Umbilical cord prolapse - Dr.Suresh Babu Chaduvula
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Transcript of Umbilical cord prolapse - Dr.Suresh Babu Chaduvula
UMBILICAL CORD
PROLAPSEDr.Suresh Babu Chaduvula
Professor
Department of Obstetrics & Gynecology
King Khalid University
Abha, Saudi Arabia
AIM To provide information and practical
guidance to enable early diagnosis and efficient initiation of emergency procedures to ensure the best possible neonatal outcome
TERMINOLOGIES Umbilical cord presentation:
Presence of cord in front of presenting part before the rupture of membranes.
Umbilical cord prolapse: Descent of umbilical cord following rupture of the membranes, through the cervix so that it lies either along side the fetal part or in front of presenting part into the cervix/ and into or out of vagina.
TERMINOLOGIES Occult prolapse – Cord lies adjacent to
the presenting part, but not beyond the presenting part in the presence of intact or without intact membranes.
Overt prolapse – cord which is visible or palpable with naked eyes following rupture of membranes.
OBJECTIVES: Identify predisposing risk factors Enable prompt diagnosis and institute
immediate action Initiate correct emergency procedures Raise awareness of the neonatal
implications
INCIDENCE Over all incidence – 0.1% -0.6% Primi gravida – 0.4 % Multi gravida – 0.6 % Cephalic presentation – 0.3 % Breech - Frank – 0.9 % - Complete – 5 % - Footling – 10 % Shoulder presentation – 15 % Contracted pelvis – 4-6 times more.
ETIOLOGY OR RISK FACTORS - 1 Non engagement of fetal head: 1.Unengaged or poorly applied presenting part 2. High parity - weak muscles 3. Unstable lie – weak muscles 4. Malpresentations 5. Breech presentations
ETIOLOGY OR RISK FACTORS -2 Related to Uterine and Pelvic
factors: 1. Polyhydramnios 2. Long umbilical cord 3. Low lying placenta 4. Contracted Pelvis
ETIOLOGY OR RISK FACTORS -3 Related to Fetal factors: 1. Prematurity 2. Low Birth Weight 3. Second twin 4. Congenital malformations
ETIOLOGY OR RISK FACTORS -4 Related to clinical procedures: 1. ARM in high presenting part 2. External cephalic version 3. Stabilizing induction of labor 4. Manual rotation of fetal head in OP position 5. Application of fetal scalp electrode 6. Internal podalic version of second twin
ETIOLOGY OR RISK FACTORS -5 Other causes 1. PROM 2. Male fetuses 3. Anomalies of uterus
COMPLICATIONS: Neonatal morbidity and Mortality –
as high as 50 % due to 1. Hypoxia - is due to cord compression by the presenting part and also due to vasospasm of umbilical vessels 2. Operative trauma 3. Delay in transport 4. Congenital malformations 5. Prematurity Maternal morbidity :
DIAGNOSIS Overt cord can be seen in the vagina or
outside the vagina- feel pulsations Variable deceleration and bradycardia
on CTG following rupture of membranes. Fetal bradycardia – following fundal
pressure Meconium stained liquor
PREVENTION Ultrasound examination for
malpresentation and cord presentation. Avoid ARM in unengaged head Routinely doing PVE following
spontaneous rupture of membranes. Controlled ARM in poly hydramnios –
Stabilizing induction. Bradycardia and variable decelerations
- do either vaginal examination or speculum examination
MANAGEMENT Depends upon viability of the fetus and
absence of fetal malformations. Quick action should be taken to
expedite the delivery. Survival of fetus depends on swift action Prepare for Emergency interventions like Cesarean section and or Instrumental delivery. Multidisciplinary approach or Team work
is required
MANAGEMENT Discontinue IV oxytocin infusion
Oxygen by mask – 15 lits/ mt
CORD – C – call for help - O – organize for delivery - R – Relieve pressure - D – Delivery Funic repositioning: with soaked warm saline reposition into vagina
ELEVATING THE PRESENTING PART Avoid presenting part pressure over cord
by digital or manual pressure. Instruct the patient to not to exert
pressure or pushing. Bladder filling with 500 700 ml of
saline. Tocolysis? Inj.Terbutaline 250 microgams
SCly Positioning of the patient:1. Knee chest position2. Trendelenburg position3. Exaggerated Sims or lateral position
TRENDELENBURG POSITION
EXAGGERATED SIM’S POSITION
DO’S AND DON’TS Do’s – Replace the cord into the vagina to
prevent from vasospasm with saline soaked pad
Continuous monitoring of FHR Inform the patient Minimal handling of cord Don'ts – Replace inside the uterus Excessive handling of the cord.
COMMUNITY LEVEL Knee chest face down position Bladder filling with saline In Ambulance – left lateral position Manual elevation – if a nurse or family
physician there Urgent transfer to center with cesarean
facilities and neonatal care.
Stage I of Labor Prepare for Emergency Cesarean section Inform the senior pediatrician Delivery should be done within 30 minutes If fetal death occurs, try for vaginal delivery. Stage II Labor: Expedite delivery with liberal episiotomy
and instrumental delivery. If there is fetal heart disturbance and not in
favor of vaginal delivery plan for Emergency Cesarean section.
Extreme prematurity with cord prolapse:
1. Below or around 24 weeks – counsel the patient.
If she wishes to continue pregnancy if FHR is normal and patient willing for up to 3 weeks
If patient does not agree allow for vaginal delivery with or without oxytocin infusion
FETAL MORTALITY Overall – 50 % First stage of labor – 75 % Second stage – 50 % Neonatal death – 4 % Perinatal mortality – 20 % Asphyxia – Hypoxic ischaemic
encaephlopathy - Cerebral palsy
PROGNOSIS Good with vertex presentation than
Breech. Good in Primigravida than in multi.
RESOURCES - 1 MEDLINE and NHS databases
RCOG Green Top Guidelines
Women’s Hospitals Australasia
Lin MG (2006). Umbilical cord prolapse. Obstetrical and Gynecological Survey 61(4):269-77. Mapp T (2005). Feelings and fears post obstetric emergencies-2. British Journal of Midwifery 13(1):36-40. Mapp T, Hudson K (2005). Feelings and fears during obstetric emergencies-1.
British Journal of Midwifery 13(1):30-5. Murphy DJ, MacKenzie IZ (1995). The mortality and morbidity associated with
umbilical cord prolapse. British Journal of Obstetrics and Gynaecology. 102(10):826-30. National Collaborating Centre for Women’s and Children’s Health (2007).
Intrapartum care: care of healthy women and their babies during childbirth. London: RCOG
Press
RESOURCES - 2 Afolabi BB, Lesi FE, Mera NA (2006). Regional versus general anaesthesia for
caesarean section. Cochrane Database of Systematic Reviews, issue 4. Boyle JJ, Katz VL (2005). Umbilical cord prolapse in current obstetric practice. Journal of Reproductive Medicine 50(5):303-6. Clinical Negligence and Other Risks Scheme (CNORIS 2009). http://www.cnoris.com [Accessed 26 March 2010]. Crofts JF, Ellis D, Draycott TJ et al (2007). Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG: An International Journal of Obstetrics and Gynaecology 114 (12):1534-41. Draycott T, Winter C, Crofts J, et al, eds (2008). Module 8. Cord prolapse in: PROMPT: Practical Obstetric MultiProfessional Training Course Manual. London: RCOG Press:117-
24. Goswami K (2007). Umbilical cord prolapse. In: Grady K, Howell C, Cox C eds. Managing Obstetric Emergencies and Trauma. The MOET course manual 2nd ed. London: RCOG Press: 233-7. Houghton G (2006). Bladder filling: an effective technique for managing cord prolapse. British Journal of Midwifery 14(2):88-9. Katz Z, Shoham Z, Lancet M et al (1988). Management of labor with umbilical cord prolapse: a 5-year study. Obstetrics and Gynecology 72(2):278-81. Koonings PP, Paul RH, Campbell K (1990). Umbilical cord prolapse. A contemporary look. Journal of Reproductive Medicine 35(7):690-2.
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