Cord prolapse
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The document discusses clinical types of umbilical cord descent and the factors influencing cord prolapse, which affects 1 in 3000 deliveries, predominantly in parous women. It outlines management protocols based on the living status and maturity of the baby, emphasizing the importance of timely delivery to reduce fetal mortality linked to cord prolapse. The management strategies vary from cesarean sections to vaginal deliveries, while emphasizing that any intervention should minimize cord compression and prevent complications.
Cord prolapse
- 2. • There are three clinical types of abnormal descent of the umbilical cord by the side of the presenting part.
- 7. • 1 in 3000 Deliveries • Mostly confined to paarous women • Incedence is reduce with the increased use of elective CS in noncephalic presentations.
- 8. • Anything which interferes with perfect adaptation of the presenting part to be the lower uterine segment, disturbing the ball valve action may favor cord prolapse. • Too often, more than one factor operates.
- 9. • Malpresentations- transverse ( common) 5-10 %, breech 3 % specially with flexed legs or footling and compound presentation 10% • Contracted Pelvis • Prematurity • Twins • Hydromnios
- 10. • Placental Factor- Minor degree of placenta previa with marginal insertion of cord or long cord • Iatrogenic- Low rupture of the membranes, manual rotation of the head, ECV, IPV • Stabilizing induction
- 11. OCCULT PROLAPSE –Difficult to diagnos –Posibilities should be suspected if there is persistence of variabledeceration of fetal heart rate pattern deteected on continuous electronic fetal monitoring
- 12. CORD PRESENTATION –The diagnosis is made by feeling the pulsation of the cord through the intact membranes
- 13. CORD PROLAPSE –The cord is palpated directly by the fingers and its pulsation can be felt if the fetus is alive. –Cord pulsation may cease during uterine contraction which, however, returns after the contraction passes off. –Temptation to pull down the loop for visualization or unnecessary handling is to be avoided to prvent vasospasm.
- 14. –Fetus may be alive even in the absence of cord pulsation. –Hence, prompt USG for cardiac movements or auscultation for FHS to be done before fetal death is declared.
- 15. FETAL –The fetus is at risk of anoxia from the moment cord is prolapsed. –The blood flow is occluded either due to mechanical compression by the the presenting part or due vasospasm of the umbilical vessels due to exposure to cold or irritation when exposed outside the vulva or as a result of handling.
- 16. –The hazards to the fetus is more in vertex presentation especially when the cord is prolapsed through the anterior segment of the pelvis or when the cervix is patially dilated. –The prognosis is however, related with the interval between its detection and delivery of the baby and if the delivery is complicated, within10-30 minutes the fetal mortality can be reduced to 5- 10%. –The overall pernatal mortality is about 15- 50 %.
- 17. MATERNAL –The maternal risks are incidental due to emergency operative delivery, especially through the vaginal route. –Operative delivery involves the risk of anesthesia, blood loss and infection.
- 18. • Internal examination should be done whenever the membranes rupture prematurely or during labour in all cases of malpresentation, twins, hydramnios or vertex presentation where the head is not engaged. • Surgical induction should preferably be conducted in the operation theatre keeping everything ready for cesarean section.
- 19. • The uterine contraction may be initiated by oxytocin, if the head is not engaged prior to low rupture of the membranes. • Internal examinationboth before and after amniotomy should be carried out with cord accident in mind. • One should exclude cord presentation or occult prolapse, in unexplained fetal distress during labour.
- 20. CORD PRESENTATION –The aim is to prevent the membranes and to expedite the delivery. –Once the diagnosis is made, no attempt should be made toreplace the cord, as it is not only ineffective but the membranes inevitably rupture leading to prolapse of the cord. –If immediate vaginal delivery is not possible or contraindicated, cesarean section is the best method of delivery.
- 21. –During the time of preparing the patient for operative delivery, she is kept in exaggerated sim's position to minimize cord compression. –A rare occasion is a multipara with longitudinal lie having good uterine contractions with the cervix three-fourth (7- 8 cm) dilated, without any evidence of fetal distress. –Watchful expectancy can be adopted till full dilatation of the cervix, when the delivery can be completed by forceps or breech extraction.
- 22. CORD PROLAPSE Management protocol is to be guided by: 1) Baby living or dead 2) Maturity of baby 3) Degree of dilatation of the cervix
- 23. BABY LIVING I. DEFINITIVE TREATMENT:- Cesarean section is the best treatment when the baby is sufficiently mature and is alive. Just prior to abdominal incision, the fetal heart should be auscultated once more to avoid unnecessary section on a dead baby. The operation should be done quickly up to the delivery of the baby.
- 24. II. IMMEIDATE SAFE VAGINAL DELIVERY IF POSSIBLE:- If the head is engaged, delivery is to be completed by forceps. Ventouse may not be ideal in such circumstances as it takes a longer time. If breech, the delivery is to be completed by breech extraction and in transverse lie, it should be completed by internal version followed by breech extraction. The same also applied in cases where the head is not engaged in second baby of twins.
- 25. III. IMMEIDATE SAFE VAGINAL DELIVERY IS NOT POSSIBLE:- FIRST AID MANAGEMENT: The aim is to minimize pressure on the cord till such time when the patient is prepared for assisted delivery or is transferred to an equipped hospital. If the oxytocin infusion is on, this should be stopped. At this time intravenous fluid and O2 by face mask is given.
- 26. BLADDER FILLING has been done to raise the presenting part off the compressed cord till such time that patient has delivered. Bladder is filled with 400-750 mL of normal saline with a Foley/s catheter, the balloon is inflated and the catheter is clamped. Bladder is emptied before cesarean delivery.
- 27. TO LIFT THE PRESENTING PART OFF THE CORD, by the gloved fingers introduced in to the vagina. The fingers should placed inside the vagina till definitive treatment is instituted. POSTURAL TREATMENT, Exaggerated and elevated sim's position with a pillow or wedge under the hip or thigh, trendelenburg or knee-chest position has been traditionally mentioned but may be tiring and risksome to the patient.
- 28. TO REPLACE THE CORD IN TO THE VAGINA, to minimize vasospasm due to irritation. DEAD BABY Labour is allowed to proceed awaiting spontaneous delivery.