2. ā¢ There are three clinical types of
abnormal descent of the umbilical cord
by the side of the presenting part.
3.
4.
5.
6.
7. ā¢ 1 in 3000 Deliveries
ā¢ Mostly confined to paarous women
ā¢ Incedence is reduce with the increased
use of elective CS in noncephalic
presentations.
8. ā¢ Anything which interferes with perfect
adaptation of the presenting part to be
the lower uterine segment, disturbing
the ball valve action may favor cord
prolapse.
ā¢ Too often, more than one factor
operates.
9. ā¢ Malpresentations- transverse ( common)
5-10 %, breech 3 % specially with flexed
legs or footling and compound
presentation 10%
ā¢ Contracted Pelvis
ā¢ Prematurity
ā¢ Twins
ā¢ Hydromnios
10. ā¢ Placental Factor- Minor degree of
placenta previa with marginal insertion
of cord or long cord
ā¢ Iatrogenic- Low rupture of the
membranes, manual rotation of the
head, ECV, IPV
ā¢ Stabilizing induction
11. OCCULT PROLAPSE
āDifficult to diagnos
āPosibilities should be suspected if
there is persistence of
variabledeceration of fetal heart rate
pattern deteected on continuous
electronic fetal monitoring
13. CORD PROLAPSE
āThe cord is palpated directly by the
fingers and its pulsation can be felt if
the fetus is alive.
āCord pulsation may cease during
uterine contraction which, however,
returns after the contraction passes
off.
āTemptation to pull down the loop for
visualization or unnecessary handling
is to be avoided to prvent vasospasm.
14. āFetus may be alive even in the
absence of cord pulsation.
āHence, prompt USG for cardiac
movements or auscultation for FHS to
be done before fetal death is declared.
15. FETAL
āThe fetus is at risk of anoxia from the
moment cord is prolapsed.
āThe blood flow is occluded either due
to mechanical compression by the the
presenting part or due vasospasm of
the umbilical vessels due to exposure
to cold or irritation when exposed
outside the vulva or as a result of
handling.
16. āThe hazards to the fetus is more in vertex
presentation especially when the cord is
prolapsed through the anterior segment of
the pelvis or when the cervix is patially
dilated.
āThe prognosis is however, related with
the interval between its detection and
delivery of the baby and if the delivery is
complicated, within10-30 minutes the fetal
mortality can be reduced to 5- 10%.
āThe overall pernatal mortality is about 15-
50 %.
17. MATERNAL
āThe maternal risks are incidental due
to emergency operative delivery,
especially through the vaginal route.
āOperative delivery involves the risk of
anesthesia, blood loss and infection.
18. ā¢ Internal examination should be done
whenever the membranes rupture
prematurely or during labour in all
cases of malpresentation, twins,
hydramnios or vertex presentation
where the head is not engaged.
ā¢ Surgical induction should preferably be
conducted in the operation theatre
keeping everything ready for cesarean
section.
19. ā¢ The uterine contraction may be
initiated by oxytocin, if the head is not
engaged prior to low rupture of the
membranes.
ā¢ Internal examinationboth before and
after amniotomy should be carried out
with cord accident in mind.
ā¢ One should exclude cord presentation
or occult prolapse, in unexplained fetal
distress during labour.
20. CORD PRESENTATION
āThe aim is to prevent the membranes and
to expedite the delivery.
āOnce the diagnosis is made, no attempt
should be made toreplace the cord, as it is
not only ineffective but the membranes
inevitably rupture leading to prolapse of
the cord.
āIf immediate vaginal delivery is not
possible or contraindicated, cesarean
section is the best method of delivery.
21. āDuring the time of preparing the patient for
operative delivery, she is kept in
exaggerated sim's position to minimize
cord compression.
āA rare occasion is a multipara with
longitudinal lie having good uterine
contractions with the cervix three-fourth (7-
8 cm) dilated, without any evidence of fetal
distress.
āWatchful expectancy can be adopted till
full dilatation of the cervix, when the
delivery can be completed by forceps or
breech extraction.
22. CORD PROLAPSE
Management protocol is to be guided by:
1) Baby living or dead
2) Maturity of baby
3) Degree of dilatation of the cervix
23. BABY LIVING
I. DEFINITIVE TREATMENT:-
ļ¼Cesarean section is the best treatment
when the baby is sufficiently mature and
is alive.
ļ¼Just prior to abdominal incision, the
fetal heart should be auscultated once
more to avoid unnecessary section on a
dead baby.
ļ¼The operation should be done quickly
up to the delivery of the baby.
24. II. IMMEIDATE SAFE VAGINAL DELIVERY IF
POSSIBLE:-
ļ¼If the head is engaged, delivery is to be
completed by forceps.
ļ¼Ventouse may not be ideal in such
circumstances as it takes a longer time.
ļ¼If breech, the delivery is to be completed
by breech extraction and in transverse lie, it
should be completed by internal version
followed by breech extraction.
ļ¼The same also applied in cases where the
head is not engaged in second baby of
twins.
25. III. IMMEIDATE SAFE VAGINAL DELIVERY
IS NOT POSSIBLE:-
FIRST AID MANAGEMENT:
ļ¼The aim is to minimize pressure on the
cord till such time when the patient is
prepared for assisted delivery or is
transferred to an equipped hospital.
ļ¼If the oxytocin infusion is on, this should
be stopped.
ļ¼At this time intravenous fluid and O2 by
face mask is given.
26. ļ¼BLADDER FILLING has been done to
raise the presenting part off the
compressed cord till such time that
patient has delivered.
ļ¼Bladder is filled with 400-750 mL of
normal saline with a Foley/s catheter,
the balloon is inflated and the catheter is
clamped.
ļ¼Bladder is emptied before cesarean
delivery.
27. ļ¼TO LIFT THE PRESENTING PART OFF
THE CORD, by the gloved fingers
introduced in to the vagina.
ļ¼The fingers should placed inside the
vagina till definitive treatment is
instituted.
ļ¼POSTURAL TREATMENT, Exaggerated
and elevated sim's position with a pillow
or wedge under the hip or thigh,
trendelenburg or knee-chest position has
been traditionally mentioned but may be
tiring and risksome to the patient.
28. ļ¼TO REPLACE THE CORD IN TO THE
VAGINA, to minimize vasospasm due to
irritation.
DEAD BABY
ļ¼Labour is allowed to proceed awaiting
spontaneous delivery.