Cord Prolapse

Question 1

What is cord prolapse?

Answer 1

umbilical cord descends through the cervix, with (or before) the presenting part of the fetus. This position compromises blood flow (and oxygen delivery) through the umbilical cord to the infant, and demands immediate delivery.

Question 3

What are the risk factors for cord prolapse?

Answer 3

*prematurity
*multiparity
*polyhydramnios
*cephalopelvic disproportion
*abnormal presentations e.g. Breech, transverse lie
High foetal head at delivery

Question 4

What is cord prolapse associated with?

Answer 4

Ruptured membranes

Question 5

What is occult prolapse?

Answer 5

the umbilical cord descends alongside the presenting part, but not beyond it.

Question 6

What is overt prolapse?

Answer 6

the umbilical cord descends past the presenting part and is lower than the presenting part in the pelvis

Question 7

What is a cardinal sign of cord prolapse?

Answer 7

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

Question 8

What investigations for sispdted cord prolapse?e

Answer 8

*Cardiotocography (CTG): To monitor foetal heart rate and maternal contractions
*Vaginal examination: To confirm the presence of the umbilical cord in the birth canal

Question 9

How does foetal hypoxia occur in cord prolapse?

Answer 9

*Occlusion – the presenting part of the fetus presses onto the umbilical cord, occluding blood flow to the fetus.
*Arterial vasospasm – the exposure of the umbilical cord to the cold atmosphere results in umbilical arterial vasospasm, reducing blood flow to the fetus.

Question 10

What is occult cord prolapse?

Answer 10

the umbilical cord descends alongside the presenting part, but not beyond it.

Question 11

What is overt cord prolapse?

Answer 11

the umbilical cord descends past the presenting part and is lower than the presenting part in the pelvis.

Question 12

How does foetal hypoxia occur with cord prolapse??

Answer 12

*Occlusion – the presenting part of the fetus presses onto the umbilical cord, occluding blood flow to the fetus.
*Arterial vasospasm – the exposure of the umbilical cord to the cold atmosphere results in umbilical arterial vasospasm, reducing blood flow to the fetus.

Question 13

What are the risk factors for cord prolapse?

Answer 13

*Breech presentation – in a footling breech, the cord can easily slip between and past the fetal feet and into the pelvis.
*Unstable lie – this is where the presentation of the fetus changes between transverse/oblique/breech and back.
*multparity
*cepahlopelvic disproportionate
*Artificial rupture of membranes – particularly when the presenting part of the fetus is high in the pelvis.
*Polyhydramnios – excessive amniotic fluid around the fetus
*Prematurity

Question 14

How to manage patient with cor prolapse at 337 weeks gestation?

Answer 14

If >37 weeks gestation, consider inpatient admission until delivery due to risk of cord prolapse

Question 15

What is cord prolapse associated with?

Answer 15

Artificial rupture of membranes

Question 16

What is a cardinal sign of umbilical cord prolapse?

Answer 16

fetal heart rate becomes abnormal and the cord is palpable vaginally, particularly variable or prolonged decelerations, detected on cardiotocography (CTG) or if the cord is visible beyond the level of the introitus.

Question 17

How to confirm cord prolapse?

Answer 17

External inspection or digital vaginal examination

Question 18

What is strongly associated as a feature of cord prolapse?

Answer 18

Foetal bradycardia

Question 19

What should point away from diagnosis of cord prolapse?

Answer 19

Bleeding from vagina

Question 20

What is the immediate management of umbilica cord prolapse??

Answer 20

*Avoid handling the cord to reduce vasospasm.
*Manually elevate the presenting part by lifting the presenting part off the cord by vaginal digital examination.
*Encourage into left lateral position with head down and pillow placed under left hip OR knee-chest position. This will relieve pressure off the cord from the presenting part.

Question 21

What to do for cor prolapse in the community?

Answer 21

Alternatively, if in the community, fill the maternal bladder with 500ml of normal saline (warmed if possible) via a urinary catheter and arrange immediate hospital transfer.

Question 22

How to handle the cord in cord prolapse?

Answer 22

Avoid handling of the cord (as this causes cord spasm); if the cord has moved past the vaginal introitus, keep it warm and moist, and do not push it back inside.

Question 23

Which medication can be adminstered in cord prolapse?

Answer 23

Administration of tocolytics:
*nifedipine (calcium channel blocker)
*atosiban (oxytocin receptor antagonist)
*terbutaline (beta antagonist))

This is to stop uterine contractions, which lead to further cord compression.

Question 24

What position should the mother be in cord prolapse?

Answer 24

All fours
Knee to chest position
Left lateral position

Question 25

What to prioritise in cord prolapse?

Answer 25

Delivery as soon as possible. This is performed via: C-section (especially if cervix is not yet fully dilated) Expedited vaginal delivery (i.e. usually involving instruments)

Question 26

What are the foetal complications of cord prolapse?

Answer 26

*Fetal hypoxia and acidosis: Cord compression reduces blood flow and oxygen delivery, risking brain injury (hypoxic-ischaemic encephalopathy, cerebral palsy). *Stillbirth or neonatal death: Prolonged compression can lead to irreversible hypoxia, especially if delivery is delayed. *Birth injuries: Trauma during emergency delivery, such as fractures or nerve injuries

Question 27

What are the maternal complications of cord prolapse?

Answer 27

*Emergency interventions: Urgent c-section or instrumental delivery, with associated risks of surgical complications (e.g. bleeding, infection). *Psychological distress: Anxiety, fear, or trauma related to the emergency and potential risks to the baby. *Increased maternal morbidity: Prolonged labour or complications from operative delivery if immediate action is delayed

Question 28

What is a key complication from cord prolapse?

Answer 28

Hypoxia ischaemic encephalopathy

Question 29

What is the first line manoeuvre for cord prolapse?

Answer 29

the presenting part of the fetus may be pushed back into the uterus to avoid compression

Question 30

What may be beneficial in cord prolapse?

Answer 30

Retrofilling the bladder with 500-700ml of saline

Question 31

How to manage vaginal vault prolapse?

Answer 31

sacrocolpopexy. This procedure suspends the vaginal apex to the sacral promontory. This support is usually afforded by the uterosacral ligaments.

Question 32

What reduced risk of cord prolapse?

Answer 32

Prolonged pregnancy Nulliparity Cephalic presentation