Mx of cord prolapse

see labour

• cord prolapse is the presentation of the cord first through the cervix once membranes rupture
• this is an obstetric emergency as fetal circulation can be rapidly compromised
• ALL staff caring for women in labour MUST know how to recognise and manage cord prolapse
• incidence of cord prolapse is uncommon (<1:300 labours)
• risk factors:
  • Abnormal lie or presentation, especially breech or transverse lie, or high head at start of labour
  • Polyhydramnios
  • Pre-term labour
  • Application of fetal scalp electrode
  • High head at start of labour
  • Contracted pelvis.
  • Low-lying placenta.
  • Multiple gestation.
  • Grand multiparity.
  • obstetric manipulations including amniotomy and external cephalic version.

• diagnosis is made on vaginal examination and may be suspected by sudden deceleration of fetal heart rate.
• the cord may be visible at the woman’s vulva.
• the fetal heart (FH) should be checked for a full minute following spontaneous rupture of membranes
• a vaginal examination following spontaneous rupture of membranes is only necessary in women at high risk for cord prolapse or when FH is abnormal
• high index of suspicion if ruptured membranes, esp. if:
  • fetal bradycardia
  • “something between my legs” after water's broke
  • pre-term, esp. if breech

• you cannot replace cord!!
• avoid over handling of the cord.
• if the cord is visible outside the vagina do not attempt to replace it.
• if cord is seen or felt:
  • contact obstetric, anaesthetic, paediatric & theatre teams for urgent C.S. if vaginal birth not possible (e.g. not at full or near full dilatation)
    • in Sunshine Hospital, Code ALERT CAESAREAN SECTION should be called when cord prolapse is detected.
  • keep the woman in bed in left lateral with hips elevated
  • if in labour:
    • vaginal examination to determine presenting part, cervical dilatation and descent
    • if the cervix is fully dilated and presenting part below spines:
      • encourage expulsive efforts.
      • consider assisted vaginal birth.
    • if the cervix is not fully dilated:
      • Assist the woman into a knee-chest or left lateral position.
      • Prepare for caesarean section.
      • Place gloved hand in vagina to lift presenting part away from cord and cervix and continue to elevate the presenting part until baby is born.
      • Avoid over handling of the cord to prevent the risk of vasospasm and compression.
      • Knee-chest position will also reduce pressure — transport woman to theatre in this position.
      • Cease any oxytocin infusion.
      • If woman is in labour give terbutaline 250mcg (0.5ml) subcutaneously.
      • Confirm fetal heart status in theatre prior to abdominal incision via sonicaid or cord pulsation.
      • If needed intravenous access and rehydration of the woman will be achieved in theatre.
      • In the rare event of delay in starting the caesarean section the bladder may be filled with 500-700mls warm saline to elevate the presenting part away from the cord. The catheter should be clamped. The clamp should be released to allow the bladder to empty immediately prior to commencing the caesarean section.
  • continuous FHR monitoring
  • large bore IV access
  • if no FH then deliver vaginally