History

Fact Explanation
Cord prolapse is usually diagnosed by seeing the umbilical cord at the introitus or feeling it within the vagina during vaginal examination. Cord prolapse is defined as the presence the umbilical cord below the presenting part of the fetus when the membranes are ruptured. It is an obstetric emergency. It has an incidence of 0.1% - 0.6% of all deliveries.[1] Cord prolapse occurs when the presenting part does not fit well into the maternal pelvis. Predisposing factors for cord prolapse include malpresentation or abnormal lie, multiple pregnancy, polyhydramnios, prematurity, placenta previa, long umbilical cord etc.[2] [3] Cord presentation is defined as the presence of the cord below the presenting part with intact membranes.
Fetal heart rate changes commencing soon after membrane rupture (spontaneous / artificial) may indicate cord prolapse The sudden decompression and gush of amniotic fluid following membrane rupture can predispose to prolapse of the cord.[2]
Cord prolapse can occur without physical signs or fetal heart rate changes. Anticipation of cord prolapse in high risk patients is required.[2]
References
  1. MURPHY DJ, MACKENZIE IZ. The mortality and morbidity associated with umbilical cord prolapse. British Journal of Obstetrics & Gynaecology, 1995, 102, 826–30.
  2. Umbilical cord prolapse. Royal College of Obstetricians and Gynaecologists, April 2008 [Viewed 05 May 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/umbilical-cord-prolapse-green-top-50
  3. DILBAZ B, OZTURKOGLU E, DILBAZ S, OZTURK N, SIVASLIOGLU AA, HABERAL A. Risk factors and perinatal outcomes associated with umbilical cord prolapse. Archives of Gynecology and Obstetrics, 2006, 274, 104–7.

Examination

Fact Explanation
Vaginal examination 1. Visualization of the cord at the introitus[1] 2. Feeling the cord within the vagina Avoid vaginal examination in clear cut cases to minimize handling of the cord which can lead to spasm.
Obstetric abdominal examination – Reduction in the fetal heart rate detected by Pinard examination. Compression of the cord by the presenting part and vasospasm of the umbilical vessels will lead to fetal hypoxia. Fetal heart rate can also be assesses by CTG or doppler.[2]
References
  1. BAKER P.N, KENNY L.C. Obstetrics by ten teachers. 19th ed. London : Hodder Arnold, 2011.
  2. KHAN RS, NARU T, NIZAMI F. Umbilical cord prolapse--a review of diagnosis to delivery interval on perinatal and maternal outcome. J Pak Med Assoc [online] 2007 Oct, 57(10):487-91 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17990422

Differential Diagnoses

Fact Explanation
Cord presentation Cord presentation is defined as the presence of the cord below the presenting part with the membranes still intact. Rupture of the membranes in this instance can lead to cord prolapse.[1]
Knots of the umbilical cord True cord knots can lead to abrupt reduction in fetal blood supply leading to fetal asphyxia and fetal death.[2] Cord knots are seen in twin pregnancy particularly in monoamniotic twins.
References
  1. Umbilical cord prolapse. Royal College of Obstetricians and Gynaecologists, April 2008 [Viewed 05 May 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/umbilical-cord-prolapse-green-top-50
  2. SZCZEPANIK ME, WITTICH AC. True knot of the umbilical cord: a report of 13 cases. Military Medicine, 2007 Aug, 172(8), 892-4.

Investigations - for Diagnosis

Fact Explanation
Diagnosis is usually clinical Detection of the prolapsed cord on vaginal examination should alert the clinician about this obstetric emergency. Prompt delivery of the fetus should be undertaken without unnecessary delay for investigations since longer the duration of cord compression worse the fetal prognosis.[1]
Cardiotocography (CTG) Not necessary for the diagnosis but will indicate fetal hypoxia. Reduced blood supply to the fetus will lead to the development of deep variable decelerations and later on fetal bradycardia.[2] [3] [4]
References
  1. Umbilical cord prolapse. Royal College of Obstetricians and Gynaecologists, April 2008 [Viewed 05 May 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/umbilical-cord-prolapse-green-top-50
  2. TEJANI S, TEJANI N, WEISS RR, NATHANSON H. Vasa previa. Diagnosis and management. New York State journal of medicine, 1979, 79, 772–3.
  3. BAILEY R.E. Intrapartum Fetal Monitoring. American Family Physician, 2009 Dec, 80(12), 1388-1396.
  4. MORRISON E.H. Common Peripartum Emergencies. American Family Physician. 1998 Nov, 58(7), 1593-1604.

Management - General Measures

Fact Explanation
Patient education and counseling The patient should be told about the condition, its fetal implications and counseled on the need for emergency delivery. Verbal consent is adequate for surgical interventions.[1]
Calling for assistance and preparation for emergency delivery Call for help – obstetric team, anesthetic team, pediatric team should be informed. The theater should be informed and the patient prepared for emergency surgery.[1]
Cord prolapse in the home setting The patient should be advised to assume a knee-chest position. During ambulance transfer a left lateral position is preferred. Methods to reduce cord compression can be adopted, filling the bladder with warm saline, manually elevating the presenting part etc.[2]
Screening for cord presentation antenatally. Routine ultrasound scanning to detect cord presentation is currently not recommended. The predictability of antenatally detected cord presentation progressing to cord prolapse is low.[1]
Prevention Avoid artificial rupture of the membranes if cord presentation is detected at vaginal examination. The clinician should be alert to the risk of cord prolapsed in presence of risk factors such as polyhydramnios, prematurity, multiple pregnancy etc.[3] A stabilizing induction can be used in the presence of a high presenting part where an assistant stabilizers the presenting part suprapubically while amniotomy is performed. Cord prolapse is excluded afterwards.
References
  1. Umbilical cord prolapse. Royal College of Obstetricians and Gynaecologists, April 2008 [Viewed 05 May 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/umbilical-cord-prolapse-green-top-50
  2. CLINICAL GUIDELINE FOR THE MANAGEMENT OF UMBILICAL CORD PROLAPSE. Royal Cornwall Hospitals NHS Trust, 2012 [Viewed on 4 May 2014]. Available from: http://www.rcht.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/MidwiferyAndObstetrics/UmblilicalCordProlapseGuidelineForTheManagementOf.pdf
  3. BOYLE JJ, KATZ VL. Umbilical cord prolapse in current obstetric practice. Journal of Reproductive Medicine, 2005, 50, 303–6.

Management - Specific Treatments

Fact Explanation
Prompt delivery of the fetus. This can be achieved via an emergency caesarian section or by vaginal delivery if the patient is at term with a favorable cervix. A category 1 caesarian section should be performed in the presence of fetal heart rate changes while a category 2 caesarian section is performed in the absence of fetal heart rate changes.[1] Vaginal delivery is attempted in the presence of full cervical dilatation and instrumental delivery can aid in quickening the vaginal delivery. Breech extraction can be attempted for the second twin in multiple pregnancy.
Minimize compression of the umbilical cord by the presenting part. 1. Move the woman to the knee-to-chest position 2. Filling of the bladder with warm saline (500ml) to displace the presenting part upwards. 3. Push up the presenting part by applying pressure vaginally.[1]
Prevention of spasm of the umbilical cord vessels Exposure of the umbilical cord to the environment can be minimized by gently reducing it into the vagina. Avoid unnecessary handling of the cord.[1] A warm saline swab can be inserted into the vagina to prevent the cord coming back out again.
If the patient is on an oxytocin infusion, stop the infusion Reduction in the uterine contractions will improve blood flow to the placental bed helping in improving fetal hypoxia.[1]
A neonatal team with resuscitation facilities should be present at the delivery.[2] The fetal outcome depends on the duration of cord compression. Compression of the cord for over 10 minutes will lead to cerebral damage and eventually death. Premature or growth restricted fetuses cope less well.[3]
Use of tocolytics Tocolytics can be administered to reduce uterine contractions and improve circulation to the placental bed. Terbutaline 250micrograms subcutaneously can be administered.[4]
Cord prolapse in the presence of prematurity Expectant management is considered in pregnancies at the limits of viability (23 weeks) while cord replacement can also be attempted.[1][5] Pregnant women who experience cord prolapse at the threshold of viability should be counseled.
Documentation Documentation of the events, interventions with a timeline is important due to legal implications. Cord prolapse and the associated fetal ischemia may lead to birth asphyxia and cerebral palsy later in life.[6] Hence it is important to monitor and document fetal parameters.
References
  1. Umbilical cord prolapse. Royal College of Obstetricians and Gynaecologists, April 2008 [Viewed 05 May 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/umbilical-cord-prolapse-green-top-50
  2. MURPHY DJ, MACKENZIE IZ. The mortality and morbidity associated with umbilical cord prolapse. British Journal of Obstetrics & Gynaecology, 1995, 102, 826–30.
  3. BAKER P.N, KENNY L.C. Obstetrics by ten teachers. 19th ed. London : Hodder Arnold, 2011. 16 ch, 253-254 pg.
  4. BARNETT WM. Umbilical cord prolapse: a true obstetrical emergency. J Emerg Med [online] 1989 Mar-Apr, 7(2):149-52 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2661671
  5. CLINICAL GUIDELINE FOR THE MANAGEMENT OF UMBILICAL CORD PROLAPSE. Royal Cornwall Hospitals NHS Trust, 2012 [Viewed on 4 May 2014]. Available from: http://www.rcht.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/MidwiferyAndObstetrics/UmblilicalCordProlapseGuidelineForTheManagementOf.pdf
  6. BLUMENTHAL I. Cerebral palsy--medicolegal aspects J R Soc Med [online] 2001 Dec, 94(12):624-627 [viewed 16 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282294