Cord Prolapse Clinical Guideline
V3.0
July 2021
1. Aim/Purpose of this Guideline
1.1. This is to give guidance to all midwives and obstetricians on the recognition and management of an umbilical cord prolapse..
1.2. This version supersedes any previous versions of this document.
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1.3. This guideline makes recommendations for women and people who are pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant, in labour and in the postnatal period. When discussing with a person who does not identify as a woman please ask them their preferred pronouns and then ensure this is clearly documented in their notes to inform all health care professionals.
2. The Guidance
2.1. Definition
Cord prolapse is 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.
2.2. Incidence
The overall incidence of cord prolapse ranges from 0.1% to 0.6%. With a breech presentation the incidence is 1%.
Cases involving cord prolapse consistently appear in the perinatal mortality enquiries. Congenital malformations account for the majority of adverse outcomes associated with cord prolapse in hospital settings but birth asphyxia is also associated.
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The principle causes of asphyxia in this context are:
Cord compression (preventing venous return to the fetus)
Umbilical vasospasm (preventing venous and arterial blood flow to and from the fetus) due to exposure to external environment
2.3. Risk Factors for cord prolapse
Any factor which prevents close application of the presenting part to the lower part of the uterus or the pelvic brim.
2.4. Avoidance of cord prolapse
50% of cases of cord prolapse are a result of obstetric intervention
2.4.1. Artificial Rupture of membranes (ARM) should be avoided if the presenting part is mobile. If ARM is clinically indicated, in the presence of risk factors for cord prolapse, this should be performed with arrangements in place for an immediate caesarean section.
2.4.2. Vaginal examinations and obstetric interventions carry the risk of upward displacement and cord prolapse, particularly with a high presenting part and ruptured membranes. Upward pressure should be kept to a minimum in such cases.
2.4.3. With transverse, oblique or unstable lie, elective admission after 37+0 weeks gestation should be considered. Such women should be advised to present immediately if there are signs of labour or suspected rupture of membranes.
2.4.4. Women with non-cephalic presentations and preterm prelabour rupture of membranes should be offered admission.
2.5. Diagnosis of cord prolapse
Cord presentation or prolapse can occur without physical signs and without fetal heart pattern abnormalities
Visual inspection or palpation of the umbilical cord on vaginal examination
Prompt vaginal examination is the most important aspect of diagnosis
Cord prolapse is suspected if persistent variable decelerations or fetal bradycardia occur, particularly following rupture of membranes
2.6. Management
This obstetric emergency requires immediate corrective measures to prevent fetal asphyxia. A coordinated team approach is essential. 2.6.1. Management in the community setting:
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Perinatal death has been described with normally formed term babies, particularly with planned home births. Perinatal mortality is increased by more than tenfold when cord prolapse occurs outside compared with inside hospital. Delay in transfer to hospital appears to be an important contributing factor.
2.6.1.1. Call ‘999’ and ask for an category 1 ambulance
2.6.1.2. Institute measures to relieve cord compression
2.6.1.3. Contact Delivery Suite and inform them of the situation and expected time of arrival using SBARD handover tool. An ultrasound scan is to be available upon arrival to Delivery Suite. The Delivery Suite co-ordinator shall immediately inform the Obstetric team and theatre team and give expected time of arrival
2.6.1.4. During the ambulance transfer, attempt to maintain elevation of the presenting part, taking into consideration the woman’s and the midwife’s safety
2.6.1.5. If delivery is imminent proceed with delivery, prepare for neonatal resuscitation, do not stand down ambulance until woman and baby are safely delivered
2.6.2. Management in the in the consultant unit
2.6.2.1. Call for help, clearly stating ‘cord prolapse’. The Delivery suite co-coordinator should call 2222 and state clearly Maternal and neonatal emergency response and state where this is taking place.
2.6.2.2. Summon for cord prolapse box.
2.6.2.3. Stop oxytocin if being administered.
2.6.2.4. Institute measures to relieve cord compression.
2.6.2.5. The Delivery Suite Coordinator to arrange for theatre to be prepared and the theatre team assembled, ensuring a USS machine is plugged in and switched on.
2.6.2.6. Consider administering a tocolytic: Terbutaline 250mcg subcutaneously
2.6.3. Options to relieve cord compression
2.6.3.1. Tip the head of the bed down. Position the woman to encourage the fetus to gravitate towards the diaphragm- knee- chest position or exaggerated Sims position.
2.6.3.2. Manual elevation of the presenting part by inserting a gloved hand in the vagina and pushing it upwards and above the pelvic
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brim
OR
2.6.3.3. Insert a foleys catheter to empty the bladder fully (to ensure the bladder is not over extended) then rapidly fill the bladder with 500mls Normal Saline via a Baxter easy flow uniset single lead irrigation set to elevate the fetal presenting part. Clamp the catheter using giving set clamp. The clamp must be released and the bladder drained before delivery.
2.6.3.4. To prevent vasospasm of the cord there should be minimum handling of loops of cord lying outside the vagina.
2.6.3.5. Continuous fetal monitoring should be undertaken and the maternal pulse palpated to differentiate. If fetal viability is in doubt, an ultrasound scan should be undertaken.
2.6.4. Where immediate vaginal delivery is not imminent or possible
2.6.4.1. Transfer to theatre for Emergency Caesarean Section immediately
2.6.4.2. If the fetal heart rate pattern is abnormal and indicates the need for urgent intervention, a Category 1 Caesarean Section should be performed
2.6.4.3. A Category 2 Caesarean Section is appropriate when the fetal heart rate classification does not meet the above BUT continuous assessment of the fetal heart is essential
2.6.4.4. Successful measures to relieve cord compression can allow regional anaesthesia to be the technique of choice
2.6.4.5. Obtain consent. This may be verbal in the case of a Category 1 Caesarean Section
2.6.4.6. Establish IV access. Take bloods for full blood count, group and save
2.6.4.7. Vaginal birth, in most cases operative, can be attempted if the cervix is fully dilated and the fetal presentation, position and station indicate this to be most expedient.
2.6.4.8. The neonatal team should be called to attend via 2222 as above and be present for delivery
2.6.4.9. Paired cord blood samples should be obtained.
2.7. Extreme Preterm Cord prolapse
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Expectant management should be discussed when the gestation is at the limits of viability - 23+0 to 24+6 weeks. Women should be counselled who are between 23+0 to 24+6 weeks by the obstetric consultant and neonatologist on whether to continue with the pregnancy at the threshold of viability.
2.8. In all cases of Cord prolapse
2.8.1. Document times of events, personnel in attendance and actions taken
2.8.2. Communicate with the parents throughout
2.8.3. Postnatal debriefing should be offered
2.8.4. Complete a clinical incident (DATIX) report
2.9. Telephone management of a woman in the community setting
2.11.1. Advise the woman (over the telephone if necessary), to adopt the knee-chest position whilst waiting for the ambulance
2.11.2. Arrange 999 ambulance transfer and request category 1 to the consultant led unit
2.11.3. Consider requesting the community midwife to attend but this must not delay transfer
2.11.4. During the ambulance transfer, advise that attempts be made to maintain elevation of the presenting part, taking into consideration the woman’s safety
2.11.5. Advice the ambulance crew that if vertex visible allow delivery to progress
2.11.6. All measures taken must not cause unnecessary delay in transfer
2.11.7. Offer debrief of the woman, partner and ambulance crew
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3. Monitoring compliance and effectiveness
Element to be See Appendix 3 for Auditing Tool monitored Lead Maternity Patient Safety Midwife
Tool Was syntocinon stopped at the diagnosis of cord prolapse? Was Terbutaline considered? Where possible, was the fetal heart continuously monitored and the maternal pulse taken to differentiate the two? If a Category 1 C/S performed, was decision to delivery time achieved within 30 minutes? Were paired cord blood samples taken and filed in the secure store envelope? Frequency A cord prolapse is a fairly rare occurrence so each case will be reviewed individually through the Maternity Patient Safety Meeting
Reporting The results will be reviewed at the time of the Maternity Patient arrangements Safety Meeting
Acting on Any deficiencies identified will be discussed at the Maternity Patient recommendations Safety Forum and Clinical Audit Forum and an action plan developed. and Lead(s) An action plan lead will be identified and a time frame for the action. The action plan will be monitored by the Maternity Patient Safety and Clinical Audit Forum
Change in Required changes to practice will be identified and actioned within practice and a time frame agreed on the action plan lessons to be A lead member of the forum will be identified to take each change shared forward where appropriate The results will be distributed to all staff through the Patient Safety Newsletter/Audit Forum as per the action plan
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
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Appendix 1. Governance Information
Document Title Cord Prolapse Clinical Guideline V3.0 This document replaces (exact title of previous version): Cord Prolapse Clinical Guideline V2.1
Date Issued/Approved: July 2021
Date Valid From: July 2021
Date Valid To: July 2024
Directorate / Department responsible Josie Dodgson, Acute Matron (author/owner): Obs and Gynae Directorate
Contact details: 01872 252684 This is to give guidance to all midwives and obstetricians on the recognition and Brief summary of contents management of an umbilical cord prolapse.
Cord, prolapse, presentation, umbilical, asphyxia, tocolytic, Terbutaline, LSCS, Suggested Keywords: Caesarean, Category 1, Preterm, prelabour RCHT CFT KCCG Target Audience Executive Director responsible for Medical Director Policy: Maternity Guidelines Group Approval route (names of Obs and Gynae Directorate committees)/consultation:
General Manager confirming approval Mary Baulch processes Name of Governance Lead confirming approval by specialty and care group Caroline Amukusana management meetings Links to key external standards None RCOG Green Top Guideline No. 50 (2014) NICE CG132 (2011)Caesarean Related Documents: Section Clinical Guideline NICE CG 190 Intrapartum Care (2014) Care of healthy women and babies during childbirth All midwives and obstetrics will attend the Training Need Identified? training in obstetric multidisciplinary
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emergencies (PROMPT) day, annually, where they will receive an update in the management of a cord prolapse. Yes. On-going at monthly PROMPT Training Need Identified? training Publication Location (refer to Policy Internet & Intranet on Policies – Approvals and Intranet Only Ratification): Document Library Folder/Sub Folder Clinical / Midwifery and Obstetrics
Version Control Table
Version Changes Made by Date Summary of Changes No (Name and Job Title) Sally Budgen 2008 V1.0 Initial version Delivery Suite Coordinator Sally Budgen Updated in line with RCOG guideline 2010 V1.1 Delivery Suite
Coordinator
Sally Budgen May 2012 V1.2 Updated and compliance monitoring added Delivery Suite Coordinator
Sally Budgen 7th May V1.3 Updated with RCOG guideline No 50(2014) Delivery Suite 2015 Coordinator 16th Trudie Roberts January 2.0 Specific guidance re bladder filling 2.6.3 Community Matron 2018 Additions following Health Safety Investigation Sarah-Jane Pedler, August 2.1 Branch (HSIB) feedback regarding escalation Practice 2019 and review of patients. Development Full version update including information on Midwife Josie Dodgson, July 2021 3.0 SBARD handover tool and emergency Acute Matron protocols
All or part of this document can be released under the Freedom of Information Act 2000
This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing
Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.
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Appendix 2. Initial Equality Impact Assessment
Section 1: Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed Cord Prolapse Clinical Guideline V3.0
Directorate and service area: New or existing document: Obstetrics and Gynaecology Directorate Existing
Name of individual completing assessment: Telephone: Josie Dodgson 01872 252684
1. Policy Aim This is to give guidance to all midwives and obstetricians on the Who is the strategy / recognition and management of an umbilical cord prolapse. policy / proposal / service function aimed at? 2. Policy Objectives To ensure timely and appropriate management of cord prolapse.
3. Policy – intended Outcomes To achieve a safe outcome for mother and baby.
4. How will you measure the Compliance Monitoring Tool. outcome? 5. Who is intended to benefit from the Compliance Monitoring Tool. policy? Local External 6a Who did you Workforce Patients Other consult with groups organisations x b). Please identify the groups who have Clinical Guideline Group been consulted about Obstetrics and Gynaecology Directorate this procedure. What was the outcome of the Guideline agreed consultation?
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7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.
Are there concerns that the policy could have differential impact on: Protected Rationale for Assessment / Existing Yes No Unsure Characteristic Evidence Age x
Sex (male, female, trans-gender / x gender reassignment)
Race / Ethnic communities x /groups Disability - Learning disability, physical impairment, sensory x impairment, mental health conditions and some long term health conditions. Religion / x other beliefs Marriage and x Civil partnership Pregnancy and x maternity Sexual Orientation, x Bisexual, Gay, heterosexual, Lesbian If all characteristics are ticked ‘no’, and this is not a major working or service change, you can end the assessment here as long as you have a robust rationale in place. I am confident that section 2 of this EIA does not need completing as there are no highlighted risks of negative impact occurring because of this policy.
Name of person confirming result of Josie Dodgson initial impact assessment: If you have ticked ‘yes’ to any characteristic above OR this is a major working or service change, you will need to complete section 2 of the EIA form available here: Section 2. Full Equality Analysis
For guidance please refer to the Equality Impact Assessments Policy (available from the document library) or contact the Human Rights, Equality and Inclusion Lead [email protected]
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Appendix 3. Monitoring Compliance and Effectiveness
Guideline Audit Tool
Applicable Guideline CORD PROLAPSE – CLINICAL GUIDELINE Audit Register Number (For audit use) Process Retrospective Audit Date (For audit use) Auditor (For audit use)
Audit Questions 1 Was help called? 2 Was syntocinon stopped (if in use) at the suspicion/ diagnosis of a cord prolapse? 3 Was terbutaline considered if contractions present? 4 Where possible was the fetal heart continuously monitored? 5 Were measured to relieve cord compression utilised? 7 If fetal compromise indicated by fetal monitoring was a Category I caesarean section called? And the baby delivered in >30minutes? 8 If no fetal compromise indicated by fetal monitoring was a Category II caesarean section called? And the baby delivered >45 minutes? 9 Were paired cord samples taken and filed securely in the secure store envelope? 10 Was a DATIX completed?
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