Umibilical Cord Prolapse

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..


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.


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.


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.


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


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.


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.



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.



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.


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.


√√

√√

√√

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.


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.



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.



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.


√√

√√

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.



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.


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.



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.


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.


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.


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 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.


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.


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 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??


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

Umibilical Cord Prolapse

Documents

suspicion of cord

management of cord

cord abnormalities

cord compression

definition cord presentation

background cases of

loops of umbilical cord

overall incidence of