Cord prolapse

Definition



The umbilical cord, upon rupture of membranes, lies either within the vagina or protruding out of the introitus.

There are 3 types of umbilical cord descent :

a) Occult prolapse

The cord is lying at the side of presenting part, cannot be felt during PV examination.

b) Cord presentation

The cord is lying beneath the presenting part, where it can be felt during PV examination through the intact membrane.

c) Cord prolapse

Aetiology

Cord prolapse can be caused by any condition that prevents the presenting part from fitting into the lower uterine segment, for eg :

a) Maternal

Multiple pregnancy
Polyhydramnios
Abnormal presentation, lie
Fetopelvic disproportion

b) Fetus

Prematurity
Small baby

c) Placenta/Cord abnormalities


Placenta previa (minor degree)
Unduly long umbilical cord

d) Iatrogenic

Amniotomy, versions, manual rotations of head

Outcome

It causes immediate fetal hypoxia since the blood supply to the fetus is interrupted, due to :

-> Arterial spasm, due to : Drying, Increased handling and Temperature of external environment

-> Compression of the cord in between the presenting part and maternal bony pelvis

Diagnosis

a) Abdominal examination : Sudden alteration in rate and rhythm of fetal heart after rupture of membranes

b) Local examination : Cord within vulva

c) Per vaginal examination : With ruptured membrane, cord is felt on vaginal examination

d) Ultrasonography : Cord is seen below the presenting part, with intact membranes (impending cord prolapse)

Management

The principle of management in cord prolapse is early anticipation.
For eg, mothers at term, who is unstable with abnormal lie - admit; Early vaginal examination after spontaneous rupture of membrane; No amniotomy unless fetal pole has deeply engaged in pelvis.

For fetus - alive and matured :

a) If cervix not sufficiently dilated - emergency LSCS
b) If cervix is fully dilated in multigravida with favourable cephalic presentation - vacuum extraction
c) If cervix is fully dilated, with breech presentation - breech extraction if vaginal delivery is expected within 10-15 min, if not - emergency LSCS

If immediate operative intervention is not possible yet :

Make sure that the cord is replaced into the vagina, to maintain warmth and moisture. Reduce handling of the cord - reduced arterial spasm. Avoid attempts to reduce the cord back into the uterus, since upon every attempt, it increases length of cord being prolapsed.

a) Mother to be positioned in an exaggerated sim's positon, that is in left lateral position, with pelvis elevated by pillows.

OR

b) Vago's method, where mother is positioned at trendelenburg's position, foley's catheter is introduced into the bladder via urinary tract. After fixation, rapid delivery of 500ml of normal saline into the bladder, inducing distention to keep presenting part at higher position, to reduce extent of compression on the cord.

Category: Obstetrics Notes