Cord prolapse

Question 1

Incidence?

Answer 1

0.1-0.6%

1% if breech

Question 2

Risk of fetal death?

Answer 2

91 per 1000

Higher if outside of hospital at the time of cord prolapse or if coexisting congenital abnormality

Question 3

Cause of fetal asphyxia?

Answer 3

Cord compression and umbilical arterial vasospasm preventing venous and arterial blood flow to and from the fetus

Question 4

General risk factors for cord prolapse

Answer 4

Multiparity 
Low birthweight (< 2.5 kg) 
Preterm labour (< 37+0 weeks) 
Fetal congenital anomalies 
Breech presentation 
Transverse, oblique and unstable lie* 
Second twin 
Polyhydramnios
Unengaged presenting part
Low-lying placenta

Question 5

Procedural risk factors for cord prolapse

Answer 5

Artificial rupture of membranes with high presenting part
Vaginal manipulation of the fetus with ruptured membranes
ECV (during procedure)
Internal podalic version
Stabilising induction of labour
Insertion of intrauterine pressure transducer
Large balloon catheter induction of labour

Question 6

How to minimise the risks of cord prolapse?

Answer 6

• With transverse, oblique or unstable lie, elective admission to hospital after 37+0 weeks of gestation
  should be discussed and women in the community should be advised to present urgently if there are
  signs of labour or suspicion of membrane rupture.
• Women with non-cephalic presentations and PPROM should be recommended inpatient care.
• ARM should be avoided whenever possible if the presenting part is mobile and/or high.
• If it becomes necessary to rupture the membranes with a high presenting part, this should be performed
  with arrangements in place for immediate caesarean section.
• Upward pressure on the presenting part should be kept to a minimum in women during vaginal
  examination and other obstetric interventions in the context of ruptured membranes because of the risk
  of upward displacement of the presenting part and cord prolapse.
• Rupture of membranes should be avoided if on vaginal examination the cord is felt below the presenting part.
• When cord presentation is diagnosed in established labour, caesarean section is usually indicated.

Question 7

When should cord prolapse be suspected?

Answer 7

Cord prolapse should be suspected when there is an abnormal fetal heart rate pattern, especially if such
changes commence soon after membrane rupture, either spontaneous or artificial.

Speculum and/or digital vaginal examination should be performed when cord prolapse is suspected

Question 8

Initial management of cord prolapse in hospital

Answer 8

CS if not imminently delivering

To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina.

To prevent cord compression:
- Elevate presenting part be elevated either manually or by filling the bladder.
- Cord compression can be further reduced by the mother adopting the knee–chest or left lateral
(preferably with head down and pillow under the left hip) position.

Consider tocolysis whilst preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically, particularly when birth is likely to be delayed.

None of these procedures should delay delivery

Question 9

Delivery options in the case of cord prolapse:

According to RCOG guideline

Answer 9

• If fully and instrumental vaginal birth (or breech extraction of twin) achievable then this can be done with care to avoid compressing cord

If not deliverable vaginally:

• Cat 1 CS if FHR abnormalities
• Cat 2 CS if FHR normal
• If an experienced anaesthetist and FHR normal can consider regional anaesthesia

Take paired cord blood samples

For women <26 weeks there should be a discussion about the chance of healthy survival should be discussed

Question 10

What is the optimal management in community settings?

Answer 10

• Midwives should assess the risk of cord prolapse for women requesting home birth or birth in centres
  without facilities for immediate caesarean section and at the start of labour in the community.
• Women with known cord prolapse should be advised by telephone to assume the knee–chest face-down
  position while waiting for hospital transfer.
• During emergency ambulance transfer, the knee–chest position is potentially unsafe and the
  exaggerated Sims position (left lateral with pillow under hip) should be used.
• Transfer to the nearest consultant-led unit for
  birth, unless an immediate vaginal examination by a competent professional reveals that a spontaneous vaginal birth is imminent.
• The presenting part should be elevated during transfer either manually or by using bladder distension.
• It is recommended that community midwives carry a Foley catheter for this purpose and equipment for
  fluid infusion.
• To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina.