Definition

Abnormal Umbilical cord position descends through or alongside the cervix passing the presenting part when the membrane is ruptured

Type

Occult

  • umbilical cord alongside presenting part
  • prolapsed cord contained within uterus
  • cord compressed by a shoulder/ head
  • noticed with changing FHR pattern ( prolong bradycardia/ variable deceleration)
  • Changing maternal position might relief the cord compression

Overt

  • umbilical cord past the presenting part
  • prolapsed cord protude into the vagina
  • occur with rupture membrane

Incidence

  • 0.1%-0.6% birth
 

Risk factors

  • transverse/ unstable lie
  • Breech (especially footling)
  • Multiple pregnancy ( especially 2nd twin)
  • Prematurity
  • Low birth weight (<2.5 kg)
  • Intervention ( ARM, ECV, IOL)
  • unengaged head, parous, CPD
  • Polyhydramios
  • Abnormal placenta (low)
  • fetal congenital anomalies
  • intervention ( ECV, ARM)

Problems

  • Cut blood supply to fetus –> hypoxia –> stillbirth, encephalopathy, CP

How to recognize

  • See: the umbilical cord @ vagina
  • Feel: the cord during VE below presenting part.

Management

  • call help (senior Obs, Paeds, Anaest, midwife, Theater staff)
  • Check cord: If pulsatile (baby alive) or not (IUD)
  • Check lie and presentation of baby (CS if transverse)
  • If baby alive, Know the stage of Labour ( 1st/ 2nd)
  • knee-chest face-down position / steep Trendelenberg position
  • Wrap cord in warm wet pack if visible at introitus
  • manual elevation of presenting part vaginally until bladder is filled / CS
  • Apply suprapubic pressure once presenting part elevated above pelvic
  • consider Tocolysis (to reduce contraction)(risk PPH due to uterine atony)
  • Fill bladder. Clamp cathether after 500-750 ml water is instilled
  • Emergency CS/ Vagina Delivery (if Os fully dilated)Expectant management ( only in case extreme prematurity ie 23-25 weeks )
  • Do not reduce/ frequent handling of cord manually –> cause vasoconstriction

Investigation

  • CTG: persistent variable deceleration/ profound bradycardia
  • US : to visualise cord presentation
  • These are the possible investigation you can get during this emergency case. Don’t waste your time for investigation.

Mode of delivery

  • Emergency CS (category 1)
  • Assisted Vaginal delivery ( only if feasible, fully dilated/ 9+ cm Os, multipara)
  • Expectant ( If IUD/ extreme preterm)

Knee-Chest Face-Down position

The physic behind this is to utilize gravity to bring fetus backward so that reducing compression of presenting part to prolapsed cord. Instillation of bladder with Saline 500-750mls also helps by minimizing such compression to prolapsed cord.

 

Manual Elevation of Presenting Part

Two fingers are used to elevate the presenting part, NOT the umbilical cord. It is vital to try avoid giving pressure to umbilical cord.
 

Abbreviations

  • FHR: Fetal Heart rate
  • ARM: Artificial ruptured of membrane
  • ECV: external Cephalic Version
  • IOL: induction of labour
  • CPD: cephalo-pelvic dispropotion
  • CP: cerebral palsy
  • VE: vaginal Examination
  • IUD: Intrauterine Death
  • CS: Caeserean Setion
References
  1. Sarris I, Bewley S, Agnihtori S. Training in Obstetrics And Gynaecology the essential curriculum. Oxford university Pres. 2009.
  2. Broek NVD.Life Saving Skills Manual: Essential Obstetric and Newborn Care. RCOG. RCOG Press UK. 2007
  3. Merk manual 2003.
  4. Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. Oxford Handbook of Obstetrics and gynaecology. Oxford University Press. 2nd edition 2008.
  5. RCOG Green-Top Guideline No 50. April 2008

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