Cord prolapse and presentation

Question 1

What is cord presentation?

Answer 1

the presence of the umbilical cord between the fetal presenting part and the cervix; with or without ruptured membranes

Question 2

What is cord prolapse?

Answer 2

where the umbilical cord descends through the cervix alongside (occult) or past the presenting fetal part in the presence of ruptured membranes

Question 3

Why does cord presentation and prolapse occur?

Answer 3

because there is a poorly fitting presenting part in the lower portion of the uterus and/or pelvic brim allowing descent of the cord to past it

Question 4

How is cord presentation usually discovered?

Answer 4

On VE

1. Cord palpated through membranes
2. Pulsating synchronously with the fetal heart - not to be confused with maternal uterine arteries pulsation which can be felt in the vagina. if in doubt pulsate maternal pulse to differentiate

Question 5

What should you do if cord presentation is discovered during a VE?

Answer 5

1. Stop VE to reduce risk of rupturing membranes
2. explain what is happening to mother and partner
3. position the woman into exaggerated Sim’s position to alleviate any cord compression
4. monitor fetal heart rate
5. notify obstetric/neonatal team
6. consider operative birth

Question 6

What are the risks of rupturing membranes in the presence of cord presentation?

Answer 6

cord is at high risk of compression and/or umbilical arterial vasospasm

Question 7

what can be the result of compression and umbilical arterial vasospasm?

Answer 7

This can prevent venous/arterial blood flow between the foetus and the placenta

Question 8

What are fetal complications of cord prolapse?

Answer 8

• fetal hypoxia related to cord compression
• bradycardia
• fetal demise

Question 9

What are maternal complications of cord prolapse?

Answer 9

• increased operative birth

- associated operative delivery complications

Question 10

what are the 2 risk factors groups for cord prolapse?

Answer 10

1. pregnancy related

2. procedure related

Question 11

What are the pregnancy related risk factors (9)?

Answer 11

1. unengaged presenting part
2. multi pregnancy (usually affects 2nd twin)
3. multiparty
4. malpresentation (shoulder presentation), malposition (breech) or unstable lie
5. polyhydamnios
6. prematurity <37 weeks/low birth weight <2.5kg
7. low lying placenta
8. fetal congenital abnormality
9. male fetus

Question 12

What are the procedure risk factors (7)?

Answer 12

1. artificial rupture of membranes (ARM) especially in presence of a high presenting part
2. external cephalic version (ECV)
3. Internal podalic version
4. controlled ARM for IOL in the presence of a high presenting part
5. rotational instrumental delivery
6. application of uterine pressure transducer
7. vaginal manipulation of the fetus with ruptured membranes e.g. application of FSE

Question 13

Whats the initial management?

Answer 13

recognise
call for help
relieve
remote

Question 14

describe ‘recognise’ in the initial management?

Answer 14

• cord visible/protruding from vagina
• cord palpable on vaginal examination
• abnormal fetal heart on auscultation/CTG

Question 15

describe ‘relieve’ in the initial management?

Answer 15

• relieve pressure on the cord
• stop syntocinon if in progress
• relieve pressure on the cord by manually elevating the presenting part
• roll the woman into either:
  knee chest
  exaggerated Sim’s
  trendelenberg position

Question 16

When should you reposition woman when in knee chest and left side exaggerated Sim’s position?

Answer 16

fetal heart rate bradycardia occurs

Question 17

Why would you ‘bladder fill’

Answer 17

raises the presenting part of the fetus off the compressed cord for an extended period of time, eliminating the need for an examiners fingers to displace the presenting part

Question 18

What is the recommended amount of saline inserted via catheter when bladder filling?

Answer 18

500-750ml

Question 19

what catheter is used when ‘ bladder filling’?

Answer 19

16-gauge

Question 20

What do you fill the bladder with when ‘bladder filling’ and what set is used?

Answer 20

0.9% saline using an intravenous blood infusion set

Question 21

What are ways to prevent cord prolapse?

Answer 21

1. RCOG (2014) recommends women with transverse, oblique or unstable lie are offered elective admission at 37 weeks before elective CS at term
2. if cord palpated below presenting part, amniotomy should be avoided
3. once membranes ruptured, any intervention carres a risk
4. amniotomy should be avoided if presenting part is disengaged and/or mobile