CORD PROLAPSE Presentation and Its Management

This is Midwifery, And it has Information about Cord prolapse and its Management, Diagnosis, its an emergency Condition that require immediate Attention when Realized

1. CORD PROLAPSE
NMT 2017
MATCHINGA

2. CORD PROLAPSE CONT’D
•SPECIFIC OBJECTIVES
•Define the following:
•Cord prolapse
•Cord presentation
•Explain the causes of cord prolapse
•Describe the prevention of cord prolapse

3. CORD PROLAPSE CONT’D
•Specific objectives continued…
•Discuss the management of:
•Cord presentation
•Cord prolapse
•Describe the management when the fetus is
dead
•Explain the complications/dangers of cord
prolapse

4. INTRODUCTION
•Cord prolapse is an obstetrical emergency
•The life of the fetus depends on early
recognition, immediate and subsequent
management, and prompt delivery of the
baby

5. CORD PROLAPSE CONT’D
•DEFINITIONS
•CORD PRESENTATION
•This occurs when the umbilical cord lies in
front of the presenting part, with the fetal
membranes still intact
•CORD PROLAPSE
•The cord lies in front of the presenting part
and the fetal membranes are ruptured

6. CORD PROLAPSE CONT’D

7. CORD PROLAPSE CONT’D
•PREDISPOSING FACTORS
•These are the same for both presentation and
prolapse of the cord
•High or ill-fitting presenting part. If the
membranes rupture spontaneously when the
fetal head is high, a loop of cord may be able to
pass between the uterine wall and the fetus,
resulting in its lying in front of the presenting
part. As the presenting part descends the cord
becomes occluded

8. CORD PROLAPSE CONT’D
•Multiparity
•The presenting part may not be engaged
when the membranes rupture and
malpresentation is more common
•Malpresentation (shoulder, brow, breech or
face) and malposition (OPP and POPP). These
are common cause of cord prolapse especially
when associated with a contracted pelvis

9. CORD PROLAPSE CONT’D
•Cord prolapse is associated with breech
presentation, especially complete or footling
breech. This relates to the ill-fitting nature of
the presenting parts and also the proximity of
the umbilicus to the buttocks
•Shoulder and compound presentation and
transverse lie carry a high risk of prolapse of
the cord occurring with spontaneous rupture
of the membranes

10. CORD PROLAPSE CONT’D
•Polyhydramnios
•The cord is liable to be swept down in a gush
of liquor if the membranes rupture
spontaneously
•The excessive liquor also prevents
engagement of the presenting part
•Controlled release of liquor during artificial
rupture of the membranes is sometimes
performed to try to prevent this

11. CORD PROLAPSE CONT’D
•FETAL
•Prematurity
•The size of the fetus in relation to the pelvis
and the uterus allows the cord to prolapse
•Babies of low birth weight (1500g) are
particularly vulnerable
•There are also more frequent malpresentation

12. CORD PROLAPSE CONT’D
•Multiple pregnancy
•Malpresentation particularly of the second
twin, is more common in multiple pregnancy
•Congenital fetal abnormalities (such as
hydrocephalus) which prevent the head from
engaging in the pelvis
•A very long cord which prolapses easily
•Locked twins

13. CORD PROLAPSE CONT’D
•PLACENTAL
•Placenta praevia
•Prevents engagement of the presenting part
•Lower-marginal insertion of the cord
•Velamentous insertion of the cord

14. CORD PROLAPSE CONT’D
•IATROGENIC
•During the artificial rupture of membranes
with a high presenting part
•During manipulations such as versions and
extraction of the fetus
•When trying to flex an extended head, in a
face presentation
•During disengagement of the head for
rotational purposes

15. CORD PROLAPSE CONT’D
•DANGERS TO THE FETUS
•ANOXIA: the fetus is at risk of having its
oxygen supply cut off because the cord is
compressed between the presenting part and
the pelvis
•With the cord lying in, or projecting from the
vagina, the umbilical vessels often go into
spasm, due to drying, cooling, and handling,
causing anoxia and the death of the fetus

16. CORD PROLAPSE CONT’D
•MARTERNAL DANGERS
•The manipulations required to serve the baby
can result in sepsis, trauma to the birth canal,
shock, and haemorrhage to the mother as
well as psychological trauma and distress

17. CORD PROLAPSE CONT’D
•CLINICAL FEATURES AND DIAGNOSIS
•AT ANTENATAL CLINIC
•Occasionally this condition is diagnosed in the
antenatal clinic on routine ultrasound
scanning, if this is available

18. CORD PROLAPSE CONT’D
•DURING LABOUR
•The diagnosis of cord prolapse is made when with
intact membranes pulsations are felt on the
examiners fingers, through the membranes on
vaginal examination
•With ruptured membranes the cord may be felt
in the vagina or, in cases where the presenting
part is very high, it may be felt in the cervical os
•A loop of cord may be visible at the vulva

19. CORD PROLAPSE CONT’D
•Cord prolapse should be suspected with an
abnormal fetal heart rate pattern
(bradycardia, severe variable decelerations)
occurring soon after spontaneous or artificial
rupture of membranes.

20. CORD PROLAPSE CONT’D
•PREVENTION
•Identification/awareness of risk factors
•artificial rupture of membranes (ARM) should
not be done when the station is high (not
engaged), there is a malpresentation of the
fetus, and with polyhydramnios.

21. CORD PROLAPSE CONT’D
•If ARM is essential to manage a difficult
obstetric situation and if the head is not
engaged and high the following process is to
be followed:
•controlled ARM by senior medical staff (with
an experienced midwife present) AND
•ensure emergency theatre is available prior to
ARM.

22. CORD PROLAPSE CONT’D
•An immediate vaginal examination must be
performed when membranes rupture
spontaneously in the following conditions:
•Especially when the presenting part is high,
with sudden unexplained fetal distress,
malpresentation, polyhydramnios in multiple
pregnancy, when the baby is markedly
preterm,

23. CORD PROLAPSE CONT’D
•At any time when performing an artificial
rupture of membranes the midwife must
always:
•Only rupture the membranes if the presenting
part is well into the pelvis (⅖ of the head
above the pelvic brim), and
•Before rupturing the membranes check for
cord presentation, and check the fetal heart
carefully for any abnormalities

24. CORD PROLAPSE CONT’D
•After rupturing the membranes check for cord
prolapse, and check the fetal heart again to
ensure that no change has taken place. If any
problems the doctor has to be notified, or the
patient should be referred to the hospital if at
a health centre

25. CORD PROLAPSE CONT’D
•NURSING DIAGNOSES THAT MAY APPLY TO A
WOMAN WITH A PROLAPSED CORDINCLUDE
THE FOLLOWING:
•Risk for impaired gas exchange in the fetus
related to decreased blood flow secondary to
compression of the umbilical cord
•Fear related to unknown outcome

26. MANAGEMENT DEPENDS ON…..
•The viability of the fetus
•The fetal condition
•The location of the emergency
•The cervical dilatation
•The type of contractions
•The parity of the client
•CPD
•Maternal cooperation

27. CORD PROLAPSE CONT’D
•MANAGEMENT OF CORD PRESENTATION
•Under no circumstances should the
membranes be ruptured
•The midwife should discontinue the vaginal
examination, in order to reduce the risk of
rupturing the membranes
•Help should be summoned including medical
aid

28. CORD PROLAPSE CONT’D
•If a continuous electronic fetal monitoring is
available, a recording may be commenced to
assess feta-wellbeing
•In the absence of continuous fetal monitoring
the fetal heart should be auscultated
continuously
•The woman should be placed in exaggerated
sim’s position or a knee-chest position to
reduce the likelihood of cord compression

29. CORD PROLAPSE CONT’D
•MANAGEMENT OF CORD PROLAPSE
•The midwife should call for urgent
assistance/shout for help and mobilize staff or
send an assistant to phone the hospital and
notify the doctor in the labour ward that the
patient will be arriving as soon as possible.
The assistant must also arrange for transport
by the quickest and safest method

30. CORD PROLAPSE CONT’D
•The midwife remains with the patient, and
remains calm, reassures the woman and her
partner, explains the problem and the
emergency measures to be undertaken
carefully and obtains the woman’s full
cooperation and reduce anxiety
•A record of the exact time of rupture of the
membranes and prolapse of the cord is
carefully made

31. CORD PROLAPSE CONT’D
•If an oxytocin infusion is in progress this
should be stopped
•The midwife should carry out a vaginal
examination and assesses the degree of
cervical dilatation, identifies the presenting
part and station. The time should also be
noted. Immediate delivery is necessary if the
fetus is viable

32. CORD PROLAPSE CONT’D
•If the cord is felt pulsating, it should be
handled as little as possible as it can cause
vasospasm
•If the cord is protruding from the vagina it
should be gently replaced using sterile
technique and using warmed swabs to try to
maintain temperature since spasm of the cord
may occur due to reduction in temperature

33. CORD PROLAPSE CONT’D
•A sterile gloved hand is gently introduced into
the vagina and the presenting part is pushed
up out of the pelvis and away from the cord to
prevent cord compression. This is to continue
until delivery is undertaken
•Instruct the patient not to bear down at any
time

34. CORD PROLAPSE CONT’D
•In certain circumstances (i.e. when there is
likely to be a long delay before delivery), the
urinary bladder may be filled with warmed
normal saline to elevate the presenting part
off the compressed cord. On doctor’s orders
an assistant inserts a 16-22 gauge Foley's
catheter into the bladder. The bulb of the
catheter is inflated with 5ml of sterile water

35. CORD PROLAPSE CONT’D
•The assistant connects an intravenous fluid
infusion of normal saline and 500mls of a
sterile normal saline is run into the bladder,
through the Foley's catheter, by means of the
intravenous infusion set. The full bladder will
inhibit contractions temporarily and help to
keep the presenting part away from the pelvic
brim and from the prolapsed cord

36. CORD PROLAPSE CONT’D
•If this procedure is completed satisfactorily the
midwife may then withdraw her hand
•The mother should be helped into an exaggerated
sim’s position or the knee-chest position. The
knee-chest position causes the fetus to gravitate
towards the diaphragm, relieving compression on
the cord
•The foot of the bed may be elevated and these
measures should be maintained until delivery of
the baby either vaginally or by caesarian section

37. CORD PROLAPSE CONT’D

38. CORD PROLAPSE CONT’D
•Administer oxygen to the woman via a mask. This
will increase oxygen capacity in the mother’s
blood and will hopefully provide the fetus with
additional oxygen
•Erect an intravenous infusion of electrolytes at 20
drops per minute
•Prepare the woman for caesarian section
•A consent form should be signed and a written
report is made of when the patient last had
something to eat and drink

39. CORD PROLAPSE CONT’D
•Once the transport arrives, the patient is
transferred to the hospital, accompanied by
the midwife who continues to monitor the
fetal condition throughout the journey
•The base hospital is informed of when the
patient leaves the clinic and is given the
expected time of arrival

40. CORD PROLAPSE CONT’D
•It is very important for the midwife to keep
the patient fully informed of the treatment
and reassure her that everything possible is
being done for her and for her baby. A simple
explanation of the possible treatment that she
may still have to undergo once they reach the
hospital, will give her time to mentally prepare
herself

41. CORD PROLAPSE CONT’D
•The midwife must remember to inform the
woman’s husband/partner or any other close
relative of what has occurred
•Once in the hospital or with the arrival of the
doctor, the patient is immediately taken to the
operating theater for an emergency caesarian
section
•Accurate records must be kept of the
management of the patient up to her arrival in
hospital and these are handed over to the labor
ward staff with suitable explanations

42. CORD PROLAPSE CONT’D
•The history and the management of the
patient are carefully recorded
•The baby will be nursed in high care

43. CORD PROLAPSE CONT’D
•THE MANAGEMENT WHEN THE FETUS IS
DEAD
–The lie is longitudinal, allow the client to
deliver vaginally
–Provide psychological and emotional
support and understanding to client and
family
–Provide narcotic analgesic

44. CORD PROLAPSE CONT’D
•Be with the client until after delivery
•In a breech presentation, a breech delivery is
carried out

45. CORD PROLAPSE CONT’D
•EVALUATION
•Expected outcomes of care include the following
•The fetal heart rate remains within the normal
range with supportive measures
•The fetus is born safely
•The woman and her family feel supported
•The woman and her partner understand the
problem and the corrective measures that are
undertaken

46. CORD PROLAPSE CONT’D
•Thank you for your time and
contributions.