CORD PRESENTATION AND PROLAPSE DEFINITION Umbilical cord prolapse
CORD PRESENTATION AND PROLAPSE
DEFINITION Umbilical cord prolapse is a condition in which the umbilical cord descends alongside or below the presenting part.
Etiology q. Improper fitting of the presenting part into the maternal pelvis q. Malpresentation q. Contracted pelvis q. Prematurity q. Twins q. Hydramnios q. Placental factor q. Iatrogenic
Clinical types • Overt cord prolapse The cord lies inside the vagina or outside the vulva following rupture of the membranes. It is the most common type. • Cord (funic) presentation The cord is slipped down below the presenting part and is felt lying in the intact bag of membranes. The umbilical cord can be palpated on vaginal examination. • Occult cord prolapse The cord is placed by the side of the presenting part and is not felt by the fingers on internal examination. It can occur with intact or ruptured membranes.
Diagnosis Overt cord prolapse ü palpated by the fingers as the membranes are absent ü pulsation can be felt if the fetus is alive. Cord presentation ü feeling the pulsation of the cord through the intact membranes. Occult cord prolapse ü It is difficult to diagnose ü clinical features of fetal bradycardia or prolonged foetal heart rate deceleration ü confirmation is by transvaginal sonography
Anticipation and early detection Internal examination when the case presents ü premature rupture of membranes ü Malpresentation ü Twins ü hydramnios ü non engaged vertex presentation. Surgical induction in the OT. ü Uterine contractions initiated by oxytocin ü if the head is not engaged prior to Exclude cord presentation or occult prolapse in unexplained fetal distress during labour
Management CORD PRESENTATION Aims to preserve the membranes and to expedite the delivery: ü No attempt should be made to repalce the cord. ü If immediate vaginal delivery is not possible or contraindicated, LSCS is the best ü A rare occasion is a multipara with longitudinal lie having good uterine contractions with the cervix ¾ dilated, without any evidence of fetal distress. Watchful expectancy can be adopted till full dilatation of the cervix, when the delivery can be completed by forceps or breech extraction.
Management of CORD PROLAPSE Cord prolapse Baby live/dead Maturity of baby Cervical dilatation Baby alive Baby dead Confirm with USG Immediate vaginal delivery spontaneous labor not possible/contraindicated Destructive operation Vertex Breech Forceps or Ventouse Breech extraction Immediate safe vaginal -W/F delivery -
Umbilical cord constriction can be due to intrinsic or extrinsic mechanisms. Constriction may lead to different degrees of flow limitation in the cord"s vessels, which can be demonstrated by pulsed Doppler flow studies. Intrinsic constriction is characterized by localized absence of Wharton"s jelly, leading to narrowing of the cord, thickening of the vascular walls and narrowing of the vascular lumens. In this setting, fetal death might occur due to acute vasospasm, acute oligohydramnios and uterine contraction, or an obliterating thrombus (10). Extrinsic constriction can be caused by:
Occasionally loops of cord may lie between the lower uterine segment and the presenting part (cord or funic presentation). This is important to recognize as it predisposes to cord prolapse and possible fetal death when the membranes rupture. Funic presentation is more common with malpresentations (especially breech and transverse lie).
- Transient and usually insignificant prior to 32 weeks. If this is persistent one must look for a cause.
- Marginal cord insertion from the caudal end of a low-lying placenta.
- Uterine fibroids / Uterine adhesions.
- Congenital uterine anomalies that may prevent the fetus from engaging well into the lower uterine segment.
- Cephalopelvic disproportion.
- Polyhydramnios.
- Multiple gestations.
- Increased umbilical cord length.
- Prolapse of the cord occurs in 0.5% of cases.
- High perinatal mortality rate due to cord compression (1).
- Selbing A. Umbilical cord compression diagnosed by means of ultrasound. Acta Obstet Gynecol Scand 1988;67:565-567.
- Hales ED, Westney LS. Sonography of occult cord prolapse. JCU 1984;12:283-285.
- Dudiak CM, Salomon CG, Posniak HV et.al. Sonography of the umbilical cord. Radiographics 1995;15:1035-1050.
- Johnson RL, Anderson JC, Irsik RD et.al. Duplex ultrasound diagnosis of umbilical cord prolapse. J Clin Ultrasound 1987;15:282-284.
- Kanayama MD, Gaffey TA, Ogburn PL Jr. Constriction of the umbilical cord by an amniotic band, with fetal compromise illustrated by reverse diastolic flow in the umbilical artery. A case report. J Reprod Med 1995 Jan;40(1):71-73.
- Boughizane S, Zhioua F, Jedoui A, Kattech R, Gargoubi N, Srasra M, Ben Romdhane K, Meriah S. Swallowing of an amniotic string by a fetus at term. J Gynecol Obstet Biol Reprod (Paris) 1993;22(4):409-410.
- Heifetz SA. Strangulation of the umbilical cord by amniotic bands: report of 6 cases and literature review. Pediatr Pathol 1984;2(3):285-304.
- Reles A, Friedmann W, Vogel M, Dudenhausen JW. Intrauterine fetal death after strangulation of the umbilical cord by amniotic bands. Geburtshilfe Frauenheilkd 1991 Dec;51(12):1006-1008.
- Sherer DM, Anyaegbunam A. Prenatal ultrasonographic morphologic assessment of the umbilical cord: a review. Part I. Obstet Gynecol Surv 1997 Aug;52(8):506-514
- Hallak M, Pryde PG, Qureshi F, Johnson MP, Jacques SM, Evans MI. Constriction of the umbilical cord leading to fetal death. A report of three cases. J Reprod Med 1994 Jul;39(7):561-565.
Cord Presentation
Cord Presentation
Definition: is a condition when the cord lies in front of the presenting part when the membranes are still intact.
1. Abnormal presentation or positions :any presentation when the presenting part is not well applied on the cervix as seen in breech, face and brow, transverse lie and occipito -posterior position
2. Contracted pelvis: flat pelvis-platypelloid when the anterior-posterior diameter is reduced.
3. Low implantation of the placenta –placenta praevia
4. Excessively long cord
5. Premature rupture of membrane
6. Grand multiparity- flabby weak muscle tone
7. Multiple pregnancy - small baby
8. Polyhydramnoius – increase mortality
9. High head
10. Prematurity –head too small to fill the birth canal
Diagnosis :
cord will be felt pulsating during vaginal examinationwith the membranes intact.
Management :
1. Prevent rupture of the membranes and compression of the cord
2. Arrange for immediate medical aid
3. Elevate foot of the bed
4. Put patient in any of the positions described in cord prolapse
5. Reassure the patient
6. Prepare for emergency caesarean section if cord is pulsating
Prognosis :
It carries 50% mortality
Usually better with footling breech then, secondary to compression or spasm of the cord.