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

1. B Y ,
M R S . J A S M I M A N U
H E A D O F T H E D E P A R T M E N T , O B G
N U R S I N G
R A M A C O L L E G E O F N U R S I N G
R A M A U N I V E R S I T Y , U T T A R P R A D E S H
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. 1. 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:
1. manual elevation of the presenting fetal part
2. repositioning of the mother to be head down with feet elevated(The knee-
chest position is typically recommended)
3. 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
1. use of tocolytics (medications to suppress labor) have been proposed, usually
in addition to bladder filling rather than a standalone intervention
2. 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.

20. KNEE CHEST POSITION

21. if head is engaged, delivery is possible
 FORCEPS
 NO VENTOUSE

22. 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).