How do you manage a prolapsed cord?
Show Umbilical cord prolapse is where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus. It affects 0.1 – 0.6% of births. Cord prolapse occurs in the presence of ruptured membranes, and is either occult or overt:
Although the incidence is relatively low, the mortality rate for such babies is high (~91 per 1000). This is largely because cord prolapse occurs more frequently in preterm babies, who are often breech, and who may also have other congenital defects. In this article, we shall look at the risk factors, clinical features and management of cord prolapse. PathophysiologyUmbilical cord prolapse is where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus. Subsequently, fetal hypoxia occurs via two main mechanisms:
Risk FactorsThe main risk factors for cord prolapse include:
Fig 1 – A footling breech and umbilical cord prolapse. Clinical Features and Differential DiagnosisCord prolapse should always be considered in the presence of a non-reassuring fetal heart rate pattern and absent membranes. It can be confirmed by external inspection or on digital vaginal examination. This is one of the reasons that vaginal assessment, after abdominal examination, encompasses a full assessment in the presence of a non-reassuring fetal heart rate pattern. The fetal heart rate patterns can vary from subtle changes, such as decelerations with some of the contractions, to more obvious signs of fetal distress, such as a fetal bradycardia. The latter is strongly associated with cord prolapse; relating to the mechanism of occlusion of the cord by the presenting part. An alternative diagnosis may be considered in the presence of bleeding per vagina or heavily blood-stained liquor with ruptured membranes. This would suggest placental abruption (the placenta starts to separate from the uterine wall) or vasa praevia (fetal vessels running in the fetal membranes adjacent to the internal os of the cervix). ManagementFirstly, call for help – umbilical cord prolapse is an obstetric emergency. It should be managed as follows:
Fig 2 – The knee-chest position, used in the management of cord prolapse. Summary
What position do you place a patient with a prolapsed cord?Repositioning of the mother to be in the knee-chest position or Trendelenburg position (head down with feet elevated), lying on left side is usually preferred. Filling of the bladder using a foley catheter can help elevate the presenting fetal part and lift it off the cord.
What is the safest position for a woman in Labour with prolapsed cord?While you wait, get on your hands and knees with your pelvis up and head down to take pressure off of the cord. On the car ride over, lie down with your hips elevated.
Is a prolapsed umbilical cord an emergency?Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal morbidity and mortality.
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