2014 50 Umbilical Cord Prolapse Flashcards
Can cord prolapse be detected antenatally?
- No routine ultrasound
- Consider selective US for women considering vaginal breech birth
How can cord prolapse or its effects be avoided?
- Consider admission of transverse, oblique or unstable lie after 37/40 vs urgent presentation with SROM or signs of labour
- Admit PPROM with non-vertex presentations
- Avoid ARM if presenting part mobile or high, or do with option of immediate CS
- Minimal upward pressure on VEs after ROM
- If cord presentation felt on VE, do not ARM, go for CS
When should cord prolapse be suspected?
- Exclude at every VE & after SROM if risk factors present
- Auscultate FH after every VE & after SROM; suspect if abnormal
- Spec &/or VE if suspected
- Do not need to VE after SROM if normal FH & no risk factors
What is the optimal initial MX of cord prolapse in a hospital setting?
- If not fully dilated, prep for immediate CS
- Don’t try to replace cord above presenting part
- Minimal handling of loops outside vagina to prevent vasospasm
- Elevate presenting part to prevent cord compression
- Adopt knee-chest or exaggerated Sim’s position
- Consider tocolysis if persistent FH abnormalities
What is the optimal mode of birth with cord prolapse?
- CS if birth not imminent, to prevent hypoxic acidosis
- Cat 1 if suspicious or pathological CTG
- Consider cat 2 with continuous CTG if FH normal
- Consider regional anaesthesia if no delay
- Can attempt vaginal birth if fully dilated & quicker
- Breech extraction considered after internal podalic version of 2nd twin
- Neonatal team presence
- Paired cord gas samples
What is the optimal Mx in community settings?
- Asses risk for home births & MLCs
- Transfer to consultant-led unit unless birth imminent
- Knee-chest face-down position while waiting for ambulance transfer
- Exaggerated Sim’s position during ambulance transfer
- Elevate presenting part manually or with bladder distension
What is the optimal MX of cord prolapse at the threshold of viability?
- Expectant Mx
- No evidence to support cord replacement
- Counsel on both continuation & termination of pregnancy
Should delayed cord clamping be used after cord prolapse?
- Consider if baby in compromised
- Prioritise immediate resuscitation if baby unwell
How is occult vs overt cord prolapse defined?
Descent of umbilical cord through the cervix
Occult: alongside the presenting part
Overt: past the presenting part
What is the incidence of cord prolapse?
Overall: 0.1-0.6%
Breech: 1%
What s the perinatal mortality rate for cord prolapse?
91 per 1000
What are the general risk factors for cord presentation & cord prolapse?
- Multiparity
- Low birth weight <2.5kg
- Preterm labour <37/40
- Fetal congenital anomalies
- Non-cephalic presentations
- 2nd twin
- Polyhydramnios
- Unengaged presenting part
- Low-lying placenta
What are the procedure-related risk factors for cord presentation & prolapse?
- ARM with high presenting part
- Vaginal manipulation of fetus following ROM
- ECV (during)
- Internal podalic version
- Stabilising IOL (oxytocin infusion during ARM)
- Insertion of intrauterine pressure transducer (measuring strength of contractions)
- Large balloon catheter IOL
What proportion of cord prolapses are precipitated by obstetric procedures?
Approx half
How much is perinatal mortality from cord prolapse increased in community settings?
More than 10x
