CORD PROLAPSE Presentation and Its Management
- 2. CORD PROLAPSE CONT’D • SPECIFIC OBJECTIVES • Define the following: • Cord prolapse • Cord presentation • Explain the causes of cord prolapse • Describe the prevention of cord prolapse
- 3. CORD PROLAPSE CONT’D • Specific objectives continued… • Discuss the management of: • Cord presentation • Cord prolapse • Describe the management when the fetus is dead • Explain the complications/dangers of cord prolapse
- 4. INTRODUCTION • Cord prolapse is an obstetrical emergency • The life of the fetus depends on early recognition, immediate and subsequent management, and prompt delivery of the baby
- 5. CORD PROLAPSE CONT’D • DEFINITIONS • CORD PRESENTATION • This occurs when the umbilical cord lies in front of the presenting part, with the fetal membranes still intact • CORD PROLAPSE • The cord lies in front of the presenting part and the fetal membranes are ruptured
- 7. CORD PROLAPSE CONT’D • PREDISPOSING FACTORS • These are the same for both presentation and prolapse of the cord • High or ill-fitting presenting part. If the membranes rupture spontaneously when the fetal head is high, a loop of cord may be able to pass between the uterine wall and the fetus, resulting in its lying in front of the presenting part. As the presenting part descends the cord becomes occluded
- 8. CORD PROLAPSE CONT’D • Multiparity • The presenting part may not be engaged when the membranes rupture and malpresentation is more common • Malpresentation (shoulder, brow, breech or face) and malposition (OPP and POPP). These are common cause of cord prolapse especially when associated with a contracted pelvis
- 9. CORD PROLAPSE CONT’D • Cord prolapse is associated with breech presentation, especially complete or footling breech. This relates to the ill-fitting nature of the presenting parts and also the proximity of the umbilicus to the buttocks • Shoulder and compound presentation and transverse lie carry a high risk of prolapse of the cord occurring with spontaneous rupture of the membranes
- 10. CORD PROLAPSE CONT’D • Polyhydramnios • The cord is liable to be swept down in a gush of liquor if the membranes rupture spontaneously • The excessive liquor also prevents engagement of the presenting part • Controlled release of liquor during artificial rupture of the membranes is sometimes performed to try to prevent this
- 11. CORD PROLAPSE CONT’D • FETAL • Prematurity • The size of the fetus in relation to the pelvis and the uterus allows the cord to prolapse • Babies of low birth weight (1500g) are particularly vulnerable • There are also more frequent malpresentation
- 12. CORD PROLAPSE CONT’D • Multiple pregnancy • Malpresentation particularly of the second twin, is more common in multiple pregnancy • Congenital fetal abnormalities (such as hydrocephalus) which prevent the head from engaging in the pelvis • A very long cord which prolapses easily • Locked twins
- 13. CORD PROLAPSE CONT’D • PLACENTAL • Placenta praevia • Prevents engagement of the presenting part • Lower-marginal insertion of the cord • Velamentous insertion of the cord
- 14. CORD PROLAPSE CONT’D • IATROGENIC • During the artificial rupture of membranes with a high presenting part • During manipulations such as versions and extraction of the fetus • When trying to flex an extended head, in a face presentation • During disengagement of the head for rotational purposes
- 15. CORD PROLAPSE CONT’D • DANGERS TO THE FETUS • ANOXIA: the fetus is at risk of having its oxygen supply cut off because the cord is compressed between the presenting part and the pelvis • With the cord lying in, or projecting from the vagina, the umbilical vessels often go into spasm, due to drying, cooling, and handling, causing anoxia and the death of the fetus
- 16. CORD PROLAPSE CONT’D • MARTERNAL DANGERS • The manipulations required to serve the baby can result in sepsis, trauma to the birth canal, shock, and haemorrhage to the mother as well as psychological trauma and distress
- 17. CORD PROLAPSE CONT’D • CLINICAL FEATURES AND DIAGNOSIS • AT ANTENATAL CLINIC • Occasionally this condition is diagnosed in the antenatal clinic on routine ultrasound scanning, if this is available
- 18. CORD PROLAPSE CONT’D • DURING LABOUR • The diagnosis of cord prolapse is made when with intact membranes pulsations are felt on the examiners fingers, through the membranes on vaginal examination • With ruptured membranes the cord may be felt in the vagina or, in cases where the presenting part is very high, it may be felt in the cervical os • A loop of cord may be visible at the vulva
- 19. CORD PROLAPSE CONT’D • Cord prolapse should be suspected with an abnormal fetal heart rate pattern (bradycardia, severe variable decelerations) occurring soon after spontaneous or artificial rupture of membranes.
- 20. CORD PROLAPSE CONT’D • PREVENTION • Identification/awareness of risk factors • artificial rupture of membranes (ARM) should not be done when the station is high (not engaged), there is a malpresentation of the fetus, and with polyhydramnios.
- 21. CORD PROLAPSE CONT’D • If ARM is essential to manage a difficult obstetric situation and if the head is not engaged and high the following process is to be followed: • controlled ARM by senior medical staff (with an experienced midwife present) AND • ensure emergency theatre is available prior to ARM.
- 22. CORD PROLAPSE CONT’D • An immediate vaginal examination must be performed when membranes rupture spontaneously in the following conditions: • Especially when the presenting part is high, with sudden unexplained fetal distress, malpresentation, polyhydramnios in multiple pregnancy, when the baby is markedly preterm,
- 23. CORD PROLAPSE CONT’D • At any time when performing an artificial rupture of membranes the midwife must always: • Only rupture the membranes if the presenting part is well into the pelvis (⅖ of the head above the pelvic brim), and • Before rupturing the membranes check for cord presentation, and check the fetal heart carefully for any abnormalities
- 24. CORD PROLAPSE CONT’D • After rupturing the membranes check for cord prolapse, and check the fetal heart again to ensure that no change has taken place. If any problems the doctor has to be notified, or the patient should be referred to the hospital if at a health centre
- 25. CORD PROLAPSE CONT’D • NURSING DIAGNOSES THAT MAY APPLY TO A WOMAN WITH A PROLAPSED CORDINCLUDE THE FOLLOWING: • Risk for impaired gas exchange in the fetus related to decreased blood flow secondary to compression of the umbilical cord • Fear related to unknown outcome
- 26. MANAGEMENT DEPENDS ON….. • The viability of the fetus • The fetal condition • The location of the emergency • The cervical dilatation • The type of contractions • The parity of the client • CPD • Maternal cooperation
- 27. CORD PROLAPSE CONT’D • MANAGEMENT OF CORD PRESENTATION • Under no circumstances should the membranes be ruptured • The midwife should discontinue the vaginal examination, in order to reduce the risk of rupturing the membranes • Help should be summoned including medical aid
- 28. CORD PROLAPSE CONT’D • If a continuous electronic fetal monitoring is available, a recording may be commenced to assess feta-wellbeing • In the absence of continuous fetal monitoring the fetal heart should be auscultated continuously • The woman should be placed in exaggerated sim’s position or a knee-chest position to reduce the likelihood of cord compression
- 29. CORD PROLAPSE CONT’D • MANAGEMENT OF CORD PROLAPSE • The midwife should call for urgent assistance/shout for help and mobilize staff or send an assistant to phone the hospital and notify the doctor in the labour ward that the patient will be arriving as soon as possible. The assistant must also arrange for transport by the quickest and safest method
- 30. CORD PROLAPSE CONT’D • The midwife remains with the patient, and remains calm, reassures the woman and her partner, explains the problem and the emergency measures to be undertaken carefully and obtains the woman’s full cooperation and reduce anxiety • A record of the exact time of rupture of the membranes and prolapse of the cord is carefully made
- 31. CORD PROLAPSE CONT’D • If an oxytocin infusion is in progress this should be stopped • The midwife should carry out a vaginal examination and assesses the degree of cervical dilatation, identifies the presenting part and station. The time should also be noted. Immediate delivery is necessary if the fetus is viable
- 32. CORD PROLAPSE CONT’D • If the cord is felt pulsating, it should be handled as little as possible as it can cause vasospasm • If the cord is protruding from the vagina it should be gently replaced using sterile technique and using warmed swabs to try to maintain temperature since spasm of the cord may occur due to reduction in temperature
- 33. CORD PROLAPSE CONT’D • A sterile gloved hand is gently introduced into the vagina and the presenting part is pushed up out of the pelvis and away from the cord to prevent cord compression. This is to continue until delivery is undertaken • Instruct the patient not to bear down at any time
- 34. CORD PROLAPSE CONT’D • In certain circumstances (i.e. when there is likely to be a long delay before delivery), the urinary bladder may be filled with warmed normal saline to elevate the presenting part off the compressed cord. On doctor’s orders an assistant inserts a 16-22 gauge Foley's catheter into the bladder. The bulb of the catheter is inflated with 5ml of sterile water
- 35. CORD PROLAPSE CONT’D • The assistant connects an intravenous fluid infusion of normal saline and 500mls of a sterile normal saline is run into the bladder, through the Foley's catheter, by means of the intravenous infusion set. The full bladder will inhibit contractions temporarily and help to keep the presenting part away from the pelvic brim and from the prolapsed cord
- 36. CORD PROLAPSE CONT’D • If this procedure is completed satisfactorily the midwife may then withdraw her hand • The mother should be helped into an exaggerated sim’s position or the knee-chest position. The knee-chest position causes the fetus to gravitate towards the diaphragm, relieving compression on the cord • The foot of the bed may be elevated and these measures should be maintained until delivery of the baby either vaginally or by caesarian section
- 38. CORD PROLAPSE CONT’D • Administer oxygen to the woman via a mask. This will increase oxygen capacity in the mother’s blood and will hopefully provide the fetus with additional oxygen • Erect an intravenous infusion of electrolytes at 20 drops per minute • Prepare the woman for caesarian section • A consent form should be signed and a written report is made of when the patient last had something to eat and drink
- 39. CORD PROLAPSE CONT’D • Once the transport arrives, the patient is transferred to the hospital, accompanied by the midwife who continues to monitor the fetal condition throughout the journey • The base hospital is informed of when the patient leaves the clinic and is given the expected time of arrival
- 40. CORD PROLAPSE CONT’D • It is very important for the midwife to keep the patient fully informed of the treatment and reassure her that everything possible is being done for her and for her baby. A simple explanation of the possible treatment that she may still have to undergo once they reach the hospital, will give her time to mentally prepare herself
- 41. CORD PROLAPSE CONT’D • The midwife must remember to inform the woman’s husband/partner or any other close relative of what has occurred • Once in the hospital or with the arrival of the doctor, the patient is immediately taken to the operating theater for an emergency caesarian section • Accurate records must be kept of the management of the patient up to her arrival in hospital and these are handed over to the labor ward staff with suitable explanations
- 42. CORD PROLAPSE CONT’D • The history and the management of the patient are carefully recorded • The baby will be nursed in high care
- 43. CORD PROLAPSE CONT’D • THE MANAGEMENT WHEN THE FETUS IS DEAD –The lie is longitudinal, allow the client to deliver vaginally –Provide psychological and emotional support and understanding to client and family –Provide narcotic analgesic
- 44. CORD PROLAPSE CONT’D • Be with the client until after delivery • In a breech presentation, a breech delivery is carried out
- 45. CORD PROLAPSE CONT’D • EVALUATION • Expected outcomes of care include the following • The fetal heart rate remains within the normal range with supportive measures • The fetus is born safely • The woman and her family feel supported • The woman and her partner understand the problem and the corrective measures that are undertaken
- 46. CORD PROLAPSE CONT’D • Thank you for your time and contributions.