Umbilical_Cord_Prolapse_Flashcards

Question 1

What is umbilical cord prolapse?

Answer 1

It involves the umbilical cord descending ahead of the presenting part of the fetus, occurring in 1/500 deliveries.

Question 2

What are the risks associated with untreated umbilical cord prolapse?

Answer 2

Compression of the cord or cord spasm, leading to fetal hypoxia, irreversible damage, or death.

Question 3

What are the risk factors for cord prolapse?

Answer 3

Prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, abnormal presentations (e.g., breech, transverse lie).

Question 4

How often do cord prolapses occur during artificial rupture of the membranes?

Answer 4

Around 50% of cord prolapses occur at artificial rupture of the membranes.

Question 5

How is the diagnosis of umbilical cord prolapse usually made?

Answer 5

When the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.

Question 6

What is the management of umbilical cord prolapse?

Answer 6

Cord prolapse is an obstetric emergency. The presenting part of the fetus may be pushed back into the uterus to avoid compression. The patient may be asked to go on ‘all fours’ or in the left lateral position. Tocolytics and retrofilling the bladder with saline may be used. Immediate caesarian section is usually required, though instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.

Question 7

How should the cord be handled if it is past the level of the introitus?

Answer 7

Minimal handling and kept warm and moist to avoid vasospasm.

Question 8

What position should the patient be in until preparations for a caesarian section are completed?

Answer 8

The patient is asked to go on ‘all fours’ or in the left lateral position.

Question 9

What role do tocolytics play in managing umbilical cord prolapse?

Answer 9

They may be used to reduce uterine contractions.

Question 10

How does retrofilling the bladder help in umbilical cord prolapse?

Answer 10

Retrofilling the bladder with 500-700ml of saline gently elevates the presenting part.

Question 11

What is the usual first-line method of delivery for umbilical cord prolapse?

Answer 11

Caesarian section, though instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.

Question 12

What has reduced the incidence of cord prolapse?

Answer 12

The increase in caesarian sections being used in breech presentations.

Question 13

What is the prognosis if umbilical cord prolapse is treated early?

Answer 13

Fetal mortality in cord prolapse is low if treated early.

Question 14

summarise umbilical cord prolapse

Answer 14

Umbilical cord prolapse

Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. This occurs in 1/500 deliveries. Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.

Risk factors for cord prolapse include:
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie

Around 50% of cord prolapses occur at artificial rupture of the membranes. The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.

Management
cord prolapse is an obstetric emergency
the presenting part of the fetus may be pushed back into the uterus to avoid compression
if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
the patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out
the left lateral position is an alternative
tocolytics may be used to reduce uterine contractions
retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.

If treated early, fetal mortality in cord prolapse is low. Incidence has been reduced by the increase in caesarian sections being used in breech presentations.

Question 15

A 27-year-old 38-week pregnant woman presents to the labour suite. She has been having contractions for the last 8 hours and her waters have ruptured. She says the baby has been moving less than usual.

On examination, the umbilical cord is visible. The cervix is 5cm dilated and the presenting part is visible.

What is the most immediate action which needs to be performed?

Foetal heart rate monitoring
Manual elevation of the presenting part
McRobert’s manoeuvre
Suprapubic manoeuvre
Tocolytic medications

Answer 15

Manual elevation of the presenting part

Following an umbilical cord prolapse, the presenting part of the fetus may be pushed back into the uterus to avoid compression

Manual elevation of the presenting part is the correct answer. In this scenario, the umbilical cord is visible on examination, indicating prolapse. This describes when the umbilical cord moves down below the foetal presenting part. It is the most important step as this will remove the pressure off the cord to enable blood to flow to the foetus.

Foetal heart rate monitoring is incorrect. An umbilical cord prolapse is an absolute emergency. Considering that the cervix is only 5cm dilated, a caesarean section will be required to deliver the baby and if there is any delay then foetal monitoring will be needed to ensure the wellbeing of the foetus. However, the immediate priority here is to ensure that the foetal head does not compress the umbilical cord as this compromises blood flow and oxygen supply to the foetus.

McRobert’s manoeuvre is incorrect. The scenario in the question is describing an umbilical cord prolapse. The McRobert’s manoeuvre is used in the immediate treatment of shoulder dystocia. Shoulder dystocia is when the foetus’ anterior shoulder gets stuck behind the pubic rami so the McRobert’s movement should be used to open up the pelvis and facilitate the delivery of the baby. This would not be suitable in this scenario.

Tocolytic medications is incorrect. Whilst tocolytic medications do form part of the initial management of umbilical cord prolapse, they are not the most immediate action which needs to be taken. Tocolytics have a role if there is likely to be a delay in labour and there is evidence of foetal heart rate abnormalities. The tocolytics reduce uterine contractions and hence reduce foetal distress.

Suprapubic manoeuvres is incorrect. These manoeuvres are used in the case of shoulder dystocia when the McRoberts manoeuvre has not worked. Suprapubic manoeuvres would not be of any benefit in this scenario as the cervix is only 5cm dilated, and it is important that the umbilical cord is handled as little as possible to reduce foetal distress.

Question 16

A 26-year-old woman who is at 38 weeks gestation has prolonged labour. Her only complication of pregnancy is the development of gestational diabetes which is well-controlled with insulin.

An artificial rupture of membranes was performed in an attempt to expedite labour. Shortly after this, foetal bradycardia and variable decelerations were noted on the cardiotocograph. An examination reveals that the umbilical cord is palpable vaginally. Help has been called for.

What is the most appropriate step in her management?

Administer an IV oxytocin infusion
Apply external suprapubic pressure
Attempt to place the cord back into the uterus
Avoid handling the cord and keep it warm and moist
Perform McRoberts’ manoeuvre

Answer 16

Following umbilical cord prolapse, if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm

Avoid handling the cord and keep it warm and moist is correct. This patient has an umbilical cord prolapse which is likely due to the artificial rupture of membranes, which is a risk factor. The presence of foetal bradycardia and late decelerations indicates foetal distress, making this scenario an obstetric emergency. Of the listed options, the most appropriate step would be to avoid handling the cord and keep it warm and moist. The reason for this is because exposure to relatively cold air can cause irritation and cooling and this alongside handling the cord can cause vasospasm of the umbilical cord, reducing the blood supply to the foetus, and risking complications such as death or permanent disability.

Attempt to place the cord back into the uterus is incorrect. This is not recommended due to the risk of vasospasm which can reduce the blood supply to the foetus, risking complications such as death or permanent disability.

Administer an IV oxytocin infusion is incorrect. This would increase the force and rate of uterine contractions which would cause or worsen cord compression leading to a reduced blood supply to the foetus.

Apply external suprapubic pressure is incorrect. This does not play a role in the management of umbilical cord prolapse and is instead used in shoulder dystocia, where the foetus is stuck mid-delivery after the head has been delivered.

Perform McRoberts’ manoeuvre is incorrect. This does not play a role in the management of umbilical cord prolapse and is instead used in shoulder dystocia, where the foetus is stuck mid-delivery after the head has been delivered.