Purpose
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To assist/advise with the prevention, diagnosis and management of cord prolapse/presentation.
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Definitions
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Cord prolapse: the umbilical cord lies in front of or beside the presenting part in the presence of ruptured membranes.
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Cord presentation: the presence of the umbilical cord between the presenting part of the fetus and the cervix.
In both conditions a loop of the cord is below the presenting part. The difference is in the condition of the membranes; if intact it is cord presentation and if ruptured it is cord prolapse.
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Incidence
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The incidence of cord prolapsed\presentation is said to occur in 0.2 - 0.5% of births. The predisposition to cord prolapse is higher in a breech presentation and with multiple gestations.
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Risk factors
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- high/ill fitting presenting part
- high parity
- prematurity
- multiple pregnancy
- polyhydramnios
- malpresentations
- obstetric manipulation
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Prevention
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- identification/awareness of risk factors
- artificial rupture of membranes (ARM) should not be done when the station is high.
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If ARM is essential to manage a difficult obstetric situation and the head is not engaged and high the following process is to be followed:
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- controlled ARM by senior medical staff (with an experienced midwife present) AND
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- ensure emergency theatre is available prior to ARM.
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The same procedure should take place in the situation of polyhydramnios.
Consider the need to identify a cord presentation on ultrasound.
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Clinical recognition
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Diagnosis of cord prolapse is made by visual inspection or palpation or on vaginal examination where the umbilical cord is felt below or beside the presenting part.
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.
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Note: In the presence of predisposing risk factors a vaginal examination should always be performed after the membranes rupture or if fetal bradycardia occurs after rupture of membranes.
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Management
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- summon urgent medical assistance (Pink Alert or Code Green may be initiated depending on clinical situation)
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- initiate immediate assessment of clinical circumstances; gestation, presentation, cervical dilatation, fetal wellbeing. Immediate delivery is necessary when the fetus is viable.
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- place the woman in either knee to chest position (refer below to: figure 1).
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Figure 1. Knee to chest position
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or alternatively an exaggerated Sims’ position (left lateral supported with 2 pillows) (refer below to: figure 2).
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Figure 2. Exaggerated Sims' position
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- prevent cord compression: the presenting part is pushed out of the pelvis upward by fingers in the vagina. This is to continue until delivery is undertaken. Note if the cord is pulsating.
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- 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.
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- avoid over-handling of umbilical cord as it can cause vasospasm
- administer oxygen to the woman via a mask (oxygenation pre-caesarean section/birth)
- discontinue oxytocics if present
- provide reassurance and explanation to the woman/ family
- continue efforts to hold the presenting part off the cord
- delivery must be expedited to reduce morbidity and mortality to the fetus:
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 | - undertake immediate LUSCS if vaginal birth not imminent
- undertake assisted vaginal birth (if conditions are suitable [e.g. fully dilated, MG, presenting part at spines or below]).
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- deep Trendelenburg position may also be useful to add gravity to other efforts to elevate the fetus off the cord
- monitor and document fetal heart rate
- consider tocolysis with terbutaline if there is a delay in caesarean section/birth
- paired umbilical cord blood samples to be collected following delivery/birth.
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Post birth
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- documentation of birth and outcome (contemporaneous and factual)
- debrief: family (by senior medical staff), medical and midwifery staff involved in the birth.
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References
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Evidence table
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Evidence Table: Cord Prolapse
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Revised and updated: 14 April 2009
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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