Cord prolapse Flashcards

1
Q

Definition

A

The descent of the umbilical cord through the cervix alongside or past the presenting foetal part in the presence of ruptured membranes.

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2
Q

Obstetric emergency complications

A
  • Cord compression
  • Umbilical artery vasospasm preventing venous artery blood flow to and from the foetus leading to birth asphyxia.
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3
Q

Epidemiology and risk factors

A
  • Multiparity
  • Low birth weight (<2.5kg)
  • Preterm labour (<37weeks)
  • Foetal congenital abnormalities
  • Breech presentation:
  • Transverse, oblique or unstable lie: leaving space below the foetus which can then be occupied by the cord
  • Second twin
  • Polyhydramnios: more space around the foetus and below the presenting part
  • Unengaged presenting part
  • Low-lying placenta
  • Preterm, prelabour rupture of membranes
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4
Q

Procedure-related risk factors

A
  • Artificial rupture of membranes (ARM) with high presenting part
  • Vaginal manipulation of foetus with ruptured membranes
  • External cephalic version (ECV)
  • Internal podalic version
  • Stabilising induction of labour
  • Insertion of intrauterine pressure transducer
  • Large balloon catheter induction of labour
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5
Q

How can obstetric procedures lead to cord prolapse?

A

By preventing close application of the presenting part to the lower part of the uterus leaving a gap for the cord to prolapse into.

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6
Q

Signs

A
  • Cord seen in vagina
  • Abnormal foetal heart rate pattern
  • There may be no clinical Sx and a normal foetal heart rate pattern
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7
Q

Symptoms

A
  • Cord felt in the vagina
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8
Q

Diagnosis

A
  • FIRST LINE = allows visualisation of the prolapsed cord. Should be excluded at every vaginal examination in labour and after SROM if RF present.
  • Foetal heart auscultation
  • Cardiotocography: abnormal foetal heart rate, although non-specific, a sign of cord prolapse.
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9
Q

Antenatal screening

A

Routine antenatal USS: for the identification of cord presentation is not recommended.
- USS screening considered in women with breech presentation at term who are considering vaginal delivery

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10
Q

Pre-delivery Treatment

A

Requires immediate delivery of the foetus:
Pre-delivery =
- Minimal handling of loops of cord lying outside the vaginal: manual replacement of the cord above the presenting part is not recommended. Handling of the cord may lead to vasospasm and hypoxic acidosis.
Elevate presenting foetal parting: manually or by filling the urinary bladder, to prevent umbilical cord compression
Mother in knee-chest or left lateral position: to prevent cord compression
Tocolysis: administer if there are persistent heart rate abnormalities whilst preparing for delivery of the foetus.

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11
Q

Delivery Treatment

A

Cesarean section: if vaginal delivery is not imminent
- Category 1 (delivery within 30 minutes): cord prolapse + suspicious/pathological foetal heart rate pattern and if maternal safety is not compromised.
- Category 2 (delivery within 75 minutes): if foetal heart rate pattern remains normal, continuous CTG monitoring is required and if the CTG becomes abnormal, conduct a category 1 section.
- Vaginal: normal operative (foreceps or vacuum extraction) if fully dilated and birth can be accomplished quickly and safely.

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12
Q

Post-delivery

A

Paired cord blood samples: for pH and base excess measurements to provide objective measurement of foetal metabolic condition at the time of birth

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13
Q

Community treatment

A
  • Knee-chest face-down position
  • Elevate presenting foetal part
  • Emergency transfer to nearest consultant led-unit
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14
Q

Complications maternal related

A

C-section:
- longer hospital stay
- higher rate of peripartum hysterectomy and maternal death, increased risk of placenta accreta and uterine rupture in future pregnancies compared with vaginal birth.
- Operative vaginal delivery: perineal and vaginal trauma.

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15
Q

Foetal complications

A

complications are related to the time interval between cord prolapse and delivery:
- Low Apgar scores: babies with low Apgar scores at delivery are more likely to require resuscitation
- Birth asphyxia: from lack of O2 to the foetus
- Hypoxic brain injury: irreversible damage to the brain due to lack of oxygen supply
- Cerebral palsy
- Perinatal death

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