Obstetrics - III

Unit 3: Obstetrics Emergency and Surgery

Unit 3. 2 : Cord Presentation and Prolapse
Unit 3.2.1: Cord /Funic Presentation:
INTRODUCTION :
Funic presentation: refers to when the umbilical
cord comes below the level of the presenting part
before the rupture of membranes
Diagnosis of funic presentation:
Is made by pelvic examination if loops of cord are
palpated through the membranes

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  U/S examination can be used to confirm cord
position when there is a clinical suspicion of cord
presentation
When funic presentation is identified antepartum,
follow-up evaluation of cord location is mandatory to
decide on the mode of delivery
Serial ultrasonographic examinations should be
performed to;
 ascertain cord position,
 presentation, and
 gestational age

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 The patient at term with funic presentation should be
delivered by C/S prior to membrane rupture

The most conservative approach is to hospitalize the

patient on bed rest in the Sims or Trendelenburg
position in an attempt to reposition the cord within
the uterine cavity
The natural out come of cord presentation, if not
reposition the cord within the uterine cavity is cord
prolapse

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 Unit 3.2.2: Cord /Funic Prolapse:
INTRODUCTION :
Umbilical cord prolapse is:
When the umbilical cord descends alongside or
beyond the fetal presenting part into the LUS
Is a rare obstetrical emergency
It is life-threatening to the fetus b/se of umbilical
vessels compression between the presenting part and
the uterus, cervix, vaginal canal or pelvic inlet

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 Compression of the umbilical cord compromises
fetal circulation
Depending on the duration and intensity of
compression, may lead to;
fetal hypoxia,
brain damage, and
Death
In overt cord prolapse, exposure of the umbilical
cord to air causes irritation and cooling of the cord,
resulting in further vasospasm of the cord vessels
and aggravate the damage

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 There are two types of cord prolapse:
1. Overt prolapse:
 refers to protrusion of the cord in advance of the fetal
presenting part, often through the cervical os and into
or beyond the vagina
 which is the most common
 The fetal membranes are invariably ruptured
 the cord is visible or palpable on examination.

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 2. Occult prolapse:
 occurs when the cord descends alongside, but not
past, the presenting part
 umbilical cord cannot be palpated during pelvic
examination
 It can also occur with intact
 The Dx should be considered in the DXX of a
sudden, prolonged fetal heart rate deceleration
 It often cannot be diagnosed with certainty, but is
suggested by clinical features (eg, fetal bradycardia)
and findings at cesarean delivery.

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 Fig. Types of prolapsed cords.
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 INCIDENCE:
 the over all Cord prolapse occurs in 0.14 to 0.62 % of
deliveries
 The incidence of overt umbilical cord prolapse in;
 cephalic presentations is 0.5%,
 frank breech 0.5%,
 complete breech 5%,
 footling breech 15%, and
 transverse lie 20%.

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 Whether occult or overt, umbilical cord prolapse is
associated with significant rates of perinatal
morbidity and mortality because of insufficient
blood flow and resultant fetal hypoxia

The perinatal mortality rate associated with all cases

of overt umbilical cord prolapse approaches 20%

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 Risk factors of cord prolapse
The two major etiologic categories of cord
prolapse are:
1. Fetomaternal factors that lead to inadequate
filling of the maternal pelvis by the fetus

2. Iatrogenic obstetrical interventions

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 Fetomaternal factors:
Risk factors associated with umbilical cord prolapse
unrelated to obstetric maneuvers includes:
Fetal malpresentation:
 Nonvertex fetal presentation is consistently associated
with a high risk of cord prolapse
 Footling breech presentation carries a higher risk of
cord prolapse than other types of breech presentation
Unengaged presenting part:

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 Prematurity(< 34 weeks' gestation):
 Infants delivered prematurely have a higher rate of
cord prolapse, probably due to the;
 smaller size of the fetus relative to the amniotic
fluid volume and
 increased frequency of malpresentation among
premature fetuses

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 Rupture of membranes:
 Iatrogenic or spontaneous rupture of membranes can
lead to cord prolapse because a forceful gush of fluid
may carry the cord beyond the presenting fetal part
 The highest risk of this occurrence is with;
 preterm premature rupture of membranes
 polyhydramnios, or
 an unengaged fetal presenting part

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 cephalopelvic disproportion
Abnormal placentation
placenta previa,
low-lying placenta,
Multiple gestation:
 The risk of cord prolapse in a term twin pregnancy is
confined to the second born twin, in whom there is
an increased probability of malpresentation

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 Multiparity:
may be related to the increased likelihood of rupture of
membranes prior to engagement of the presenting part
engagement in multiparas often occurs after labor has
begun and later than in nulliparas
Polyhydramnios:
Polyhydramnios is often associated with
an unstable lie or unengaged presenting part
copious flow of amniotic fluid after membrane
rupture

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 Long umbilical cord:
 Cord prolapse virtually never occurs with cords
shorter than 35 cm;
 the incidence is 0.4% with normal-length cords (35
to 80 cm) and
 4% to 6% with cords longer than 80 cm.
Pelvic deformities
Uterine tumors or malformations
Congenital anomalies

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 Iatrogenic obstetrical
intervention:
Disengagement of the fetal head during the
intervention and a high outward flow of amniotic
fluid allow the umbilical cord to be carried into the
birth canal.
Interventions that may predispose to cord prolapse
include:
Iatrogenic rupture of membranes
Application of an internal scalp electrode

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 Insertion of an intrauterine pressure catheter
Manual rotation of the fetal head
Amnioinfusion or amnioreduction
External cephalic version
Application of forceps or vacuum
expectant management of preterm premature
rupture of membranes.

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 Clinical manifestations and diagnosis:
The first sign of cord prolapse is usually;
a severe, prolonged fetal bradycardia or
moderate to severe variable decelerations after a
previously normal tracing
It should always be suspected where the abnormal
fetal heart rate pattern develops soon after
membrane rupture
The loop of cord is palpable upon vaginal examination
in the vaginal canal if there is overt prolapse

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 Less commonly, the patient may see or feel an overt
cord prolapse or
the care provider may initially palpate a pulsating
cord on a vaginal examination
If cord prolapse is not overt, the suspected diagnosis
cannot be confirmed until a cesarean delivery is
performed
prolapse can occur at any cervical dilation from
minimal to full dilatation

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 Differential diagnosis:
Other causes of fetal bradycardia of abrupt onset
following a normal tracing include;
maternal hypotension
placental abruption
uterine rupture, and
vasa previa
 In contrast to cord prolapse, placental abruption,
uterine rupture, and vasa previa are usually
accompanied by vaginal bleeding
 abruption and rupture are often painful

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 Management
The optimal obstetrical management of cord prolapse
is prompt delivery to avoid fetal compromise or
death
Immediate cesarean birth is generally the best mode
of delivery
Successful OVD with vacuum or forceps has been
reported when C/D could not be performed
immediately
Vaginal delivery is the route of choice for the
previable or dead fetus

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 Overt Cord Prolapse:
overt cord prolapse demands immediate action to
preserve the life of the fetus
An immediate pelvic examination should be
performed to determine;
 cervical effacement and dilatation
 station of the presenting part, and
 strength and frequency of pulsations within the
cord vessels

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 If the fetus is viable;
 the patient should be placed in the knee–chest position
 examiner should apply continuous upward pressure
against the presenting part to alleviate compression
of the prolapsed cord until preparations for C/D
 Alternatively, 400–700 mL of saline can be instilled
into the bladder in order to elevate the presenting part

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  Oxygen should be given to the mother until the
anesthesiologist administer a rapid-acting inhalation
anesthetic for delivery
 Abdominal delivery should be accomplished as
rapidly as possible through a generous midline
abdominal incision
 pediatric team should be on standby for immediate
resuscitation of the newborn

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 Occult Cord Prolapse:
Suspect if variable decelerations of the FHR are
recognized during labor
Immediate pelvic examination should be performed
to rule out overt cord prolapse
The patient should be placed in the lateral Sims or
Trendelenburg position in an attempt to alleviate
cord compression

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  If the FHR returns to normal, labor can be allowed
to continue, provided no further fetal insult occurs

 Oxygen should be administered to the mother, and

the FHR should be continuously monitored

If the cord compression pattern persists or recurs to

the point of fetal jeopardy, a rapid cesarean
section should be accomplished.

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 Vaginal delivery is most likely in patients if at the
time of prolapse;
 the cervix is fully dilated,
 cephalopelvic disproportion is not anticipated,
and
 an experienced physician determines that
delivery is imminent
 full dilation with breech presentation or
 undergoing birth of the second twin at the time
of the event

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 The following preoperative maneuvers can be helpful for
reducing pressure on the cord
1. Manipulation of the cord and exposure to a cool
environment should be minimized
2. Funic decompression:
 This is the most common method of alleviating cord
compression
 After Dx of cord prolapse, the examiner's hand is placed in
the vagina and used to elevate the fetal head off of the cord
while preparations for an emergency C/D are made
 The patient can be placed in steep Trendelenburg or the
knee-chest position to move the fetus and alleviate cord
occlusion
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 3. Bladder filling:
placing the patient in Trendelenburg position and
inserting a Foley catheter into the bladder; the
bladder is then rapidly filled with 500 to 700
milliliters of normal saline
The distended bladder elevates the presenting part
and keeps it off of the cord, thus relieving the
compression
Bladder filling may be particularly useful when
immediate cesarean delivery is not possible.

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 4. Funic reduction:
The procedure involves elevating the fetal head
with gentle suprapubic pressure or
transvaginally or both and then sliding the cord
over the widest part of the pelvis and placing it in
the nuchal area
It is employed to alleviate pressure on the cord
from the presenting part while preparations for C/D
are being made
Gentle suprapubic fixation of the head decreases
the chance of creating an oblique or transverse lie.

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 OUTCOME:
The interval between cord prolapse and delivery is a
major determining factor in the immediate neonatal
outcome and perinatal mortality
Team training can significantly lower the time from Dx to
delivery
Prognosis:
1. Maternal
 Maternal complications include those related to;
 Anesthesia
 blood loss, and
 infection following cesarean section or operative vaginal
delivery
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 2. Neonatal:
 prognosis for intrapartum cord prolapse is greatly
improved
 fetal mortality and morbidity rates still can be
high, depending on
the degree and duration of umbilical cord
compression
neonatal resuscitation is started

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  If the Dx is made early and the duration of
complete cord occlusion is less than 5 minutes,
the prognosis is good
GA and trauma at delivery also affect the final
neonatal outcome
If complete cord occlusion has occurred for
longer than 5 minutes or if intermittent partial
cord occlusion has occurred over a prolonged
period of time, fetal damage or death may occur

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 Prevention :
 Pts at risk for cord prolapse should be treated as
high-risk
 Pts with;
 PROM
 Malpresentation
 Poorly applied cephalic presentations are at
particular risk of prolapse

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  Those at risk Pts should be closely monitored
 Options include;
checking for FHR decelerations continuously when
the patient is on the labor unit and
intermittent FHR monitoring if not on labour
educating the patient regarding the S/S of cord
prolapse
 Avoiding unnecessary obstetric interventions in
Pts at risk for cord prolapse

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  If possible, amniotomy should be performed only
when the presenting part is well applied to the
cervix
 When amniotomy is necessary in fetal vertex is not
well applied, controlled amniotomy with small
gauge needle and simultaneous application of
fundal pressure may decrease the risk of prolapse
 Controlled amniotomy minimizes the risk of
gushing amniotic fluid and dropping down of the
cord

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  Avoid disengaging the fetal presenting part when
performing procedures such as;
 amnioinfusion,
 forceps application, and
 manual rotation of the fetal head
 At the time of spontaneous membrane rupture, a
prompt, careful pelvic examination should be
performed to rule out cord prolapse

Thank you !!!!!!!

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 References:
1. Uptodate
2. Danforth's Obstetrics and Gynecology, 10th Edition
3. NMS Obstetrics and Gynecology, 6th Edition
4. Williams Obstetrics 22/edition 2005
5. Current Diagnosis and Treatment in Obstetrics and
Gynecology
6. Management protocol on selected obstetrics topics
(FMOH) January, 2010
7. Steven G. Gabbe Obstetrics Normal and Problem
Pregnancies
8. MYLES TEXT BOOK FOR MIDWIVES,15th edition

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