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MANAGEMENT OF MANAGEMENT OF
UMBILICAL CORD UMBILICAL CORD
PROLAPSEPROLAPSE
Dr. Ashraf FoudaDr. Ashraf Fouda
Obstetrics & Gynecology Obstetrics & Gynecology consultantconsultant
Damietta General HospitalDamietta General Hospital
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
DefinitionDefinition
Cord prolapseCord prolapse
has been defined as has been defined as descent of descent of
the umbilical cord through the cervixthe umbilical cord through the cervix
alongside alongside (occult)(occult) or past the or past the
presentingpresenting partpart (overt)(overt) in the in the
presence of ruptured membranes. presence of ruptured membranes.
DefinitionDefinition
Cord presentationCord presentation
is the presence of is the presence of one or more one or more
loops of umbilical cord between the loops of umbilical cord between the
fetal presenting part and the cervix, fetal presenting part and the cervix,
without membrane rupture. without membrane rupture.
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
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
Prematurity and congenital Prematurity and congenital
malformationmalformation account for the majority account for the majority
of adverse outcomes associated with cord of adverse outcomes associated with cord
prolapse in hospital settings, but cord prolapse in hospital settings, but cord
prolapse is also associated with prolapse is also associated with birth birth
asphyxia and perinatal deathasphyxia and perinatal death with with
normally-formed term babies, particularly normally-formed term babies, particularly
with with home birthhome birth. .
Delay in transfer to hospitalDelay in transfer to hospital appears appears
to be an important factor with home birth.to be an important factor with home birth.
BackgroundBackground
AsphyxiAsphyxia a may also result in may also result in hypoxic-hypoxic-
ischaemic encephalopathy and cerebral ischaemic encephalopathy and cerebral
palsypalsy. .
The principal causes of The principal causes of asphyxia asphyxia in this in this
context are thought to be :context are thought to be :
cord compressioncord compression preventing venous return preventing venous return
to the fetus and to the 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
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
Clinical areasClinical areas
What are the risk factors for cord What are the risk factors for cord prolapseprolapse??
Several risk factors are associated with Several risk factors are associated with cord prolapse . cord prolapse .
In general, they predispose to cord In general, they predispose to cord prolapse by prolapse by preventing close application preventing close application of the presenting part to the lower part of of the presenting part to the lower part of the uterus and/or pelvic brim. the 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++++
Cord abnormalitiesCord abnormalities (such as true (such as true
knots or low content of Whartonknots or low content of Wharton’’s s
jelly) and jelly) and Fetal hypoxia-acidosisFetal hypoxia-acidosis may may
alter the turgidity of the cord and alter the turgidity of the cord and
predispose to prolapse.predispose to prolapse.
What are the risk factors for cord What are the risk factors for cord prolapseprolapse??
Evidence level 4Evidence level 4
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 artificial rupture of membranes, particularly
with an unengaged presenting partwith an unengaged presenting part, are the , are the
interventions that most frequently precede cord interventions that most frequently precede cord
prolapse. prolapse.
Risk factors for cord prolapseRisk factors for cord prolapse
Evidence level 3Evidence level 3
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 What are the risk factors for cord prolapseprolapse??
Evidence level 2Evidence level 2++++
Risk factors for cord prolapse
Risk factors for cord prolapse
Can cord presentation Can cord presentation be detected antenatally? be detected antenatally?
Ultrasound examinationUltrasound examination
is not sufficiently sensitive or is not sufficiently sensitive or
specific for identification of cord specific for identification of cord
presentation antenatally and presentation antenatally and should should
not be performed routinely to not be performed routinely to
predict cord prolapsepredict cord prolapse..Grade B
Can cord prolapse or its effects be Can cord prolapse or its effects be avoidedavoided??
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
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 abnormal lie is an indication for
caesarean section. caesarean section.
Can cord prolapse or its effects be Can cord prolapse or its effects be
avoidedavoided??
Evidence level Evidence level
33
Bradycardia or variable fetal heart Bradycardia or variable fetal heart
rate decelerationsrate decelerations have been have been
associated with cord prolapse and their associated with cord prolapse and their
presence should prompt presence should prompt vaginal vaginal
examinationexamination..
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 Can cord prolapse or its effects be avoidedavoided??
Evidence level Evidence level
22
Speculum and/or a digital vaginal Speculum and/or a digital vaginal
examination should be performed when examination should be performed when
cord prolapse is suspected, regardless of cord prolapse is suspected, regardless of
gestation.gestation.
Prompt vaginal examination is the Prompt vaginal examination is the
most important aspect of diagnosis. most important aspect of diagnosis. It is important to avoid digital vaginal It is important to avoid digital vaginal
examinations in women with preterm labour, examinations in women with preterm labour,
but suspicion of cord prolapse was regarded as but suspicion of cord prolapse was regarded as
an exception to that rule.an exception to that rule.
Can cord prolapse or its effects be Can cord prolapse or its effects be avoidedavoided??
Evidence level Evidence level
33
Artificial rupture of membranes should Artificial rupture of membranes should
be avoided whenever possible if the be avoided whenever possible if the
presenting part is unengaged and presenting part is unengaged and
mobile. mobile.
If it becomes necessary to rupture the If it becomes necessary to rupture the
membranes in such circumstances, membranes in such circumstances,
this should be performed in theatre this should be performed in theatre
with capability for immediate with capability for immediate
caesarean birth. caesarean birth.
Can cord prolapse or its effects be Can cord prolapse or its effects be avoidedavoided??
Grade B
Vaginal examination and obstetric Vaginal examination and obstetric
interventions in the context of ruptured interventions in the context of ruptured
membranes carry a risk of upwards membranes carry a risk of upwards
displacement of the presenting part and cord displacement of the presenting part and cord
prolapse. prolapse.
Pressure on the presenting part should be Pressure on the presenting part should be
kept to a minimum in such women. kept 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 Can cord prolapse or its effects be avoidedavoided??
√√
√√
√√
When should cord prolapse be When should cord prolapse be suspectedsuspected??
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 spontaneous rupture of membranes
in labour. in labour. √√
√√
Cord prolapse should be suspected Cord prolapse should be suspected
when there is an when there is an abnormal fetal abnormal fetal
heart rate pattern (bradycardia, heart rate pattern (bradycardia,
variable decelerations etc) in the variable decelerations etc) in the
presence of ruptured membranespresence of ruptured membranes, ,
particularly if such changes occur particularly if such changes occur
soon after membrane rupture, soon after membrane rupture,
spontaneously or with amniotomy. spontaneously or with amniotomy.
When should cord prolapse be When should cord prolapse be suspectedsuspected??
Grade B
Speculum and/or digital vaginal
examination should be
performed at preterm gestations
when cord prolapse is suspected.
When should cord prolapse When should cord prolapse be suspectedbe suspected??
Grade D
What is the optimum management of What is the optimum management of cord prolapse in hospital settingscord prolapse 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. .
There are insufficient data for the evaluation There are insufficient data for the evaluation
of of manual replacement of the prolapsed cord manual replacement of the prolapsed cord
above the presenting partabove the presenting part to allow to allow
continuation of labour. continuation of 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 covered in
surgical packs soaked in warm saline. surgical packs soaked in warm saline.
What is the optimum management of What is the optimum management of cord prolapse in hospital settingscord prolapse in hospital settings??
Grade D
√√
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 What is the optimum management of cord prolapse in hospital of cord prolapse in hospital
settingssettings??
Grade D
√√
Elevation of the presenting partElevation of the presenting part is thought to is thought to
relieve pressure on the umbilical cord and prevent relieve pressure on the umbilical cord and prevent
mechanical vascular occlusion. mechanical vascular occlusion.
Manual elevationManual elevation is performed by inserting a gloved is performed by inserting a gloved
hand or two fingers in the vagina and pushing the hand or two fingers in the vagina and pushing the
presenting part upwards. presenting part upwards.
Excessive displacementExcessive displacement may encourage more cord may encourage more cord
to prolapse. to prolapse.
Remove the handRemove the hand from the vagina once the presenting from the vagina once the presenting
part is above the pelvic brim, and apply continuous part is above the pelvic brim, and apply continuous
suprapubic pressure.suprapubic pressure.
What is the optimum management of What is the optimum management of cord prolapse in hospital settingscord prolapse in hospital settings??
Evidence level 4Evidence level 4
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 may be more practical. be more practical.
Bladder fillingBladder filling can be achieved quickly by can be achieved quickly by inserting the cut end of an intravenous giving inserting the cut end of an intravenous giving set into a Foleyset into a Foley’’s catheter. s catheter.
The catheter should be clamped onceThe catheter should be clamped once 500-750 500-750 ml have been instilled. ml 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 What is the optimum management of cord prolapse in hospital settingscord prolapse in hospital settings??
Evidence level 3Evidence level 3
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 What is the optimum management of cord prolapse in hospital settingscord prolapse in hospital settings??
√√
√√
A caesarean section is the A caesarean section is the
recommended mode of delivery in recommended mode of delivery in
cases of cord prolapsecases of cord prolapse when vaginal when vaginal
delivery is not imminent, in order delivery is not imminent, in order
to prevent hypoxia-acidosis.to prevent hypoxia-acidosis.
What is the optimal mode of delivery with cord prolapse?
Grade B
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.
Caesarean section is associated with a Caesarean section is associated with a lower perinatal mortality and reduced risk lower perinatal mortality and reduced risk of APGAR score <3 at 5 minutesof APGAR score <3 at 5 minutes compared to spontaneous vaginal compared to spontaneous vaginal delivery in cases of cord prolapse when delivery in cases of cord prolapse when delivery is not imminent.delivery is not 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
A caesarean section of urgency A caesarean section of urgency
category 1category 1 should be performed should be performed
within 30 minutes or less if there is within 30 minutes or less if there is
cord prolapse associated with a cord prolapse associated with a
suspicious or pathological fetal heart suspicious or pathological fetal heart
rate pattern.rate pattern.
Verbal consent is satisfactory.
What is the optimal mode of delivery with cord prolapse?
Grade B
√√
The 30-minute decision-to-delivery interval The 30-minute decision-to-delivery interval (DDI)(DDI) is the target for category 1 CS. is 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 (severe bradycardia), category 1 caesarean section should be advised section should be advised
For women with a grossly pathological pattern For women with a grossly pathological pattern at at extremely preterm gestationsextremely preterm gestations (24-26 (24-26 weeks), a discussion of the chance of survival weeks), a discussion of the chance of survival should be offered and the options of delivery should be offered and the options of delivery and expectant management discussed.and expectant management discussed.
What is the optimal mode of delivery with cord prolapse?
Evidence level 2Evidence level 2
Category 2 caesarean section is
appropriate for women in whom the fetal
heart rate pattern is normal.
The presenting part should be kept The presenting part should be kept
elevated while anaesthesia is induced.elevated 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
Vaginal birth, in most cases operativeVaginal birth, in most cases operative, can , can
be attempted at full dilatation if it is be attempted at full dilatation if it is
anticipated that delivery would be anticipated that delivery would be
accomplished within 20 minutes from accomplished within 20 minutes from
diagnosis.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 there are severe CTG abnormalities and an
easy delivery is anticipated. easy delivery is anticipated.
What is the optimal mode of delivery with cord prolapse?
Grade D
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 internal podalic version for the
second twin, or for singleton breech second twin, or for singleton breech
babies when the presenting part is babies when the presenting part is
distending the perineum.distending the perineum.
What is the optimal mode of delivery with cord prolapse?
Grade C
A A practitioner competent in the practitioner competent in the
resuscitation of the newbornresuscitation of the newborn, usually a , usually a
neonatologist, should attend all deliveries neonatologist, should attend all deliveries
with cord prolapse.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 needing neonatal
resuscitationresuscitation, as evidenced by a high rate of , as evidenced by a high rate of
low APGAR scores (<7); 21% at one minute and low APGAR scores (<7); 21% at one minute and
7% at five minutes.7% at five minutes.
What is the optimal mode of delivery with cord prolapse?
Evidence level 3Evidence level 3
What is the optimal What is the optimal
management in management in
community settings?community settings?
What is the optimal management in What is the optimal management in community settingscommunity settings??
Women should be advised, over the Women should be advised, over the
telephone if necessary, to assume the telephone if necessary, to assume the
knee-chest face-downknee-chest face-down or or steep steep
Trendelenburg positionTrendelenburg position while waiting for while waiting for
hospital transfer. hospital transfer.
During emergency ambulance transfer,
the knee–chest is potentially unsafe and
the left-lateral position should be used.√√
√√
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
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
To prevent vasospasm, there
should be minimal handling of
loops of cord lying outside the
vagina.
What is the optimal What is the optimal management in community management in community
settingssettings??
√√
Perinatal mortalityPerinatal mortality is increased by is increased by
more than more than ten-foldten-fold in cases occurring in cases occurring
outside hospitaloutside hospital compared to inside the compared to inside the
hospital, and hospital, and neonatal morbidityneonatal morbidity
is also increased in this circumstance.is also increased in this circumstance.
What is the optimal management in What is the optimal management in community settingscommunity settings??
Evidence level 3Evidence level 3
What is the optimal What is the optimal
management of cord management of cord
prolapse before prolapse before
viabilityviability??
What is the optimal management of What is the optimal management of cord prolapse before viabilitycord prolapse before viability??
Expectant management can be considered Expectant management can be considered
for cord prolapse complicating for cord prolapse complicating
pregnancies with gestational age at the pregnancies with gestational age at the
limits of viability.limits of viability.
Women should be offered both Women should be offered both
continuation and termination of continuation and termination of
pregnancy following cord prolapse before pregnancy following cord prolapse before
24 completed weeks of pregnancy.24 completed weeks of pregnancy.
Grade D
√√
At At extreme preterm gestational ageextreme preterm gestational age (before (before
28 weeks), 28 weeks), expectant managementexpectant management has been has been
recorded for periods up to three weeks.recorded for periods up to three weeks.
Prolongation of pregnancyProlongation of pregnancy at such gestational at such gestational
ages creates a chance of survival but morbidity ages creates a chance of survival but morbidity
from prematurity remains a frequent serious from prematurity remains a frequent serious
problem.problem.
Some women might prefer to choose Some women might prefer to choose
termination of pregnancytermination of pregnancy, perhaps after a short , perhaps after a short
period of observation to see if labour period of observation to see if labour
commences spontaneously.commences 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
Postnatal debriefing should Postnatal debriefing should
be offered to every woman be offered to every woman
with cord prolapse.with cord prolapse.
DebriefingDebriefing
Grade D
After severe obstetric emergencies, women After severe obstetric emergencies, women
might be psychologically affected with might be psychologically affected with
postnatal depressionpostnatal depression, , post-traumatic stress post-traumatic stress
disorderdisorder, or , or fear of further childbirthfear of 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 important part of maternity
carecare and should be offered by a and should be offered by a suitably trained suitably trained
professional. professional.
DebriefingDebriefing