- Cord prolapse should be suspected when there is an abnormal fetal heart rate pattern (bradycardia, variable decelerations etc) in the presence of ruptured membranes, particularly if such changes occur soon after membrane rupture, spontaneously or with amniotomy.

- Speculum and/or digital vaginal examination should be performed at preterm gestations when cord prolapse is suspected.

- On vaginal examination you may feel cord in front of presenting part alongside presenting part in the vagina,At the introitus

-Do not attempt to replace the cord in the vagina if it is exposed at rupture of the membranes

-The FHR may become bradycardic or prolonged deceleration

-woman may feel the cord at the introitus

MANAGEMENT OF CORD PROLAPSE AND PRESENTATION

- When cord prolapse is diagnosed before full dilatation :

- Keep woman in knee chest position.

- Venous access should be obtained.

- Consent taken and Preparations made for immediate delivery in theatre.

- Manual replacement of the prolapsed cord above the presenting part to allow continuation of labour. This practice is not recommended

Prevention of vasospasm, Have minimal handling of loops of cord lying outside the vagina ,cover with sterile gause soaked in warm saline.

- To prevent cord compression, it is recommended that the presenting part be elevated either manually or by filling the urinary bladder.

Excessive displacement may encourage more cord to prolapse.

Remove the hand from the vagina once the presenting part is above the pelvic brim, and apply continuous suprapubic pressure

- Cord compression can be further reduced by the mother adopting the knee–chest position or head-down tilt (preferably in left-lateral position).

- A caesarean section is the recommended mode of delivery in cases of cord prolapse when vaginal delivery is not imminent, in order to prevent hypoxia-acidosis.

Recommendation:

➖ Reassess cervical dilatation (particularly in the multigravida in strong labour) prior to commencing an emergency caesarean section as the woman may well have achieved full dilatation and may now be suitable for an assisted vaginal delivery.

➖ Optimal mode of delivery with cord prolapse. Caesarean section is good as it lowered perinatal mortality and reduced risk of APGAR score <3 at 5 minutes compared to spontaneous vaginal delivery in cases of cord prolapse when delivery is not imminent.

Category 1.

A caesarean section of urgency should be performed within 30 minutes or less if there is cord prolapse associated with a suspicious or pathological fetal heart rate pattern.

Verbal consent is satisfactory.

For women at term with a grossly pathological fetal heart rate pattern on transfer from home (severe bradycardia), caesarean section should be advised for women with a grossly pathological pattern at extremely preterm gestations (24-26 weeks), a discussion of the chance of survival should be offered and the options of delivery, possibly SVD.

Category 2

caesarean section is appropriate for women in whom the fetal heart rate pattern is normal.The presenting part should be kept elevated while anaesthesia is induced. Esp. regional anesthesia.

Vaginal birth, in most cases operative, can be attempted at full dilatation if it is anticipated that delivery would be accomplished within 20 minutes from diagnosis.

With parous women or for second twins, ventouse extraction can be attempted by experienced operators at 9 cm dilatation .

Breech extraction can be performed under some circumstances, e.g. after internal podalic version for the second twin, or for singletone breech babies when the presenting part is distending the perineum

A practitioner competent in the resuscitation of the newborn, usually a neonatologist, should attend all deliveries with cord prolapse.

Neonates live born after cord prolapse are at significant risk of needing neonatal resuscitation, as evidenced by a high rate of low APGAR scores (<7); 21% at one minute and 7% at five minutes

What is the optimal management in community settings?

Women should be advised, over the telephone if necessary, to assume the knee-chest face-down or steep Trendelenburg position while waiting for hospital transfer.

During emergency ambulance transfer, the knee–chest is potentially unsafe and the left-lateral position should be used.

The presenting part should be elevated during transfer by either manual or bladder filling methods.

It is recommended that community midwives carry a Foley catheter for this purpose and equipment for fluid infusion.To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina Perinatal mortality is increased by more than ten-fold in cases occurring outside hospital compared to inside the hospital,and neonatal morbidity is also increased in this circumstance

Expectant management can be considered for cord prolapse complicating pregnancies with gestational age at the limits of viability.

Women should be offered both continuation and termination of pregnancy following cord prolapse before 24 completed weeks of pregnancy.