CORD PROLAPSE AND CORD PRESENTATION.pptx

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1.   PREPARED BY:- MS.DEEPTI KUKRETI PG NURSING TUTOR OBSTETERICS & GYNAECOLOGY CORD PROLAPSE/PRESENTATION

2. introduction Cord prolapse is one of the many causes of fresh stillbirth. It is one of the obstetric emergencies seen in maternity units in obstetrics and timely delivery is the hallmark of good clinical management. In many developing countries like ours, mobilizing the theatre for emergency Caesarean Section may pose a challenge and patients with cord prolapse with partially dilated cervix may have to travel long distances before reaching a hospital equipped for Caesarean Section which usually results in fetal deaths.

3. definition Cord prolapse cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes. Cord presentation cord below presenting part with intact membranes.

4. TYPES Occult cord prolapse Cord is adjacent to the presenting part. Cannot be palpated during pelvic examination. Might lead to variable decelerations or unexplained foetal distress. Funic (cord) presentation Prolapse of the umbilical cord below the level of the presenting part before the rupture of foetal membranes. Cord can often be easily palpated through the membranes . Often the harbinger of cord prolapse.   Overt cord prolapse  Umbilical cord lies below the presenting part associated with rupture of membranes, and displacement of the cord through the vagina.

5. OTHER TYPES TRUE CORD KNOTS An inter-twining of a segment of umbilical cord,   Circulation is usually not obstructed,   commonly formed by the fetus slipping through a loop of the cord.

6. NUCHAL CORD The umbilical cord is wrapped around the neck of the fetus in utero or of the baby as it is being born. It is usually possible to slip the loop or loops of cord gently over the child's head. The condition occurs in more then 25% of deliveries, more often with long cords than with short ones.

7. INCIDENCE Overall Incidence of overt cord prolapse is between 0.1% to 0.6% 0.5% in cephalic presentation 0.5% frank breech complete breech 5% footling breech 15%, and transverse lie 20%

8. Aetiology/ risk factors GENERAL ❖ Multiparity ❖ Low birth weight (<2.5 kg) ❖ Prematurity (<37 wks ) ❖ Foetal congenital anomalies ❖ Breech presentation ❖ Transverse, oblique and unstable ❖ lie  

9. Polyhydramnios Low-lying placenta, other abnormal placentation Unengaged presenting part Second twin   Procedure related 50% ARM   Vaginal manipulation of the fetus with ruptured membranes   ECV (during procedure) Internal podalic version Stabilising induction of labour   Insertion of uterine pressure transducer

10. Diagnostic evaluation Difficult to diagnose Suspect if persistence of variable deceleration of fetal heart rate pattern. Cord presentation: feeling of pulsation of the cord through the intact membranes. Cord prolapse: cord palpated by fingers and pulsation if fetus is alive.

11. management INITIAL MANAGEMENT OF CORD PROLAPSE IN HOSPITAL Assistance should be immediately called. Preparations made for immediate delivery Manual replacement of the prolapsed cord above the presenting part to allow continuation of labour is not recommended. Prevent vasospasm:-minimal handling of loops of cord lying outside the vagina. Prevent cord compression:- presenting part be elevated either manually or by bladder filling.

12. knee–chest position or head-down tilt (preferably in left- lateral position). Manual elevation:- By inserting a gloved hand or two fingers in the vagina and pushing the presenting part upwards. A variation is to remove the hand from the vagina once the presenting part is above the pelvic brim and apply continuous suprapubic pressure upwards. Excessive displacement may encourage more cord to prolapse.

13. Bladder filling:- If the decision-to-delivery interval is likely to be prolonged, particularly if it involves ambulance transfer. Moderate Trendelenburg position. By inserting the end of a blood giving set into a Foley’s catheter. The catheter should be clamped once 500–750 ml has been instilled. Empty the bladder again just before any delivery attempt, be it vaginal or CS.

14. Tocolysis :- Terbutaline:0.25 mg SC( to reduce contractions)

15. Mode of delivery with cord prolapse CS:- when vaginal delivery is not imminent{prevent hypoxia– acidosis}. Vaginal:- When vaginal birth is imminent {outcomes are similar or better when compared with CS}.

16. CS: Category 1:Delivering within 30 min or less if there is suspicious or pathological FHR but without unduly risking maternal safety. Verbal consent is satisfactory. Category 2: FHR is normal. The outcome for emergency CS is not worse for deliveries occurring up to 60 min from decision, provided that the situation is not immediately life- threatening for the fetus.

17. Vaginal birth Most cases operative. Very favourable characteristics: full cervical dilatation delivery would be accomplished quickly and safely. Decision-to-delivery interval: 30 min or less. Continuous CTG during labour . Ultrasound of Fetus heart {audible heart tones and cord pulsation may cease prior to delivery even though the foetal remains alive}

18. Breech extraction: Performed after internal podalic version for the second twin. Forceps or ventouse : Depend on clinical circumstances and level of skill. No difference in neonatal outcomes for fetal distress.

19. MANAGEMENT IN COMMUNITY SETTINGS Waiting for hospital transfer: knee–chest face-down position During ambulance transfer:- left-lateral position Elevate presenting part: manual or bladder filling Prevent vasospasm: minimal handling of loops of cord lying outside the vagina.

20. Management of cord prolapse before viability women should be counselled on both continuation and termination of pregnancy planning of health education EXPECTANT MANAGEMENT:- Gestational age at the limits of viability. Uterine cord replacement may be attempted. Prolongation of pregnancy at such gestational ages creates a chance of survival but morbidity from prematurity remains a frequent serious problem. DELIVERY:- signs of severe fetal compromise once viability has been reached or gestational age associated with a reasonable neonatal outcome is achieved.

21. TRAINING:- All staff involved in maternity care should receive at least annual training in the management of obstetric emergencies including the management of cord prolapse. Updates on the management of obstetric emergencies (including the interpretation of fetal heart rate patterns) are a proactive approach to risk management. All staff involved in maternity care should attend annual multidisciplinary rehearsals (skill drills) including the management of cord prolapse.

22. CLINICAL INCIDENT REPORTING:- Clinical incident forms should be submitted for all cases of cord prolapse. AUDITABLE STANDARDS:- Proportion of staff receiving annual training in cord prolapse. Audit of the management of cord prolapse in hospital settings. Audit of the management of cord prolapse in community settings. Diagnosis–delivery interval for spontaneous and assisted vaginal deliveries and CS in cases of cord prolapse.

23. PREVENTION Women with transverse, oblique or unstable lie should be offered elective admission to hospital at 37 weeks of gestation, or sooner if there are signs of labour or suspicion of ruptured membranes. Women with non-cephalic presentations and preterm pre- labour rupture of the membranes should be offered admission. In-patient care will minimize delay in diagnosis and management of cord prolapse. Labour or ruptured membranes of an abnormal lie is an indication for caesarean section. Bradycardia or variable fetal heart rate decelerations have been associated with cord prolapse. prompt vaginal examination.

24. Mismanagement of abnormal fetal heart rate patterns is the commonest feature of substandard care identified in perinatal death associated with cord prolapse Speculum vaginal examination should be performed when cord prolapse is suspected, regardless of gestation. Artificial rupture of membranes should be avoided whenever possible if the presenting part is unengaged and mobile. If it becomes necessary to rupture the membranes in such circumstances, this should be performed in theatre with capability for immediate caesarean birth. Rupture of membranes should be avoided if on vaginal examination the cord is felt below the presenting part in labour (Cord presentation). A caesarean section should be performed.

25. complication Fetal distress Intrapartum fetal death Neonatal asphyxia Early neonatal death

26. CONCLUSION Cord prolapse is a frightening and life- threatening event that occurs in labour . Rapid identification and immediate appropriate response may well save the life of a neonate. Therefore, clinicians should be knowledgeable in its recognition and management.

27. bibliography DC Dutta’s, Textbook Of Obstetrics, 8th Edition, Hiralal Konar Publications, Page 106-108. htt ps://www.slideshare.net/katt e ysquare/cord-prolapse www.slideshare.net/fasikab/cord-prolapse www.wikipedia.com