Cord Prolapse CPG

Cord Prolapse:

Where the umbilical cord lies in front of or beside the presenting part in the presence of ruptured membranes.

• Incidence

• Predisposing factors

• Clinical assessment

• Management

• Prevention

Incidence

• Cephalic 0.2-0.4%

• Breech 2-4%

• Multiple Pregnancies 4%

Predisposing factors

• High / ill fitting presenting part

• High parity

• Prematurity

• Multiple pregnancy

• Polyhydraminos

• Malpresentations

Clinical assessment

• Diagnosis of cord prolapse is made by visual inspection or palpation on vaginal examination where the umbilical cord is felt below or beside the presenting part.

• CTG abnormality (bradycardia, severe variable decelerations) suggestive of cord prolapse

• Where predisposing risk factors exist a vaginal examination should be performed after the membranes rupture or if fetal bradycardia occurs after rupture of membranes.

Management

• Summons medical assistance; obstetrician, anaesthetist, paediatrician.

• Immediate assessment of clinical circumstances;gestation, presentation, cervical dilatation, fetal wellbeing. Immediate delivery is necessary when the fetus is viable.

• Woman placed in knee to chest position, alternatively exaggerated Simms position - Left lateral supported with 2 pillows.

• The presenting part is pushed out of the pelvis upward by fingers in the vagina to relieve pressure on the cord by the presenting part. This is to continue until delivery is commenced.

• If the cord is protruding replace it into the vagina. Avoid overhandling as it can cause spasm.

• Administer oxygen to the woman via a mask, discontinue oxytocics if present.

• Provide reassurance and explanation to the woman.

• Delivery must be expedited to reduce morbidity and mortality to the fetus. CODE GREEN (Immediate LUSCS) if vaginal birth not imminent. Continue efforts to hold the presenting part off the cord. Deep trendelenburg position is also useful to add gravity to other efforts to elevate the fetus off the cord.

• Monitor fetal heart rate.

Prevention

• Identify risk factors or identify a cord presentation on ultrasound

• controlled ARM by senior medical staff AND

• ensure emergency theatre is available prior to ARM.