Umibilical_cord_prolapse pregnancy anc..

umbilical cord prolapse in pregnancy

1. MANAGEMENT OF MANAGEMENT OF
UMBILICAL CORD UMBILICAL CORD
PROLAPSEPROLAPSE
Dr. Ashraf FoudaDr. Ashraf Fouda
Obstetrics & Gynecology consultantObstetrics & Gynecology consultant
Damietta General HospitalDamietta General Hospital

2. SOURCESSOURCES

Medline and NHSMedline and NHS databases databases
Women’s Hospitals Australasia – Clinical
Practice Guidelines - Cord Prolapse – Last
Reviewed June 2005
RCOG - Green-top Guideline - No. 50 - April
2008

7. DefinitionDefinition

Cord prolapseCord prolapse
has been defined as has been defined as descent of the descent of the
umbilical cord through the cervixumbilical cord through the cervix
alongside alongside (occult)(occult) or past the or past the
presentingpresenting partpart (overt)(overt) in the presence in the presence
of ruptured membranes. of ruptured membranes.

8. DefinitionDefinition

Cord presentationCord presentation is is
the presence of the presence of one or more loops of one or more loops of
umbilical cord between the fetal umbilical cord between the fetal
presenting part and the cervix, presenting part and the cervix,
without membrane rupture. without membrane rupture.

9. 
The overall The overall incidence incidence of cord prolapse of cord prolapse
ranges from ranges from 0.1 to 0.6 %.0.1 to 0.6 %.

With With breech presentationbreech presentation, the , the incidenceincidence
is just is just above 1%.above 1%.

Male fetusesMale fetuses seem to be predisposed. seem to be predisposed.

The incidence is higher in The incidence is higher in multiple multiple
gestationsgestations..
BackgroundBackground

10. 
Cases of cord prolapse appear Cases of cord prolapse appear
consistently in consistently in perinatal mortality perinatal mortality
enquiriesenquiries, and one large study found a , and one large study found a
perinatal mortality rate of perinatal mortality rate of 91 per 100091 per 1000..
BackgroundBackground

11. 
Prematurity and congenital malformationPrematurity and congenital malformation
account for the majority of adverse account for the majority of adverse
outcomes associated with cord prolapse in outcomes associated with cord prolapse in
hospital settings, but cord prolapse is also hospital settings, but cord prolapse is also
associated with associated with birth asphyxia and birth asphyxia and
perinatal deathperinatal death with normally-formed term with normally-formed term
babies, particularly with babies, particularly with home birthhome birth. .

Delay in transfer to hospitalDelay in transfer to hospital appears to be appears to be
an important factor with home birth.an important factor with home birth.
BackgroundBackground

12. 
AsphyxiAsphyxia a may also result in may also result in hypoxic-ischaemic hypoxic-ischaemic
encephalopathy and cerebral palsyencephalopathy and cerebral palsy. .

The principal causes of The principal causes of asphyxia asphyxia in this context are in this context are
thought to be :thought to be :

cord compressioncord compression preventing venous return to the preventing venous return to the
fetus and fetus and

umbilical arterial vasospasmumbilical arterial vasospasm secondary to secondary to
exposure to vaginal fluids and/or air. exposure to vaginal fluids and/or air.
BackgroundBackground

13. 
Because of the Because of the emergent natureemergent nature and and rare rare
incidenceincidence of the condition, there are of the condition, there are no no
randomised controlled trialsrandomised controlled trials comparing comparing
interventions. interventions.

There are a There are a large numberlarge number of of case reports, case reports,
case-control studies and case series. case-control studies and case series.
Identification and assessment of Identification and assessment of
evidenceevidence

14. Clinical areasClinical areas

15. What are the risk factors for cord prolapseWhat are the risk factors for cord prolapse??

Several risk factors are associated with cord Several risk factors are associated with cord
prolapse . prolapse .

In general, they predispose to cord prolapse In general, they predispose to cord prolapse
by by preventing close application of the preventing close application of the
presenting part to the lower part of the presenting part to the lower part of the
uterus and/or pelvic brim. uterus and/or pelvic brim.

Rupture of membranes in such Rupture of membranes in such
circumstances compounds the risk of circumstances compounds the risk of
prolapse. prolapse.
Evidence level 2Evidence level 2++++

16. 
Cord abnormalitiesCord abnormalities (such as true knots or (such as true knots or
low content of Whartonlow content of Wharton’’s jelly) and s jelly) and Fetal Fetal
hypoxia-acidosishypoxia-acidosis may alter the turgidity may alter the turgidity
of the cord and predispose to prolapse.of the cord and predispose to prolapse.
What are the risk factors for cord prolapseWhat are the risk factors for cord prolapse??
Evidence level 4Evidence level 4

17. 
About About half of caseshalf of cases of prolapse being preceded by of prolapse being preceded by
some form of obstetric manipulation.some form of obstetric manipulation.

The manipulation of the fetus in the presence of The manipulation of the fetus in the presence of
membrane rupture membrane rupture (external cephalic version, (external cephalic version,
internal podalic version of the second twin, manual internal podalic version of the second twin, manual
rotation, placement of intrauterine pressure rotation, placement of intrauterine pressure
catheters)catheters) or or

The The artificial rupture of membranes, particularly with artificial rupture of membranes, particularly with
an unengaged presenting partan unengaged presenting part, are the interventions , are the interventions
that most frequently precede cord prolapse. that most frequently precede cord prolapse.
Risk factors for cord prolapseRisk factors for cord prolapse
Evidence level 3Evidence level 3

18. 
Induction of labour with Induction of labour with
prostaglandins prostaglandins per seper se is not is not
associated with cord prolapse.associated with cord prolapse.
What are the risk factors for cord prolapseWhat are the risk factors for cord prolapse??
Evidence level 2Evidence level 2++++

19. Risk factors for cord prolapse

20. Risk factors for cord prolapse

21. Can cord presentation be Can cord presentation be
detected antenatally?detected antenatally?

Ultrasound examinationUltrasound examination is is
not sufficiently sensitive or specific not sufficiently sensitive or specific
for identification of cord presentation for identification of cord presentation
antenatally and antenatally and should not be performed should not be performed
routinely to predict cord prolapseroutinely to predict cord prolapse..
Grade B

23. Can cord prolapse or its effects be avoidedCan cord prolapse or its effects be avoided??

Women with Women with transverse, oblique or unstable transverse, oblique or unstable
lielie should be offered should be offered elective admission to elective admission to
hospital at 37+6 weeks of gestationhospital at 37+6 weeks of gestation, or sooner if , or sooner if
there are signs of labour or suspicion of there are signs of labour or suspicion of
ruptured membranes.ruptured membranes.
Women with noncephalic presentations and
preterm prelabour rupture of the membranes
should be offered admission.
Grade D
Grade C

24. 
In-patient care will In-patient care will minimise delay in minimise delay in
diagnosis and managementdiagnosis and management of cord of cord
prolapse. prolapse.

Labour or ruptured membranes of an Labour or ruptured membranes of an
abnormal lie is an indication for caesarean abnormal lie is an indication for caesarean
section. section.
Can cord prolapse or its effects be avoidedCan cord prolapse or its effects be avoided??
Evidence level 3Evidence level 3

25. 
Bradycardia or variable fetal heart rate Bradycardia or variable fetal heart rate
decelerationsdecelerations have been associated with have been associated with
cord prolapse and their presence should cord prolapse and their presence should
prompt prompt vaginal examinationvaginal examination..

Mismanagement of abnormal fetal heart Mismanagement of abnormal fetal heart
rate patterns is the rate patterns is the commonest feature of commonest feature of
substandard caresubstandard care identified in perinatal identified in perinatal
death associated with cord prolapse.death associated with cord prolapse.
Can cord prolapse or its effects be avoidedCan cord prolapse or its effects be avoided??
Evidence level 2Evidence level 2

26. 
Speculum and/or a digital vaginal examination Speculum and/or a digital vaginal examination
should be performed when cord prolapse is should be performed when cord prolapse is
suspected, regardless of gestation.suspected, regardless of gestation.

Prompt vaginal examination is the most Prompt vaginal examination is the most
important aspect of diagnosis. important aspect of diagnosis.

It is important to avoid digital vaginal examinations It is important to avoid digital vaginal examinations
in women with preterm labour, but suspicion of in women with preterm labour, but suspicion of
cord prolapse was regarded as an exception to that cord prolapse was regarded as an exception to that
rule.rule.
Can cord prolapse or its effects be avoidedCan cord prolapse or its effects be avoided??
Evidence level 3Evidence level 3

27. 
Artificial rupture of membranes should be Artificial rupture of membranes should be
avoided whenever possible if the avoided whenever possible if the
presenting part is unengaged and mobile. presenting part is unengaged and mobile.

If it becomes necessary to rupture the If it becomes necessary to rupture the
membranes in such circumstances, this membranes in such circumstances, this
should be performed in theatre with should be performed in theatre with
capability for immediate caesarean birth. capability for immediate caesarean birth.
Can cord prolapse or its effects be avoidedCan cord prolapse or its effects be avoided??
Grade B

28. 
Vaginal examination and obstetric interventions Vaginal examination and obstetric interventions
in the context of ruptured membranes carry a in the context of ruptured membranes carry a
risk of upwards displacement of the presenting risk of upwards displacement of the presenting
part and cord prolapse. part and cord prolapse.

Pressure on the presenting part should be kept Pressure on the presenting part should be kept
to a minimum in such women. to a minimum in such women.

Rupture of membranes should be avoided if on Rupture of membranes should be avoided if on
vaginal examination the cord is felt below the vaginal examination the cord is felt below the
presenting part in labour (Cord presentation) presenting part in labour (Cord presentation)

A caesarean section should be performed.A caesarean section should be performed.
Can cord prolapse or its effects be avoidedCan cord prolapse or its effects be avoided??
√√
√√
√√

29. When should cord prolapse be suspectedWhen should cord prolapse be suspected??

Cord presentation and prolapse may Cord presentation and prolapse may
occur without outward physical signs. occur without outward physical signs.

The cord should be felt for at every The cord should be felt for at every
vaginal examination and after vaginal examination and after
spontaneous rupture of membranes in spontaneous rupture of membranes in
labour. labour.
√√
√√

30. 
Cord prolapse should be suspected when Cord prolapse should be suspected when
there is an there is an abnormal fetal heart rate abnormal fetal heart rate
pattern (bradycardia, variable pattern (bradycardia, variable
decelerations etc) in the presence of decelerations etc) in the presence of
ruptured membranesruptured membranes, particularly if such , particularly if such
changes occur soon after membrane changes occur soon after membrane
rupture, spontaneously or with rupture, spontaneously or with
amniotomy. amniotomy.
When should cord prolapse be suspectedWhen should cord prolapse be suspected??
Grade B

31. Speculum and/or digital vaginal
examination should be performed at
preterm gestations when cord
prolapse is suspected.
When should cord prolapse be When should cord prolapse be
suspectedsuspected??
Grade D

32. What is the optimum management of cord What is the optimum management of cord
prolapse in hospital settingsprolapse in hospital settings??

When cord prolapse is diagnosed When cord prolapse is diagnosed
before full dilatation :before full dilatation :
1.Assistance should be immediately called ,
2.2.Venous access should be obtained, Venous access should be obtained,
3.3.Consent taken and Consent taken and
4.4.Preparations made for Preparations made for immediate immediate
delivery in theatredelivery in theatre. .

33. 
There are insufficient data for the evaluation of There are insufficient data for the evaluation of
manual replacement of the prolapsed cord above manual replacement of the prolapsed cord above
the presenting partthe presenting part to allow continuation of to allow continuation of
labour. labour. This practice is not recommended

To To prevent vasospasmprevent vasospasm, , there should be minimal
handling of loops of cord lying outside the vagina
which can be which can be covered in surgical packs soaked in covered in surgical packs soaked in
warm saline. warm saline.
What is the optimum management of cord What is the optimum management of cord
prolapse in hospital settingsprolapse in hospital settings??
Grade D
√√

34. To prevent cord compression, it is
recommended that the presenting part be
elevated either manually or by filling the
urinary bladder.
Cord compression can be further reduced by the
mother adopting the knee–chest position or
head-down tilt (preferably in left-lateral
position).
What is the optimum management of cord What is the optimum management of cord
prolapse in hospital settingsprolapse in hospital settings??
Grade D
√√

35. 
Elevation of the presenting partElevation of the presenting part is thought to relieve is thought to relieve
pressure on the umbilical cord and prevent mechanical pressure on the umbilical cord and prevent mechanical
vascular occlusion. vascular occlusion.

Manual elevationManual elevation is performed by inserting a gloved hand is performed by inserting a gloved hand
or two fingers in the vagina and pushing the presenting or two fingers in the vagina and pushing the presenting
part upwards. part upwards.

Excessive displacementExcessive displacement may encourage more cord to may encourage more cord to
prolapse. prolapse.

Remove the handRemove the hand from the vagina once the presenting part from the vagina once the presenting part
is above the pelvic brim, and apply continuous suprapubic is above the pelvic brim, and apply continuous suprapubic
pressure.pressure.
What is the optimum management of cord What is the optimum management of cord
prolapse in hospital settingsprolapse in hospital settings??
Evidence level 4Evidence level 4

36. 
If the decision-to-delivery interval is likely to be If the decision-to-delivery interval is likely to be
prolonged, prolonged, particularly if it involves ambulance particularly if it involves ambulance
transfer,transfer, elevation through elevation through bladder fillingbladder filling may be may be
more practical. more practical.

Bladder fillingBladder filling can be achieved quickly by inserting can be achieved quickly by inserting
the cut end of an intravenous giving set into a the cut end of an intravenous giving set into a
FoleyFoley’’s catheter. s catheter.

The catheter should be clamped onceThe catheter should be clamped once 500-750 500-750 ml ml
have been instilled. have been instilled.

It is essential to empty the bladder again just It is essential to empty the bladder again just
before any delivery attempt, be it vaginal or before any delivery attempt, be it vaginal or
caesarean section. caesarean section.
What is the optimum management of cord What is the optimum management of cord
prolapse in hospital settingsprolapse in hospital settings??
Evidence level 3Evidence level 3

37. Tocolysis can be considered while preparing for
caesarean section if there are persistent fetal
heart rate abnormalities after attempts to
prevent compression mechanically and when
the delivery is likely to be delayed.
Although the measures described above are
potentially useful during preparation for
delivery, they must not result in unnecessary
delay.
What is the optimum management of cord What is the optimum management of cord
prolapse in hospital settingsprolapse in hospital settings??
√√
√√

38. 
A caesarean section is the recommended A caesarean section is the recommended
mode of delivery in cases of cord prolapsemode of delivery in cases of cord prolapse
when vaginal delivery is not imminent, in when vaginal delivery is not imminent, in
order to prevent hypoxia-acidosis.order to prevent hypoxia-acidosis.
What is the optimal mode of delivery with
cord prolapse?
Grade B

39. 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.

40. 
Caesarean section is associated with a Caesarean section is associated with a lower lower
perinatal mortality and reduced risk of perinatal mortality and reduced risk of
APGAR score <3 at 5 minutesAPGAR score <3 at 5 minutes compared to compared to
spontaneous vaginal delivery in cases of spontaneous vaginal delivery in cases of
cord prolapse when delivery is not cord prolapse when delivery is not
imminent.imminent.

However, However, when vaginal birth is imminentwhen vaginal birth is imminent, ,
outcomes are equivalent to and possibly outcomes are equivalent to and possibly
better than those for caesarean.better than those for caesarean.
What is the optimal mode of delivery with
cord prolapse?
Evidence level 2Evidence level 2

41. 
A caesarean section of urgency A caesarean section of urgency category category
11 should be performed within 30 minutes should be performed within 30 minutes
or less if there is cord prolapse or less if there is cord prolapse
associated with a suspicious or associated with a suspicious or
pathological fetal heart rate pattern.pathological fetal heart rate pattern.
Verbal consent is satisfactory.
What is the optimal mode of delivery with
cord prolapse?
Grade B
√√

42. 
The 30-minute decision-to-delivery interval (DDI)The 30-minute decision-to-delivery interval (DDI) is is
the target for category 1 CS. the target for category 1 CS.

For women For women at termat term with a grossly pathological with a grossly pathological
fetal heart rate pattern on transfer from home fetal heart rate pattern on transfer from home
(severe bradycardia), category 1 caesarean section (severe bradycardia), category 1 caesarean section
should be advised should be advised

For women with a grossly pathological pattern at For women with a grossly pathological pattern at
extremely preterm gestationsextremely preterm gestations (24-26 weeks), a (24-26 weeks), a
discussion of the chance of survival should be discussion of the chance of survival should be
offered and the options of delivery and expectant offered and the options of delivery and expectant
management discussed.management discussed.
What is the optimal mode of delivery with cord
prolapse?
Evidence level 2Evidence level 2

43. Category 2 caesarean section is appropriate for
women in whom the fetal heart rate pattern is
normal.

The presenting part should be kept elevated The presenting part should be kept elevated
while anaesthesia is induced.while anaesthesia is induced.
Regional anaesthesia may be considered in
consultation with an experienced anaesthetist.
What is the optimal mode of delivery with
cord prolapse?
Grade C

44. 
Vaginal birth, in most cases operativeVaginal birth, in most cases operative, can be , can be
attempted at full dilatation if it is anticipated attempted at full dilatation if it is anticipated
that delivery would be accomplished within 20 that delivery would be accomplished within 20
minutes from diagnosis.minutes from diagnosis.

With parous women or for second twins, With parous women or for second twins,
ventouse extractionventouse extraction can be attempted by can be attempted by
experienced operators at 9 cm dilatation if experienced operators at 9 cm dilatation if
there are severe CTG abnormalities and an easy there are severe CTG abnormalities and an easy
delivery is anticipated. delivery is anticipated.
What is the optimal mode of delivery with cord
prolapse?
Grade D

45. 
Breech extractionBreech extraction can be performed can be performed
under some circumstances, e.g. after under some circumstances, e.g. after
internal podalic version for the second internal podalic version for the second
twin, or for singleton breech babies when twin, or for singleton breech babies when
the presenting part is distending the the presenting part is distending the
perineum.perineum.
What is the optimal mode of delivery with
cord prolapse?
Grade C

46. 
A A practitioner competent in the resuscitation of practitioner competent in the resuscitation of
the newbornthe newborn, usually a neonatologist, should , usually a neonatologist, should
attend all deliveries with cord prolapse.attend all deliveries with cord prolapse.

Neonates liveborn after cord prolapse are at Neonates liveborn after cord prolapse are at
significant risk of significant risk of needing neonatal resuscitationneeding neonatal resuscitation, ,
as evidenced by a high rate of low APGAR scores as evidenced by a high rate of low APGAR scores
(<7); 21% at one minute and 7% at five minutes.(<7); 21% at one minute and 7% at five minutes.
What is the optimal mode of delivery with
cord prolapse?
Evidence level 3Evidence level 3

47. What is the optimal What is the optimal
management in community management in community
settings?settings?

48. What is the optimal management in What is the optimal management in
community settingscommunity settings??

Women should be advised, over the telephone if Women should be advised, over the telephone if
necessary, to assume the necessary, to assume the knee-chest face-downknee-chest face-down
or or steep Trendelenburg positionsteep Trendelenburg position while waiting while waiting
for hospital transfer. for hospital transfer.
During emergency ambulance transfer, the
knee–chest is potentially unsafe and the left-
lateral position should be used.
√√
√√

49. All women with cord prolapse should be advised
to be transferred to the nearest consultant unit
for delivery, unless an immediate vaginal
examination by a competent professional
reveals that a spontaneous vaginal delivery is
imminent.
Preparations for transfer should still be made.
What is the optimal management in What is the optimal management in
community settingscommunity settings??
Grade B

50. 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.
What is the optimal management in What is the optimal management in
community settingscommunity settings??
Grade D

51. To prevent vasospasm, there should
be minimal handling of loops of cord
lying outside the vagina.
What is the optimal management in What is the optimal management in
community settingscommunity settings??
√√

52. 
Perinatal mortalityPerinatal mortality is increased by more is increased by more
than than ten-foldten-fold in cases occurring in cases occurring outside outside
hospitalhospital compared to inside the hospital, compared to inside the hospital,
and and neonatal morbidityneonatal morbidity is also is also
increased in this circumstance.increased in this circumstance.
What is the optimal management in What is the optimal management in
community settingscommunity settings??
Evidence level 3Evidence level 3

53. What is the optimal What is the optimal
management of cord management of cord
prolapse before viabilityprolapse before viability??

54. What is the optimal management of cord What is the optimal management of cord
prolapse before viabilityprolapse before viability??

Expectant management can be considered for Expectant management can be considered for
cord prolapse complicating pregnancies with cord prolapse complicating pregnancies with
gestational age at the limits of viability.gestational age at the limits of viability.

Women should be offered both continuation Women should be offered both continuation
and termination of pregnancy following cord and termination of pregnancy following cord
prolapse before 24 completed weeks of prolapse before 24 completed weeks of
pregnancy.pregnancy.
Grade D
√√

55. 
At At extreme preterm gestational ageextreme preterm gestational age (before 28 (before 28
weeks), weeks), expectant managementexpectant management has been recorded has been recorded
for periods up to three weeks.for periods up to three weeks.

Prolongation of pregnancyProlongation of pregnancy at such gestational ages at such gestational ages
creates a chance of survival but morbidity from creates a chance of survival but morbidity from
prematurity remains a frequent serious problem.prematurity remains a frequent serious problem.

Some women might prefer to choose termination Some women might prefer to choose termination
of pregnancyof pregnancy, perhaps after a short period of , perhaps after a short period of
observation to see if labour commences observation to see if labour commences
spontaneously.spontaneously.
What is the optimal management of cord What is the optimal management of cord
prolapse before viabilityprolapse before viability??
Evidence level 3Evidence level 3

56. 
Postnatal debriefing should be Postnatal debriefing should be
offered to every woman with offered to every woman with
cord prolapse.cord prolapse.
DebriefingDebriefing
Grade D

57. 
After severe obstetric emergencies, women might After severe obstetric emergencies, women might
be psychologically affected with be psychologically affected with postnatal postnatal
depressiondepression, , post-traumatic stress disorderpost-traumatic stress disorder, or , or fear fear
of further childbirthof further childbirth. .

Women with cord prolapse who undergo urgent Women with cord prolapse who undergo urgent
transfers to hospital are possibly particularly transfers to hospital are possibly particularly
vulnerable to psychological trauma.vulnerable to psychological trauma.

Debriefing is an Debriefing is an important part of maternity careimportant part of maternity care
and should be offered by a and should be offered by a suitably trained suitably trained
professional. professional.
DebriefingDebriefing