Cord prolapse & cord presentation

a brief note for Cord prolapse & cord presentation......

1. BY, Mrs.Jasmi Manu Head of the department , OBG nursing Rama college of Nursing Rama university, Uttar Pradesh CORD PROLAPSE &PRESENTATION

2. Meaning Abnormal descent of the umbilical cord by side of the presenting part Cord prolapse  has been  defined  as the descent of the umbilical  cord  through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes .  Cord  presentation is the presence of the umbilical  cord  between the fetal presenting part and the cervix, with or without membrane rupture

3. A prolapsed umbilical cord occurs when the umbilical cord precedes the presenting part of the fetus so that the blood circulating inside the cord is clamped off by the passing fetus through the birth canal. This is considered an obstetric emergency.

4. CLINICAL TYPES OCCULT PROLAPSE CORD PRESENTATION CORD PROLAPSE

5. Incidence 1 in 300 deliveries Incidence is reduced due to increased C.S in case of non-cephalic presentation

6. ETIOLOGY Malpresentations Contracted pelvis Prematurity Twins Hydramnios Placental factors-minor degree placenta previa, with marginal insertion of cord or long cord Iatrogenic-low rupture of membranes, manual rotations of the head, ECV Stabilizing induction

7. Risk factors spontaneous factors : fetal malpresentation : abnormal fetal lie tends to result in space below the fetus in the maternal pelvis, which can then be occupied by the cord. polyhydramnios , or an abnormally high amount of amniotic fluid prematurity : likely related to increased chance of malpresentations and relative polyhydramnios . low birth weight : usually described as <2500g at birth, though some studies will use <1500g. Cause is likely similar to those for prematurity.

8. multiple gestation , or being pregnant with more than one fetus at a given time: more likely to occur in the fetus that is not born first. spontaneous  rupture of membranes : about half of prolapse occur within 5 minutes of membrane rupture, two-thirds within 1 hour, 95% within 24 hours. treatment associated factors: artificial rupture of membranes placement of internal monitors (for example, internal scalp electrode or  intrauterine pressure catheter ) manual rotation of fetal head

9. DIAGNOSIS Deceleration of fetal heart Sound pattern Persistent fetal Soufflé Irregular Heart sound Pulsation on the cord

10. Occult prolapse -very difficult to diagnose -suspected if Deceleration of fetal heart Sound pattern by Continuous Electronic Fetal Monitoring 2.Cord presentation -feeling Pulsation on the cord through the intact membranes

11. 3.Cord prolapse -The cord is palpated directly by the fingers and its pulsation can be felt if the fetus is alive -USG to be done for cardiac movements or FHS to be done to declare the fetus is alive

12. Prognosis Fetal Anoxia Cord compression Death Maternal Its incidental emergencies

13. MANAGEMENT LIFT THE PRESENTING PART OFF THE CORD POSTURAL TREATMENT REPLACE THE CORD INTO THE VAGINA CAESEREAN SECTION

14. Management The gold standard for treatment of umbilical cord prolapse in the setting of a  viable pregnancy  typically involves immediate delivery by the quickest and safest route possible. This usually requires cesarean section, especially if the woman is in early labor. Occasionally, vaginal delivery will be attempted if clinical judgment determines that is a safer or quicker method. Other interventions during management of cord prolapse are typically used to decrease the chance of complications while preparations for delivery are being made. These interventions are focused on reducing pressure on the cord to prevent fetal complications from cord compression.

15. CORD PROLAPSE

16. The following maneuvers are among those used in clinical practice: manual elevation of the presenting fetal part  repositioning of the mother to be  head down with feet elevated ( The knee-chest position is typically recommended) filling of the  bladder  by a  foley catheter  to elevate the presenting fetal part  (400-750 ml of normal saline with a foley’s catheter use of  tocolytics  (medications to suppress labor) have been proposed, usually in addition to bladder filling rather than a standalone intervention  If the mother is far from delivery, funic reduction (manually placing the cord back into the uterine cavity) has been attempted, with successful cases reported.

17. Firstly, call for help – umbilical cord prolapse is an  obstetric emergency . It should be managed as follows: Avoid handling the cord  to reduce vasospasm. Manually elevate the presenting part  by lifting the presenting part off the cord by vaginal digital examination. Alternatively, if in the community, fill the maternal bladder with 500ml of normal saline (warmed if possible) via a urinary catheter and arrange immediate hospital transfer. Encourage into left lateral position  with head down and pillow placed under left hip OR knee-chest position. This will relieve pressure off the cord from the presenting part.

18. Consider tocolysis (e.g. terbutaline )  – if delivery is not imminently available this will relax the uterus and stop contractions, relieving pressure off the cord. It may be sufficient to allow enough time for transfer to a location where delivery is feasible (e.g. an operating theatre for a Caesarean section). This is a particularly useful strategy if there are fetal heart rate abnormalities while preparing for a C-section. Delivery is usually via emergency Caesarean section If fully dilated and vaginal delivery appears imminent, encourage pushing or consider instrumental delivery. If at threshold for viability (23 + 0 weeks – 24 + 6 weeks) and extreme prematurity, expectant management may be discussed due to significant maternal morbidity with caesarean at this gestation and poor fetal outcomes.

19. KNEE CHEST POSITION

20. if head is engaged, delivery is possible FORCEPS NO VENTOUSE

21. Summary Umbilical cord prolapse occurs when the cord descends through the cervix and is alongside or below the presenting part of the fetus. It is an obstetric emergency, with a fetal mortality rate of 91 per 1000. The diagnosis should be suspected in any patient with a non-reassuring fetal heart trace and absent membranes. The first step is to call for help when the diagnosis is made. Manage by manually elevating the presenting part, and deliver via the quickest mode (usually Caesarean section).