Download Management of Cord Prolapse: A Clinical Guideline and more Study Guides, Projects, Research Obstetrics in PDF only on Docsity!
Cord prolapse
Key Points
- Risks factors include malpresentation, prematurity and obstetric interventions e.g. artificial rupture of membranes with a high presenting part.
- Cord prolapse should be suspected when there is an abnormal fetal heart rate pattern, particularly shortly after rupture of membranes (spontaneously or with amniotomy).
- This is an obstetric emergency which requires urgent delivery.
- If cord prolapse is diagnosed, relieve the pressure of the presenting part on the cord by manual displacement or by filling the bladder with normal saline via a Foley catheter until delivery.
- Delivery by emergency Caesarean section is usually indicated unless the cervix is fully dilated and head below ischial spines, when an instrumental delivery may be considered.
Version: 2.
Guidelines Lead(s): A Kirkpatrick (Consultant Obstetrician FPH) & O Eniola (Consultant Obstetrician WPH)
Contributors: E Hutchinson (ST3 Doctor O&G)
Lead Director/ Chief of Service: Anne Deans
Ratified at: Obstetrics and Gynaecology Clinical Governance Committee, 22nd^ June 2020
Date Issued: July 2020
Review Date: June 2023
Pharmaceutical dosing advice and formulary compliance checked by:
Ruhena Ahmad and Ruth Botting 1st^ July 2020
Key words: Cord prolapse, artificial rupture of membranes, presenting part
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.
Version Control Sheet
Version Date Guideline Lead(s) Status Comment 1.0 September 2016
Alison Kirkpatrick O. Eniola
Final First cross site version
2.0 June 2020 Alison Kirkpatrick, O. Eniola, E. Hutchinson
Final Updated and approved at OGCG 22.06.
Related Documents
Document Type Document Name
Abbreviations
ARM Artificial rupture of membranes CTG Cardiotocography
1. INTRODUCTION
Cord presentation: the cord is between the fetal presenting part and the cervix, with or without intact membranes.
Cord prolapse: the cord is through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membranes.
Cord prolapse occurs in 1-6 in 1000 births and is more common in breech presentation (more than 1 in 100 births) 1.
2. RISK FACTORS
50% of cases occur after an obstetric intervention.
General Procedure related
- Low birthweight (< 2.5kg)
- Multiparity
- Prematurity less than 37 weeks
- Fetal congenital abnormality
- Malpresentation (breech, oblique, transverse and unstable lie)
- Second twin
- Polyhydramnios
- Unengaged presenting part
- Low-lying placenta or other abnormal placentation - Artificial rupture of membranes - Manipulation of fetus with ruptured membranes - External cephalic version - Internal podalic version - Stabilising induction of labour - Large balloon catheter induction of labour (if filled >180mls)
3. PREVENTION / REDUCING RISK
- Women with transverse, oblique or unstable lie should be advised to present urgently if there are signs of labour or rupture of membranes. Elective admission to hospital after 37 weeks of gestation should be discussed.
- Avoid artificial rupture of membranes (ARM) whenever possible if the presenting part is mobile.
- If it becomes necessary to rupture the membranes, this should be performed with arrangements in place for immediate caesarean delivery.
- Vaginal examination and obstetric intervention in the context of ruptured membranes and a high presenting part carries the risk of upward displacement and cord prolapse. Upward pressure on the presenting part should be kept to a minimum in such women.
- Rupture of membranes should be avoided if, on vaginal examination, there is cord felt below the presenting part.
- When cord presentation is diagnosed in established labour, caesarean section is usually indicated. Vaginal delivery may be possible if the CTG remains normal, labour is progressing well and birth is imminent. The woman should be prepared for an emergency caesarean section or instrumental delivery.
4. DIAGNOSIS
Cord presentation and prolapse may occur without outward physical signs and with a normal fetal heart rate pattern.
- Cord prolapse or presentation should be excluded at every vaginal examination in labour. The fetal heart rate should be auscultated after every vaginal examination and rupture of membranes.
- Cord prolapse should be suspected where there is an abnormal fetal heart rate pattern, particularly if the fetal heart rate becomes abnormal soon after membrane rupture, spontaneously or with amniotomy.
- The cord may be felt on vaginal examination or seen at the introitus.
This is an obstetric emergency.
5. MANAGEMENT
INITIAL MANAGEMENT
- Call for help – dial 2222 for ‘obstetric emergency’.
- Inform the woman what has happened and the need for immediate delivery.
- Replace the cord in the vagina gently if visible externally without handling the cord excessively.
- Confirm fetal viability by auscultation of the fetal heart or ultrasound scan as appropriate. If a fetal heart rate cannot be heard, an ultrasound scan should be performed immediately.
FIRST STAGE OF LABOUR Relieve the pressure of the presenting part on the cord:
- Insert a hand into the vagina and gently push up the presenting part. Place a hand suprapubically to keep the presenting part out of the pelvis.
- The presenting part can be elevated manually or by filling the bladder. The latter may facilitate regional anaesthesia for delivery.
- Insert a Foley catheter and fill the bladder with 500mls sodium chloride 0.9% via a giving set to elevate the presenting part. Clamp the catheter. 2,3,4,5^ The equipment is available in the cord prolapse emergency box on labour ward, the antenatal ward and antenatal clinic.
- Place the woman in left lateral (exaggerated Sim’s position) with a wedge under the hip.
- Switch off oxytocin (Syntocinon®) if running and consider tocolysis with subcutaneus 0.25mg terbutaline. 1
- Offer 4g intravenous bolus of magnesium sulphate (give over 15 minutes) for neuroprotection of the baby for women between 24 and 32+0 weeks gestation. 6
- Consider giving magnesium sulphate (as above) between 22+3 – 33+6 weeks gestation. 6
- Transfer to theatre for: Category I Caesarean section if the CTG shows abnormal features Category II Caesarean section if the CTG is normal (consider regional anaesthesia by experienced anaethetist if CTG normal).
- Unclamp the catheter and empty the bladder just prior to cleaning the skin for Caesarean section.
8. MONITORING COMPLIANCE
The patient safety / risk management midwives will identify cases via incident reporting or clinical triggers and will arrange a review of the notes by the appropriaye clinician (lead obstetrician, anaesthetist, paediatrician or senior midwife). Any relevant risk issues identified will be discussed and actioned in the maternity risk management group or obstetric clinical governance group.
9.0 REFERENCES
1 – Royal College of Obstetricians and Gynaecologists (2014) Green-top Guideline No. 50 Umbilical Cord Prolapse. RCOG. London
2 – Katz Z. Management of labour with umbilical cord prolapse: a 5 year study. Obstetrics & Gynaecology. 1988;72 (2): 278-81.
3 – Vago T. Prolapse of the umbilical cord. A method of management. AJOG 1970;107:967-9.
4 – Chetty RM, Moodley J. Umbilical cord prolapse S Afr Med J 1980;57:128-9.
5 – Caspi E, Lotan Y, Schreyer P. Prolapse pf the cord: reduction of perinatal mortality by bladder instillation and caesarean section. Isr J Med Sci 1983;19:541-5.
6 – NICE guideline [NG25] Preterm labour and birth (August 2019)
7 – British Association of Perinatal Medicine (2019) Perinatal Management of Extreme Preterm Birth Before 27 Weeks Gestation – A Framework For Practice. BAPM
9. Caesarean section - Category 1 or 2 as appropriate.
MANAGEMENT OF CORD PROLAPSE IN HOSPITAL SETTING
2. Position the women in left lateral with her knees to her chest
1. Call for help – dial 2222 for obstetric emergency.
3. Perform vaginal 4. Monitor fetal heart. examination. Replace the cord in the vagina. Apply digital pressure to elevate the presenting part. Assess the cervical dilatation.
7. Catheterisation Consider^8. Transfer to theatre. filling the bladder with 500 mL of sodium chloride 0.9% if appropriate.
6. Consider terbutaline 0.25mg subcutaneous.
5. Turn off oxytocin (Syntocinon®)
10. Expedite delivery with forceps or vacuum extraction if appropriate.
