Post on 06-Jul-2018
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Cases o cord prolapse appear consistentl# in perinatal
mortalit# en%uiries, and one large stud# ound a
perinatal mortalit# rate o &1'1000. rematurit# andcongenital malormations account or the maorit# o
adverse outcomes associated with cord prolapse in
hospital settings1 but birth asph#xia is also associated
with cord prolapse. erinatal death has beendescribed with normall# ormed term babies,
particularl# with planned home birth. *ela# in transer
to hospital appears to be an important contributing
actor. +sph#xia ma# also result in h#poxicischaemic
encephalopath# and cerebral pals#.
The principal causes o asph#xia in this context are
thought to be cord compression and umbilical arterial
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vasospasm preventing venous and arterial blood $ow
to and rom the etus. There is a paucit# o long-term
ollow-up data o babies born alive ater cord prolapse
in both hospital and communit# settings.
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"n
general,
these
actors
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predispose to cord prolapse b# preventing close
application o the presenting part to the lower part o
the uterus and'or pelvic brim. upture o membranes
in such circumstances compounds the ris/ o prolapse.
ome authorities have also speculated that cord
abnormalities (such as true /nots or low content o
harton2s ell#) and etal h#poxiaacidosis ma# alterthe turgidit# o the cord and predispose to prolapse.
"nterventions can result in cord prolapse with about
30 o cases being preceded b# obstetric
manipulation.
The manipulation o the etus with or without prior
membrane rupture (external cephalic version, internal
podalic version o the second twin, manual rotation,
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placement o intrauterine pressure catheters) and
planned artifcial rupture o membranes, particularl#
with an unengaged presenting part, are the
interventions that most re%uentl# precede cordprolapse.
Can cord presentation be detected antenatally?
outine ultrasound examination is not su4cientl#
sensitive or specifc or identifcation o cordpresentation antenatall# and should not be perormed
to predict increased probabilit# o cord prolapse,
unless in the context o a research setting.
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Can cord prolapse or its efects be avoided?
ith transverse, obli%ue or unstable lie, elective
admission to hospital ater 567! wee/s o gestation
should be discussed and women should be advised to
present %uic/l# i there are signs o labour or suspicion
o membrane rupture. omen with noncephalic
presentations and preterm prelabour rupture o themembranes should be o8ered admission.
+rtifcial membrane rupture should be avoided
whenever possible i the presenting part is mobile. " it
becomes necessar# to rupture the membranes, this
should be perormed with arrangements in place or
immediate caesarean deliver#.
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9aginal examination and obstetric intervention in the
context o ruptured membranes and a high presenting
part carr# the ris/ o upward displacement and cordprolapse. :pward pressure on the
presenting part should be /ept to a minimum in such
women.
upture o membranes should be avoided i, on
vaginal examination, the cord is elt below the
presenting part. hen cord presentation is diagnosed
in established labour, caesarean section is usuall#
indicated.
When should cord prolapse be suspected?
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Cord presentation and prolapse ma# occur without
outward ph#sical signs and with a normal etal heart
rate pattern. The cord should be examined or at ever#
vaginal examination in labour and ater spontaneous
rupture o membranes i ris/ actors are present or i
cardiotocographic abnormalities commence soon
thereater.
ith spontaneous rupture o membranes in the
presence o a normal etal heart rate patterns and the
absence o ris/ actors or cord prolapse, routinevaginal examination is not indicated i the li%uor is
clear.
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Cord prolapse should be suspected where there is
an abnormal etal heart rate pattern (brad#cardia,
variable decelerations etc), particularl# i such
changes commence soon ater membrane rupture,spontaneousl# or with amniotom#. peculum and'or
digital vaginal examination should be perormed at
preterm gestations when cord prolapse is suspected.
What is the optimal initial management o cord
prolapse in hospital settings?
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hen cord prolapse is diagnosed beore ull dilatation,
assistance should be immediatel# called and
preparations made or immediate deliver# in theatre.
There are insu4cient data to evaluate manualreplacement o the prolapsed cord above the
presenting part to allow continuation o labour. This
practice is not recommended.
To prevent vasospasm, there should be minimal
handling o loops o cord l#ing outside the vagina. To
prevent cord compression, it is recommended that the
presenting part be elevated either manuall# or b#flling the urinar# bladder. Cord compression can be
urther reduced b# the mother adopting the /nee
chest position or head-down tilt (preerabl# in let-
lateral position).
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Tocol#sis can be considered while preparing or
caesarean section i there are persistent etal heart
rate abnormalities ater attempts to prevent
compression mechanicall# and when the deliver# is
li/el# to be dela#ed.
+lthough the measures described above are
potentiall# useul during preparation or deliver#, the#
must not result in unnecessar# dela#.
What is the optimal mode o delivery with cord
prolapse?
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+ caesarean section is the recommended mode o
deliver# in cases o cord prolapse when vaginal
deliver# is not imminent, to prevent h#poxiaacidosis.
+ categor# 1 caesarean section should be perormed
with the aim o delivering within 50 minutes or less i
there is cord prolapse associated with a suspicious or
pathological etal heart rate pattern but withoutundul# ris/ing maternal saet#. 9erbal consent is
satisactor#.
Categor# ; caesarean section is appropriate or
women in whom the etal heart rate pattern is normal.
egional anaesthesia ma# be considered in
consultation with an experienced anaesthetist.
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What is the optimal management in community
settings?
omen should be advised, over the telephone i
necessar#, to assume the /neechest ace-downposition while waiting or hospital transer. *uring
emergenc# ambulance transer, the /neechest is
potentiall# unsae and the let-lateral position should
be used.
+ll women with cord prolapse should be advised to be
transerred to the nearest consultant-led unit or
deliver#, unless an immediate vaginal examination b#
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a competent proessional reveals that a spontaneous
vaginal deliver# is imminent. reparations or transer
should still be made.
The presenting part should be elevated during transer
b# either manual or bladder flling methods. "t is
recommended that communit# midwives carr# a
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with prolapse occurring inside the hospital. =eonatal
morbidit# is also increased in this circumstance
What is the optimal management o cord
prolapse beore viability?
>xpectant management should be discussed or cord
prolapse complicating pregnancies with gestational
age at the limits o viabilit#.
:terine cord replacement ma# be attempted. omen
should be counselled on both continuation and
termination o pregnanc# ollowing cord prolapse at
the threshold o viabilit#.
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Clinical governance
Debrieng
ostnatal debriefng should be o8ered to ever# woman with
cord prolapse. +ter severe obstetric emergencies, women
might be ps#chologicall# a8ected with postnatal depression,
post-traumatic stress disorder or ear o urther childbirth.
omen with cord prolapsewho undergo urgent transer to hospital might be
particularl# vulnerable to emotional problems.
*ebriefng is an important part o maternit# care and should
be o8ered b# a proessional competent in counselling
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:mbilical Cord
rolapse? is/ pidemiolog#Presentati
on
9e
rtex
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apid esponseto rolapse
?ecognie non-reassuring tracing
?9isuall# inspect'palpatecord to diagnose
?+ssess etal status(
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revention o
rolapse
? "denti# ris/ actors- @alpresentation, highpresentation
- atient education reF membrane
rupture
at home
? =o +G@ when station
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high
- @a# HneedleH membranes underdouble
set-up
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praevia, D, operativedeliver#
? *i#gosit# (raternal) K;'5
- "ncreases with age, parit#,
amilialactors
? @ono#gosit# (identical) K
1'5????????
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*
i
a
g
n
o
s
is o @ultiple
IestationGvulation induction
arl# "D>levated @+
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ol#h#dramnios
?????
+ssociated
Complicationsrematurit#
Congenital anomaliesregnanc#-induced
h#pertension
lacenta praevia
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< etal deathF 0.3 - !.B
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*elivering Twin
M
? +ttempt internal podalicversion? Mreech deliver# is reasonable
choicewhenF
- >xternal version unsuccessul or
not
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ummar
#
? ix t#pes o
malpresentations
? *iagnosis b# ph#sical exam
andimaging
? Me alert to etiologicassociation
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? Me alert to potential
complications ? 9aginal deliver#ma# be consideredor G, breech, ace andcompoundpresentation