What position should a patient be placed in if a cord prolapse is detected?
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Cord prolapse has been defined as the descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes. Cord presentation is the presence of the umbilical cord between the fetal presenting part and the cervix, with or without membrane rupture. The overall incidence of cord prolapse ranges from 0.1% to 0.6%. In the case of breech presentation, the incidence is slightly higher than 1%. It has been reported that male fetuses appear to be predisposed to cord prolapse. The incidence is influenced by population characteristics and is higher where there is a large percentage of multiple gestations. Show
Cases of cord prolapse appear consistently in perinatal mortality enquiries, and one large study found a perinatal mortality rate of 91/1000. Prematurity and congenital malformations account for the majority of adverse outcomes associated with cord prolapse in hospital settings but birth asphyxia is also associated with cord prolapse. Perinatal death has been described with normally formed term babies, particularly with planned home birth. Delay in transfer to hospital appears to be an important contributing factor. Asphyxia may also result in hypoxic–ischaemic encephalopathy and cerebral palsy. The principal causes of asphyxia in this context are thought to be cord compression and umbilical arterial vasospasm preventing venous and arterial blood flow to and from the fetus. There is a paucity of long-term follow-up data of babies born alive after cord prolapse in both hospital and community settings. The management of prolapsed cord is one of the labour ward guidelines mandated by the Clinical Negligence Scheme for Trusts (CNST), Welsh Pool Risk and Clinical Negligence and Other Risks Scheme (CNORIS) maternity standards in England, Wales and Scotland, respectively. The purpose of this guideline is to describe modalities to prevent, diagnose and manage cord prolapse. It addresses those pregnant women at high risk of or with a diagnosis of cord prolapse in hospital and community settings. Pregnancies complicated by fetal malformation or with cord prolapse before 22 completed weeks of gestation ate not covered by this guideline. All later gestations are included. COVID disclaimerThis guideline was developed as part of the regular programme of Green-top Guidelines, as outlined in our document Developing a Green-top Guideline: Guidance for developers (PDF), and prior to the emergence of COVID-19. Version historyThis is the second edition of this guideline. Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request. Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It usually occurs during labor but can occur anytime after the rupture of membranes. The greatest risk factors are an abnormal position of the baby within the uterus and a premature or small baby. Other risk factors include a multiple pregnancy, more than one previous delivery, and too much amniotic fluid. Whether medical rupture of the amniotic sac is a risk is controversial. The diagnosis should be suspected if there is a sudden decrease in the baby's heart rate during labor. Seeing or feeling the cord confirms the diagnosis. Management focuses on quick delivery, usually by cesarean section. Filling the bladder or pushing up the baby by hand is recommended until this can take place. Sometimes women will be placed in a knee-chest position or the Trendelenburg position in order to help prevent further cord compression. With appropriate management, the majority of cases have good outcomes. Umbilical cord prolapse occurs in about 1 in 500 pregnancies. The risk of death of the baby is about 10%. However, much of this risk is due to congenital anomalies or prematurity. It is considered an emergency. Signs and symptoms[edit]The first sign of umbilical cord prolapse is usually a sudden and severe decrease in fetal heart rate that does not immediately resolve. On fetal heart tracing (a linear recording of the fetal heart rate) this would usually look like moderate to severe . In overt cord prolapse, the cord can be seen or felt on the vulva or vagina. A majority of umbilical cord prolapse cases happen during the . Risk factors[edit]Risk factors that are associated with umbilical cord prolapse tend to make it difficult for the baby from appropriately engaging and filling the maternal pelvis or are related to abnormalities of the umbilical cord. The two major categories of risk factors are spontaneous and iatrogenic (those that result from medical intervention).
Diagnosis[edit]Umbilical cord prolapse should always be considered a possibility when there is a sudden decrease in fetal heart rate or variable decelerations, particularly after the rupture of membranes. With overt prolapses, the diagnosis can be confirmed if the cord can be felt on vaginal examination. Without overt prolapse, the diagnosis can only be confirmed after a cesarean section, though even then it will not always be evident at time of procedure. There are three types of umbilical prolapse that can occur:
Management[edit]The knee-chest position is typically recommended The typical treatment of umbilical cord prolapse in the setting of a viable pregnancy involves immediate delivery by the quickest and safest route possible. This usually requires cesarean section, especially if the woman is in early labor. Occasionally, vaginal delivery will be attempted if clinical judgment determines that is a safer or quicker method. Other interventions during management of cord prolapse are typically used to decrease the chance of complications while preparations for delivery are being made. These interventions are focused on reducing pressure on the cord to prevent fetal complications from cord compression. The following maneuvers are among those used in clinical practice:
If the mother is far from delivery, funic reduction (manually placing the cord back into the uterine cavity) has been attempted, with successful cases reported. However, this is not currently recommended by the Royal College of Obstetricians and Gynaecologists (RCOG), as there is insufficient evidence to support this maneuver. Outcomes[edit]The primary concern with umbilical cord prolapse is inadequate blood supply, and thus oxygen, to the baby if the cord becomes compressed. The cord can become compressed either due to mechanical pressure (usually from the presenting fetal part) or from sudden contraction of the vessels due to decreased temperatures in the vagina in comparison to the uterus. This can lead to death of the baby or other complications. Historically, the rate of fetal death in the setting of cord prolapse has been as high 40%. However, these estimates occurred in the context of home or births outside of the hospital. When considering cord prolapses that have occurred in inpatient labor and delivery settings, the rate drops to as low as 0-3%, though the mortality rate remains higher than for babies without cord prolapse. The reduction in mortality for hospital births is likely due to the ready availability of immediate cesarean section. Many other fetal outcomes have been studied, including Apgar score (a quick assessment of a newborn's health status) at 5 minutes and length of hospitalization after delivery. While both measures are worse for newborns delivered after cord prolapse, it is unclear what effect this has in the long-term. Relatively large studies that have tried to quantify long-term effects of cord prolapse on children found that less than 1% (1 in 120 studied) had a major neurologic disability, and less than 1% (110 in 16,675) had diagnosed cerebral palsy. Epidemiology[edit]Rates of umbilical cord prolapse ranges from 0.1 to 0.6% of all pregnancies. This rate has remained stable over time. A recent study estimates 77% of cord prolapses occur in singleton pregnancies (where there is only one baby). In twin pregnancies, cord prolapses occur more frequently in the second twin to be delivered, with 9% in the first twin and 14% in the second twin. Which position is recommended in cord prolapse?Repositioning of the mother to be in the knee-chest position or Trendelenburg position (head down with feet elevated), lying on left side is usually preferred. Filling of the bladder using a foley catheter can help elevate the presenting fetal part and lift it off the cord.
On what position will the nurse put the client with cord prolapse?The immediate priority is to minimize pressure on the cord. Thus the nurse's initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord.
What is the safest position for a woman in labour with prolapsed cord?Encourage into left lateral position with head down and pillow placed under left hip OR knee-chest position. This will relieve pressure off the cord from the presenting part.
What is the priority intervention when a cord prolapse has occurred?As soon as a prolapsed umbilical cord is diagnosed, an obstetrician should be notified immediately, and the team should prepare for delivery. An emergency cesarean birth is the preferred mode of delivery, but vaginal delivery might be considered if birth is imminent.
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