Cord prolapse

Question 1

Scenario

Answer 1

Jean is a 38 year old para 4+0 at 37 weeks gestation, who works in a part time job. She has polyhydramnios and unstable lie. She is attending clinic for an antenatal appointment. She reports to be feeling reduced movements and is in for monitoring. Whist outside have a cigarette she rupture her membranes. She comes into day care draining clear amniotic fluid. You listen into FHR which is 90bpm.

Question 2

What do you expect may have happened in this scenario

Answer 2

Cord prolapse

Question 3

What factors led you to this conclusion

Answer 3

Unstable lie with polydramnios
High parity
Following a sponatanous rupture of membranes there appears to be a lower FHR

Question 4

Demonstrate and discuss how you would manage this situation

Answer 4

introduce myself
Ask to have a look to diagnose cord prolapse
Pull emergency buzzer
Out with osce first thing i would do is insert my fingers into the posterior vagina to relive the pressure of the presenting part on the cord and stay there until knife to skin- due to the osce just state this and continue.
Call 2222- say where i am, senior obstetrician, anaesthetics, charge midwife, paediatric team an other availed staff and contact theatre to let them know this is happening.
Relief pressure off cord- wash hands and apply PPE
Once help has arrived give SBAR.
Explain going to theatre for cat1 section
Ask for consent to insert fingers into vagina.
Going in posteriorly, pushing presenting part up, trying to not touch cord to reduce chance of spasm, also assess dilation to see if birth is imminent however only 4cm so needs to be section. Explain to Jean.

Question 5

positions that can be done to relive pressure

Answer 5

for purposes of OSCE remove fingers and show the different positions.
1st- lie Jean flat on bed and show the trandelomberg position- Move bed out, tilt the head side down to relive pressure of the presenting part.
2nd- Physically show on mat- Knee chest position
3rd-exaggerated sims- left lateral told with pillow under hip. if in an ambulance/ community setting this position is safest.
Another option it to fill the bladder with 500mlof saline using a catheter- make sure the water is warm so it doesn’t shock the bladder- this can help push the presenting part up if unable to keep fingers in situ.
Can also administer tocaltic - 0.25mg of terbutaline subcutaneously.

Question 6

moving to theatre

Answer 6

MOVE acronym
Moving in the bed
Leave observations till theatre
Not currently requiring oxygen so no need for tank
venus access will be done in theatre

Question 7

In theatre

Answer 7

Get emergency trolly
Give jean 30mls of sodium citrate orally to stop aspiration of the lungs
Administer 15 litres of oxygen through a trauma mask- to pre oxygenate lungs for a general anastasia
Put two venus access in each arm, sterile environment and will be flushed by someone i’ve trained - take a group and save in case of bag bleed, full blood count to check pre operative haemoglobin, platelets and white cell count
Take observations- pulse, bp and temp and document on mews- aiming for seats over 94%( put things where meant to go)
Assess capillary refill time which should be less than 2 seconds- my pressing on finger and watching the refill
Insert catheter due to general anaesthetic- size 12 indwelling- ask consent and do in a sterile environment.

Question 8

Theatre checklist

Answer 8

Start from head
Theatre cap and hair up with bobble that doesn’t contain metal
Asl for consent- if possible written but die to severity verbal i okay
Ask if she has allergies
Take piercing out of tape up
ask if any dentures of loos teeth
contact lenses
hearing aids
Pace makers
venus access in situ
ID bands
Skin prep- shaved
Have notes and drug cardex
wedding bands tapes or taken off
nails poilish removes on finger needed
catheter in situ
Put up a bag of heart and to keep jean hydrated
Before operation starts- FHR will be auscultated as if no fetal heart detected operation will not go ahead
If FH present cat1 section would be taken place

Question 9

After operation

Answer 9

Ensure documentation if accurate- date and time cord prolapse was diagnosed, when help was called, who was there, when moved to theatre, when cannulas and catheter was interred when drugs were given, FH before operation, when section commenced, time of birth, cord gases, apgars.
At delivery cord gases will be obtained to determine if fetal assadosis has occurred
Resuscitation team would there in cases of fetal hypoxia.
Debrief jean after recovered from GA