CORD PROLAPSE

Definition
• Cord prolapse is 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 membrane

• When the membrane are intact ,it is called CORD presentation

• It is one of the obstretrics emergency seen in maternity ward & timely

delivery is the hallmark of good clinical management
TYPES
Occult cord prolapse:
. Cord is adjacent to the presenting part
.can not be palpated during pelvic examination
.might lead to variable deceleration or unexplained fetal distress
Funic[cord] presentation :
.prolapse of the umbilical cord below the level of the
presenting part before the rupture of fetal membrane
.cord can often be easily palpated
.Often the harbinger of cord prolapse
• Overt cord prolapse:
.umbilical cord lies below the presenting part
.associated with rupture of membrane and displacement of the cord
through the vagina
OTHER TYPES OF CORD PROLAPSE:

• True cord knots:

. an intertwining of a segment of umbilical cord
.Circulation is usually not obstructed
.Commonly formed by the fetus slipping through a loop of the cord
• Nuchal cords:
.The umbilical cord is wrapped around the neck of the fetus in
utero or of the baby as it is being born
.It is usually possible to slip the loop of cord gently over the
childs head
.The condition occurs in more than 25% of deliveries,more
often with long cords than with shorts one
INCIDENCE
Overall incidence of overt cord prolapse is between 0.1% to 0.6%

0.5% in cephalic presentation

0.5% in frank breech, complete breech 5%
Footling breech 15%
Transverse lie 20%
AETIOLOGY /RISK FACTORS
• The common denominator is incomplete fitting of the presenting part into the
maternal pelvis at the time of rupture of membrane
• Can be spontaneous or iatrogenic
 Spontaneous factor are fetal, maternal & placental
 Iatrogenic factors are procedure related

FETAL FACTORS:
• Prematurity & IUGR
• Abnormal lies
• Malpresentation
• Fetal anomalies
• Multiple pregnancy
MATERNAL FACTORS:
• rupture of membrane:
. Spontaneous[including preterm ROM]
. Amniotomy[ARM]
• Pelvic tumors e.g cervical fibroid
• Pelvic contraction
• Preterm labour

PLACENTAL CAUSE:
• Polyhydramnios
• Minor degree of placenta previa
Procedure related:
• Amniotomy
• External cephalic version
• Internal podalic version
• Stabilizing induction of labor
• Applying fetal scalp electrode
• Amnion infusion
• Placement of a cervical ripening balloon catheter
CONSEQUENCES
Cord compression umbilical artery vasospasm

birth asphyxia

Hypoxic ischaemic injury perinatal death

DIAGNOSIS
• Cord presentation & prolapse may occur without outward physical signs
• Suspected during clinical examinations:
abnormal fetal heart rate pattern may suggest overt or occult
cord prolapse(bradycardia, marked variable decelerations etc)
in the presence of ruptured membranes, particularly if such
changes occur soon after membrane rupture, spontaneously or with
amniotomy

Confirmed by VAGINAL EXAMINATION:

sudden appearance of a loop of umbilical cord at the introitus, usually
just after membrane rupture
may palpate cord during a vaginal examination in the absence of intact
membranes
• Cord presentation , sometimes felt below the presenting part when
membranes are intact

• Cord(funic) presentation can also be diagnosed with USS before the

onset or during early labor but is not sufficiently sensitive or specific
for identification of cord presentation antenatally and should not be
performed routinely to predict cord prolapse
 MANAGEMENT
 the various modalities of managements aim at raising the pelvis, and therefore
bring the cervix to a higher level than the fundus of the uterus
• Depends on the type of cord prolapse
OCCULT PROLAPSE:
Immediate Vaginal examination to rule out cord prolapse
Left lateral position
O2 to mother
Discontinue oxytocin infusion if in place
Allow labour to progress if FH returns to normal & no further insult
Cont. fetal heart rate monitoring
Amnioinfusion
CS if cord compression pattern continues
CORD PRESENTATION
• TERM: CS prior to membrane rupture
• PREMATURE: no consensus on management
.hospitalize patients on bed rest in Sim’s position or
trendelenberg position
.serial USS to ascertain cord position ,presentation & GA
OVERT CORD PROLAPSE
• Speed is of the essence & perinatal outcome is largely dictated by the
diagnosis- delivery interval
• The three component of management are:
1. Prevent or relieve cord compression and vasospasm
2. Fetal assessment
3. Prompt delivery of the patient
1.Prevent or relieve cord compression and
vasospasm
Manual replacement:
.manual elevation
.funic reduction
N/B : 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 & 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:

• If the decision to delivery interval is likely to be prolonged, elevation

through bladder filling may be more practical
• 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
Maternal position assessment:
• Knee chest position(genu-pectoral):
Gives maximum elevation of the presenting part
Provide 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
• Sims lateral position:
 more relaxed & dignified for the pt
• Elevate buttock with pillow

• Trendelenberg position:
 a head down position
2.FETAL ASSESSMENT
IS THE BABY VIABLE?
intervention for fetal reasons are not necessary for:
. already dead body
. too immature to survive
. lethal fetal anomaly eg. Anencephaly
• in this cases, allow labor to progress and deliver vaginally unless there’s a
contraindication to vaginal delivery

• IF BABY IS ALIVE:
• Quickest to tell is by palpating the presence or absence of pulsation in the cord
• Beware of mistaking folds of membrane or tips of fetal finger and toes
for the cord or clinicians finger pulsation
• Absence of pulsation should be confirmed between contraction in
case cord compression and pulsation return
• Fetal heart auscultation best determines whether or not the fetus is
alive. electronic fetal heart monitoring using fetal scalp electrode may
be useful
• Real time USS if available
Prompt Delivery
Cervix fully dilated:
• Vaginal birth can be attempted at full dilatation if it is anticipated that delivery
would be accomplished within 20mimutes from diagnosis
• Depending on the circumstances ,this may involve delivery by forceps, vacuum or
breech extraction
• breech extraction e.g after IPV for 2nd twin ,or for singleton breech babies with
presenting part distending the perinium

Cervix not fully dilated:

• An immediate caeserian section (usually within 30minutes) is the recommended
mode of delivery in cases of cord prolapse when vaginal delivery is not imminent,
in order to prevent hypoxia- acidosis
• The 30minutes decision- to-delivery interval is the target for CS
• 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
• Regional anaesthesia may be considered in consultation with an
experienced anaesthetist
• 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
score(<7)
MANAGEMENT IN COMMUNITY SETTINGS
• There is an increase in perinatal mortality in cases of cord prolapse occurring
outside the hospital ,even compared with an unmonitored fetus whose cord
prolapsed while in the hospital

• Women should be advised, over the telephone if necessary , to assume the knee-
chest or steep Trendelenberg position while waiting for hospital transfer

• During emergency ambulance transfer, the knee-chest is potentially unsafe and

the left-lateral 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
• The presenting part should be elevated during transfer by either
manual or bladder filling methods
• It is recommended that community midwives carry a Foley’s catheter
for this purpose and equipment for fluid infusion
PREVENTION
• Women with transverse ,oblique or unstable lie shoulb be offered
elective admission to hospital at 37weeks of gestation or sooner if
there are signs of labor or suspicion of ruptured membranes
• Women with non cephalic presentations and preterm pre-labour
rupture of the membranes should be offered admission
• In-patient care will minimize delay in diagnosis and management of
cord prolapse
• Labor or ruptured membranes of an abnormal lie is an indication for
ceserian section
• Bradycardia or variable fetal heart rate decelerations have been associated
with cord prolapse and their presence should prompt vaginal examination

• Mismanagement of abnormal fetal heart rate patterns in sthe commonest

feature of substandard care identified in perinatal death associated with
cord prolapse
• Speculum and/or digital vaginal examination should be performed when
cord prolapse is suspected ,regardless of gestation

• Prompt vaginal examination is the most important aspect of diagnosis

• Articial rupture of membrane should be avoided whenever possible if the
presenting part is unengaged and mobile

• If it becomes necessary to rupture the membrane in such circumstances,this

should be performed in theatre with capability for immediate caeserian birth

• Vaginal examination & obstetric interventions in the context of ruptured

membrane carry a risk of upwards displacement of the presenting part and cord
prolapse

• Rupture of membrane should be avoided of on vaginal examination the coed is

felt below the presenting part in labour( cord presentation). A caeserian section
should be performed
COUNCELLING
• Postnatal debriefing should be offered to every woman with cord
prolapse
• After severe obstetric emergencies, women might be psychologically
affected with postnatal depression ,post traumatic stress disorder, or
fear for further childbirth
• Women with cord prolapse who undergo urgent transfer to hospital
are possibly vulnerable to psychological trauma
• Debriefing is an important part of maternity care and should be
offered by a suitably trained professional
CONCLUSION
• Cord prolapse is a frightening and life threatening event that occurs in
labor. Rapid identification and immediate appropriate response may
well save the life of a neonate
• therefore , clinician should be knowledgeable in its recognition and
management