Umbilical_Cord_Prolapse_Flashcards
What is umbilical cord prolapse?
It involves the umbilical cord descending ahead of the presenting part of the fetus, occurring in 1/500 deliveries.
What are the risks associated with untreated umbilical cord prolapse?
Compression of the cord or cord spasm, leading to fetal hypoxia, irreversible damage, or death.
What are the risk factors for cord prolapse?
Prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, abnormal presentations (e.g., breech, transverse lie).
How often do cord prolapses occur during artificial rupture of the membranes?
Around 50% of cord prolapses occur at artificial rupture of the membranes.
How is the diagnosis of umbilical cord prolapse 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.
What is the management of umbilical cord prolapse?
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.
How should the cord be handled if it is past the level of the introitus?
Minimal handling and kept warm and moist to avoid vasospasm.
What position should the patient be in until preparations for a caesarian section are completed?
The patient is asked to go on ‘all fours’ or in the left lateral position.
What role do tocolytics play in managing umbilical cord prolapse?
They may be used to reduce uterine contractions.
How does retrofilling the bladder help in umbilical cord prolapse?
Retrofilling the bladder with 500-700ml of saline gently elevates the presenting part.
What is the usual first-line method of delivery for umbilical cord prolapse?
Caesarian section, though instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.
What has reduced the incidence of cord prolapse?
The increase in caesarian sections being used in breech presentations.
What is the prognosis if umbilical cord prolapse is treated early?
Fetal mortality in cord prolapse is low if treated early.
summarise umbilical cord prolapse
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.
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
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.
