Umbilical cord prolapsed and
presentation
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 CS 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 CS. This usually results in fetal
deaths.
CORD PROLAPSE
• Defined as descent of the umbilical cord into the
lower uterine segment where it may lie adjacent
to the presenting part or below the presenting
part, without intact fetal membranes.
• When the membranes are intact, it is called
CORD PRESENTATION.
Umbilical cord prolapse and presentation
• Definition
The umbilical cord drops (prolapses) through
the open cervix into the vagina ahead of the
baby, where it may lie adjacent to the presenting
part (occult- hidden cord prolapse) or below the
presenting part (overt cord prolapse).
1. Occult cord prolapse
• Cord is adjacent to the presenting part
• Cannot be palpated during pelvic examination.
• Might lead to variable slow or unexplained fetal
distress.
2. Funic (cord) presentation
• Prolapse of the umbilical cord below the level of
the presenting part before the rupture of fetal
membranes
• Cord can often be easily palpated through the
membranes
• Often the signal of cord prolapse
3. Overt cord prolapse
• Umbilical cord lies below the presenting part
•Associated with rupture of membranes, and
displacement of the cord through the vagina.
INCIDENCE
• The incidence of occult cord prolapse is unknown
because it can be detected only by fetal heart rate
changes characteristic of umbilical cord compression.
• Overall Incidence of overt cord prolapse is between
0.1% to 0.6%1
• 0.5% in cephalic presentation
• 0.5% frank breech
• complete breech 5%
• footling breech 15%,
• transverse lie 20%
• MANAGEMENT OF OVERT CORD PROLAPSE
The three components of management are:
1. Prevent or relieve cord compression and
vasospasm
2. Fetal assessment
3. Prompt delivery of the infant
1. Prevent/relieve cord compression and vasospasm
Manual replacement
Manual elevation
Funic reduction
There should be minimal handling of loops of cord
lying outside the vagina
cover in surgical packs soaked in warm saline.
Rough handling of the cord, and colder temperature
outside the vagina can lead to vasospasm
Gently replace in the vagina if outside the vagina
Bladder filling
Adjust maternal position
Bladder filling
• Alternatively, 400–700 mL of saline can be
instilled into the bladder in order to elevate the
presenting part.
• It is essential to empty the bladder again just
before any delivery attempt, be it vaginal or CS.
• Physiologically inhibits uterine contraction.
There may be contractions but not strong
enough for the presenting part to effectively
compress the cord.
Tocolytics can also be used to achieve this
Maternal Position Adjustment
Knee-chest position
• Gives maximum elevation of the presenting
part.
• Provides good initial evaluation of the
presenting part.
• A tiring posture to maintain. • If any length of
time is involved, move to the Sim’s lateral
position
Sim’s lateral position
• More relaxed and dignified for the patient.
• Elevate buttocks with pillow
Trendelenburg position
• A head-down tilt.
• Very tiring
2. FETAL ASSESSMENT IS THE BABY VIABLE?
Interventions for fetal reasons are not necessary
for:
• Already dead baby
• Too immature to survive (e.g. before age of fetal
viability)
• Lethal fetal anomaly (e.g. anencephaly)
• In these cases, allow labour to progress and
deliver vaginally unless there’s a contraindication
to vaginal delivery
IF BABY IS ALIVE
• Quickest way to tell is by palpating the presence or
absence of pulsations in the cord.
• Beware of mistaking folds of membranes or tips of fetal
fingers and toes for the cord. Or clinician’s finger
pulsation.
• Absent pulsations should be confirmed between
contractions in case cord compression is released and
pulsations return.
• Fetal heart auscultation best determines whether or not the
fetus is alive.
Electronic fetal heart monitoring using fetal scalp electrode
may be useful..
3. PROMPT DELIVERY
CERVIX FULLY DILATED
Vaginal birth can be attempted at full dilatation if
it is anticipated that delivery would be
accomplished within 20 minutes from diagnosis.
Depending on the circumstances, this may
involve delivery by forceps, vacuum or breech
extraction.
• CERVIX NOT FULLY DILATED
An immediate Caesarean Section (usually within
30 minutes) is the recommended mode of
delivery in cases of cord prolapse when vaginal
delivery is not imminent, in order to prevent
hypoxia-acidosis.
The 30-minute decision-to-delivery interval
(DDI) is the target for CS.
Oxygen should be given to the mother until the
anesthesiologist is prepared to administer a rapid-
acting inhalation anesthetic for delivery
• The presenting part should be kept elevated during
induction of anaesthesia and placement of sterile
sheets.
• Remember to drain bladder before incision.
• Recheck fetal heart before incision.
• A practitioner competent in the resuscitation of the
newborn, usually a neonatologist, should attend all
deliveries with cord prolapse.
• Neonates born after cord prolapse are at significant
risk of needing neonatal resuscitation, as evidenced
by a high rate of low APGAR scores (<7)
