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. 2
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.

3
 Definition

 Cord Presentation: Cord in front of

presenting part before the rupture of
membranes
 Cord Prolapse: Cord in front of
presenting part after rupture of
membranes
TYP
ES
• Occult cord prolapse
• Cord is adjacent to the presenting part
• Cannot be palpated during pelvic examination.
• Might lead to variable decelerations or unexplained fetal
distress.
• 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 harbinger of cord prolapse
• Overt cord prolapse
• Umbilical cord lies below the presenting part
• Associated with rupture of membranes, and displacement of
the cord through the
5
vagina.
Cord presentation Cord prolapse
vs.
 Occult cord prolapse
• Cord lying alongside the presenting
part
• Occult vs. presentation vs. prolapsed cord
 Incidence
 0.45%
P r imigra
vida 0.66% (Risk ratio

 Multigravid 0.3%
 Cephalic
a 2:3)
0.9%
 Fra n k breech
5%
 Complete breech
10%
 Footling
15%
 Shoulder
 Causes
 Malpresentation - face, brow, breech and shoulder
 Prematurity

 Polyhydramnios

 Multiple pregnancy

 L o n g cord (90-100 cm)

 PROM

 CPD
Aetiology/
Risk Factors
• The common denominator is incomplete fitting of
the presenting part into the maternal pelvis at the
time of rupture of membranes.
• Factors are interrelated.

• Can be SPONTANEOUS OR IATROGENIC.

• SPONTANEOUS factors are fetal, placental and

maternal.

• IATROGENIC factors are procedure-related. 11

Aetiology/
Risk Factors
FETAL FACTORS

• Prematurity &
IUGR
• Abnormal lies
• Malpresentati
on
• Fetal anomaly
• Multiple
pregnancy 12
Aetiology/ Risk Factors
MATERNAL
• Rupture of membranes
• Spontaneous (including preterm ROM)
• Amniotomy (ARM)
• Pelvic tumors e.g cervical fibroid
• Pelvic contraction
• Preterm labour

PLACENTAL
• Polyhydramnios
• Minor degree of placenta previa
13
 Dangers
• Mortality rate as high as 50%
• Hypoxia
• Spasm of vessels
• Operative trauma to suboxgenated
fetus
Consequences
• Cord Umbilical artery
compression vasospasm

Birth
asphyxia

Hypoxic- Perinatal
Ischemic death

Encephalopa 15
 Diagnosis
Cord pulsations

 CTG shows
variable decelerations
 Fundal pressure
causes bradycardia
US – cord loops Cord outside
vulva
 DIAGNOSIS
• Cord presentation and 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 18
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.
19
 Prevention
1. Do US for malpresentation and
cord presentation

2.FHR monitoring

3.Avoid ARM in an unengaged head

4.PV exam after ROM

 Management
 Lift presenting part off the cord

 Instruct patient NOT to push

 Position
1. Knee chest

2.Trendelenburg
Knee chest position
Trendelenburg position
Exaggerated sim’s position
 Management (cont..)
• Vulval pad
• Replacement of cord
• Tocolysis (ritodrine)
 Fu n i c Reduction

 Manual replacement of cord into uterus

 Cord gently pushed above presenting

part while other cord decompression
techniques are applied
 Stage II Labor:

- Expedite delivery with episiotomy and

vacuum extraction or forceps
 Prepare for resuscitation of the
newborn.
MANAGE
MENT
 The various modalities of management 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 VE to rule out cord prolapse
 Left lateral position
 O2 to mother
 Discontinue oxytocin infusion if in place
 Allow labor to progress if FH returns to normal and no further insult.
 Continuous fetal heart rate monitoring
 Amnioinfusion
 CS if cord compression pattern continues
27
MANAGEMENT OF OVERT
CORD PROLAPSE
Speed is of the essence and perinatal outcome is
largely dictated by the diagnosis-delivery interval.

The three components of management are:

1. Prevent or relieve cord compression and

vasospasm
2. Fetal assessment
3. Prompt delivery of the infant
28
 1. Prevent/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,
and colder
temperature
outside the
vagina can 29
lead to
Bladder
filling
• If the decision-to-delivery interval prolong
is likely to be ed,
elevation through bladder filling may be
more practical.
• Introduced by Vago4 in 1970

• It is essential to empty the bladder again just

before any delivery
attempt, be it vaginal or CS.
• Physiologically inhibits uterine contraction.
contractions
There but not
maystrongbeenough for the
presenting part to effectively compress the
cord.
• Tocolytics can also be used to achieve this (Katz et al.,
1982)
4Vago, T. Prolapse of the umbilical cord: a
method of management. 30
Am J. Obstet Gynecol,1970.
Maternal Position
•Adjustment
Knee-chest position (Genu-pectoral)
• 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

31
• Sim’s lateral position
• More relaxed and dignified for
the patient.
• Elevate buttocks with pillow

• Tredelenburg position
• A head-down tilt.
• Very tiring

32
33
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.
34
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.
• Breech extraction e.g after IPV for 2nd twin, or for
singleton breech babies
with presenting part distending the perineum 35
3. PROMPT
DELIVERY
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 targetfor

CS.
• Some investigators have noted that the interval to
delivery had little effect on Apgar scores if they
delivered within 30 minutes. 36
3. PROMPT
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.

• Regional anaesthesia may be considered in consultation with an

experienced anaesthetist
37
MANAGEMENT IN
COMMUNITY SETTING

There’s 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.

38
MANAGEMENT IN
COMMUNITY SETTING
• Women should be advised, over the telephone
if necessary, to assume the knee-chest or
steep Trendelenburg position while waiting for
hospital transfer.

• During emergency ambulance transfer, the

knee–chest is potentially unsafe and the left-39
• 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.

40
• 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.
41
PREVENT
ION
• Women with transverse, oblique or unstable lie should
be offered elective admission to hospital at 37 weeks of
gestation, or sooner if there are signs of labour or
suspicion of ruptured membranes.

• Women with non-cephalic presentations and preterm pre-

labour rupture of the membranes should be offered
admission.
42
PREVENTION
(Cont’d)
• In-patient care will minimise delay in diagnosis
and management of

cord prolapse.

• Labour or ruptured membranes of an abnormal lie

is an indication for

caesarean section.
43
 PREVENTION
(Cont’d) or variable
• Bradycardia fetal heart rate
decelerations have been associated with
cord prolapse and their presence should
prompt vaginal examination.

• Mismanagement of abnormal fetal heart

rate patterns is the commonest feature of
44
substandard care identified in perinatal
PREVENTION
(Cont’d)
• Speculum and/or a digital vaginal examination should be
performed when cord prolapse is suspected, regardless of
gestation.

• Prompt vaginal examination is the most

important aspect of diagnosis.

45
PREVENTION
(Cont’d)
•Artificial rupture of membranes should be avoided
whenever possible if the presenting part is
unengaged and mobile.

• If it becomes necessary to rupture the membranes

in such circumstances, this should be performed in
theatre with capability for immediate caesarean
birth. 46
PREVENTION
(Cont’d)
• Vaginal examination and obstetric interventions in the
context of ruptured membranes carry a risk of upwards
displacement of the presenting part and cord prolapse.

• Rupture of membranes should be avoided if on vaginal

examination the cord is felt below the presenting part in
labour (Cord presentation). A caesarean section should be
performed.

47
COUNSELL
ING
• 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 of
further childbirth. 48
COUNSELL
ING
• Women with cord prolapse who undergo urgent
transfers to hospital are possibly particularly
vulnerable to psychological trauma.

• Debriefing is an important part of maternity

care and should be offered by a
suitably trained professional.

49
COUNSELL
ING
• Women with cord prolapse who undergo urgent
transfers to hospital are possibly particularly
vulnerable to psychological trauma.

• Debriefing is an important part of maternity

care and should be offered by a
suitably trained professional.

50
 FFeettaallMMoor
• Overall - 50%
• 1st stage oftrlabour
atlaitlyty
i- 70%
• 2nstage
d of labour -30%
• Neonatal death - 4%
• Perinatal mortality- 20%
 FetaPlrMogonrot
• More with vertex than breech
asliisty
• More with anterior than posterior.

• More in prime than multi

• < 5 minutes, prognosis good, > 5 mins,

damage and death.
THANK YOU