BY DR WILLIAMS EMMANUEL A.

CORD PROLAPSE

Introduction

 Cord prolapse is an obstetric emergency

 One of the many causes of fresh stillbirths.
 Improper fitting of the presenting part into the
maternal pelvis at the time of membranes rupture
predisposes to cord prolapse.
 Sometime, cord prolapse occurs at a time in labour
when cervix is not sufficiently dilated for vaginal
delivery. Timely delivery by caesarean section is
the hallmark of good clinical management for this
condition.
 Prolapse of the cord leads to intermittent
compression between presenting part and pelvic
inlet, cervix or vagina canal.
 Compression of the foetal cord compromises the
foetal circulation. Prolapse of the cord beyond the
introitus to the outside leads to spasm of the blood
vessels accelerarating foetal demise.
 Whether overt or occult prolapse, both carries
significant rates of perinatal morbidity and
mortality.
  Different management techniques are applied as
temporary measures until a caesarean section is
performed
 Cord prolapse pose more problems when there is
no theatre for caesarean section as in some
communities in developing countries.
 Fetus suffers from;

 Hypoxia

 Possible intrauterine fetal death

 Residual handicap in survivors

Definition of terms
 Cord prolapse (overt cord prolapse) is defined as
descent of the umbiblical cord below the foetal
presenting part with membranes ruptured.
 Cord presentation (funic presentation) is the
presence of unbiblical cord below the presenting
part of the foetus with intact membranes.
Cord easily palpated through intact membranes

 Incidence varies beteen 0.09-0.63 %()UPTH-over

ten year review -1989-1999
  Incidence for cephalic presentation o.5%,Frank
breech o.5%, complete breech 0.%, Transverse lie
20 %

Occult cord prolapse is when the cord lies beside

the presenting part and is not detected by examining
fingers
 Unexplained foetal heart declerations and foetal
distress are features.

RISK FACTORS FOR CORD PROLAPSE

 Poor fitting of the foetal presenting part to maternal
pelvis is a major factor e.g-Transverse lie
 Prelabour rupture of foeetal membranes
 Multiple gestations
 Congenitally exta- long umbilical cord
 Prematurity

 Abnormal presentations-breech, brow, compound,

face, occipito posterior position.
 Pelvic tumours
 Polyhydramnios

 Obstetric interventions – could contribute to cord

prolapse eg;
(a)Amniotomy- rule out cord prolase each time
 membrane ruptures ( auscultate foetal heart rate
before
and after amniotomy)
(b)External cephalic version (ECV)
(c) During expectant management of preterm
premature rupture of membranes

Diagnosis of cord prolapse

1. Overt cord prolapse –cord visualized at introitus or

outside the vagina
 Or cord palpated in vaginal canal.
2. Cord presentation
 Cord palpated through intact membranes
 Transvaginal ultrasound may be helpful

3. Occult presentation
 Rarely palpated in vagina
 Inferred only when foetal heart changes
 Variable declaration
 Bradycardia
 Or both
 All above due to head compression
- Rapid delivery
  Transvaginal ultrasound

4. Fetus
 Sudden foetal activities or movements as a
sequalae of cord compression
 Variable fetal heart rate decelerations
 Prolonged cord compression leads to fetal
Bradycardia or hypoxia

OBSTETRIC MANAGEMENT OF UMBILICAL

CORD PROLAPSE.
Principles of mgt.

Baby alive and of viable gestation

 Elevation of presenting part off the cord while
preparing for delivery
 Rapid delivery

Elevating presenting part off the cord. (Do one of two

things)
1. Push the presenting part upward with the examining
finger and hold it there while patient is made to
assume:
 Knee chest or Sims lateral positions.
  This releases the compression of the cord.
2. Where referral is necessary due to lack of facilities
for c/s
 Do bladder filling – this elevates presenting part
off the cord during transfer.
Bladder filling
A no 16 Foley catheter with a 5ml balloon passed into
urinary bladder.
Bladder filled with 1-1.5l of normal saline via the
catheter.
Quantity of saline needed is determined by the amount
that is able to lift up the presenting part from the
prolapsed cord.
Inflate the balloon with 5ml of sterile injection water to
secure it from falling out. Then clamp the catheter with
an artery forceps.
At caesarean section, on abdominal entry, a third assistant
removes the catheter clamp to let out the water in the
bladder and also deflate the catheter balloon.
Special precaution: Note that under emergency
conditions as cord prolapse, a midline subumbilical
incision is preferred to Pfannenstiel incision at
caesarean section- for rapidity of access to the
peritoneal cavity to deliver the baby.
Note that you need less than 30 minutes from
diagnosis of cord prolapse and all the pre-operative
maneuvers to caesarean delivery to salvage the baby.
It is a dire emergency.
Obstetric units like ours and others needs routine
rehearsals on the management of obstetric
emergencies such as cord prolapse.

 The time of diagnosis to the time of delivery

(otherwise known as diagnosis-delivery interval)
is directly related to the delivery of a healthy live
baby, stillbirth or neonatal death. When the cord
prolapse at home or where there are no facilities
for caesarian delivery, poor prognosis for the
baby’s survival.
 State of cervical dilatation.
 Cervix fully dilated – expedite delivery
by:
  Cervix ≥ 8cm expedite delivery with
vacuum.
 Administer 02 to mother while preparing for
delivery
 Replace back the cord in the vagina while
preparing for delivery. Pack the cord in the vagina
with gauze soaked in saline. This is because the
vagina is warmer than the atmospheric air thereby
preventing spasm of the cord that could lead to the
occlusion of blood flow to the baby.

Elevating presenting part off the cord.

1. Push the presenting part upward with the examing
finger and hold it there while patient is made to
assume:
 Knee chest or Sims lateral positions.
 This releases the compression of the cord.
2. Where referral is necessary due to lack of facilities
for c/s
 Do bladder filling elevates presenting part off
during transfer.
  Paediatrician must be present at the delivery of the
baby..

Prevention of cord prolapse

 Treat patient at risk of cord prolaps as high risk
patients
 Confirm malpresentation, abnormal lies by
ultrasound.
 Most prolapse occur during labour – be vigilant
always auscultate for fetal heart changes
 In prematuree rupture of membranes, rule out cord
prolapsed- do sterile speculum examinations.
 Artificial rupture of membranes should be done
with diligence.
 Rule out cord prolaps after each ARM.and after
spontenous rupture of membranes.
 Let out amniotic fluid slowly after ARM until
presenting part settles against the cervix

Complication of cord porlapse

A – Maternal
 Risk of C/S
 Risk of instrumental deliveries
 Laceration of cervix, vagina, perineum

B – Neonatal
  Hypoxia
 Still birth
 Handicap

CONCLUSION
Cord prolase is a dire obstetric emergency that require
high sense of urgency and action to salvage the baby.
Obstetric units needs rehearsals to forestall infant
morbidity, mortality and handicap.

LEARNING OBJECTIVES
 The student should note the ‘introduction’ of this
subject. It is vital to the understanding of the whole
subject.
 Learn and understand the definitions of the three
types of cord prolaps and note the commonest in
practice
 Note the preparations you need to make in the interim
between diagnosis of cord prolapse and preparation
 for vaginal delivery or caesarean section (whichever
is applicable)
 Note the risk factors for cord prolapse.
 Note Electrocardiogram changes that could alert you
to the possibility of cord prolapse.
 Note that ‘midline subumbilical incision’ is
preferable to Pfannenstiel in cord plrolapse for
rapidity at C/S
 Note what is meant by rehearsal in obstetric
management.
 Risk facors for cord prolapse.
 Prevention of cord prolapse.
 Note the incidence at NDUTH and in our environs
(UPTH Port-Harcourt and Nigeria in general)
 Note how some obstetric practice could lead to cord
prolapse.