Cord Prolapse Guideline for Management
1. Introduction and who the guideline applies to: This document sets out the procedures and processes to follow in the event of a cord prolapse with the intention of providing safe and effective care to this patient group.
Scope: These guidelines are for the use of all staff involved in the management of cord prolapse. This includes midwifery, obstetric and anaesthetic staff.
Risk Management:
A clinical incident reporting form must be completed for all obstetric emergencies. Please refer to the Maternity Services Risk Management Strategy for details.
Related documents:
Document:
Women declining blood and blood products
Maternity Records Documentation Policy
Patient case note documentation policy (trust wide)
Thermal protection of the newborn
Swabs, instruments, needles and other accountable items within maternity
Resuscitation of the newborn
Fetal heart rate monitoring in Labour
Guideline Development Methodology:
Extensive literature searches were undertaken of the Cochrane, CINAHL, MEDLINE, and Embase databases. Few papers were identified of appropriate trials on which to base recommendations on management of emergencies. A textbook search was performed, and the following texts chosen to support recommendations:
Dewhursts Textbook of Obstetrics and Gynaecology for Postgraduates, 8th edition (2012) ed. K Edmond, Oxford: Blackwell Turnbull’s Obstetrics 3rd Edition (2001) eds. Geoffrey Chamberlain. Edinburgh: Churchill Livingstone Obstetrics and the Newborn 3rd Edition (1997) eds. NA Beischer, EV Mackay, PB Colditz Fundamentals of Obstetrics and Gynaecology 9th Edition (2010) Derek Llewellyn-Jones. London: Mosby
Cord Prolapse – Guideline for Management Page 1 of 7 Authors: Original Working Party - updated by N Ling Written: February 2001 Contact: L Matthews, Clinical Risk and Quality Standards Midwife Last Review: April 2019 Approved by: Maternity Service Governance Group Next Review: April 2022 Guideline Register No: C226/2016 Please note that this may not be the most recent version of the document. A definitive version is in the Policy and Guidelines Library.
2. Guidance:
Definition: 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 presenting part and the cervix, without membrane rupture.
Cord prolapse is an obstetric emergency, as asphyxia secondary to compression of the cord between the presenting part and the pelvis, or spasm of the cord vessels secondary to manipulation or cold increases perinatal morbidity and mortality.
Incidence ranges from 0.1 to 0.6% with cephalic presentation, but can be as high as 1% in breech presentation.
A high presenting part due: Risk factors: Malpresentation; e.g. breech, transverse or oblique lie Multiparity Prematurity <37 weeks Low birth weight <2.5kg Second twin Polyhydramnios Multiple pregnancy Anencephaly Low-grade placenta praevia Long cord Contracted Pelvis Pelvic tumours Human factor- Artificial rupture of membrane(ARM), External Cephalic Version and vaginal manipulations of fetal head after membrane rupture
Cord Prolapse – Guideline for Management Page 2 of 7 Authors: Original Working Party - updated by N Ling Written: February 2001 Contact: L Matthews, Clinical Risk and Quality Standards Midwife Last Review: April 2019 Approved by: Maternity Service Governance Group Next Review: April 2022 Guideline Register No: C226/2016 Please note that this may not be the most recent version of the document. A definitive version is in the Policy and Guidelines Library.
Prevention: ARM should be avoided if on vaginal examination the cord is felt below the presenting part. When cord presentation is diagnosed in established labour caesarean section is usually indicated. Consider ultrasound examination with colour flow Doppler to confirm cord presentation if clinically suspected or in women with breech presentation considering vaginal birth. ARM should be avoided whenever possible if the presenting part is mobile. If it becomes necessary to rupture the membranes this should be undertaken with arrangements in place for immediate caesarean section. Vaginal examination and obstetric intervention with 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. Women with non-cephalic presentation and preterm pre-labour rupture of membranes should be offered admission to the hospital Women with transverse, oblique or unstable lie should be advised to present quickly if there are any signs of labour or suspicion of membrane rupture should she not be in the hospital environment.
Diagnosis: Diagnosis is made during vaginal examination by visual inspection or palpation. A sudden bradycardia or a sudden onset of variable decelerations may suggest cord prolapse. Speculum and digital vaginal examination should be performed at preterm gestation if cord prolapse is suspected.
A vaginal examination should be performed in labour and after spontaneous rupture of membranes (SROM) if risk factors for cord prolapse are present or cardiotocographic abnormalities commence soon after SROM.
Management: Ring the emergency bell for help and summon the obstetric registrar, core midwife, anaesthetist, O.D.A. and neonatologist (SHO and SpR)
Tilt the head of the bed downwards preferably with the woman in the left lateral position or ask the mother to adopt the knee – chest position. Stop Syntocinon infusion, if any.
Quickly explain the situation to the woman and her partner
Ensure fetus is alive or confirm demise with ultrasound
The registrar should perform an immediate vaginal examination to assess the cervical dilatation, progress of labour and whether immediate vaginal delivery is possible. Vaginal delivery using (ventouse/forceps, or in the case of the second twin, breech extraction) should only be considered if it is anticipated to be straightforward.
To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina. There is insufficient data to evaluate manual replacement of the prolapsed cord above the presenting part to allow continuation of labour. This practice is not recommended.
If the situation does not permit immediate spontaneous or assisted vaginal delivery then a prompt Caesarean section is indicated. The Cord Prolapse – Guideline for Management Page 3 of 7 Authors: Original Working Party - updated by N Ling Written: February 2001 Contact: L Matthews, Clinical Risk and Quality Standards Midwife Last Review: April 2019 Approved by: Maternity Service Governance Group Next Review: April 2022 Guideline Register No: C226/2016 Please note that this may not be the most recent version of the document. A definitive version is in the Policy and Guidelines Library.
ideal diagnosis to delivery interval is 15 minutes; the acceptable diagnosis to delivery interval is 30 minutes1. Verbal consent must be obtained and documented.
Tocolysis can be considered to reduce contractions while preparing for caesarean section. The suggested tocolytic regimen is terbutaline 0.25mg subcutaneously.
Whilst it is important to prevent compression of the cord by the fetal head, Staff safety is paramount. It is unnecessary to push the weight off the cord where the CTG is normal or suspicious. Where the CTG is pathological, the following manoeuvre can be used: keep the fingers in the vagina, pushing the weight of the presenting part off the umbilical cord. Maintain digital pressure on the presenting part to avoid cord compression.
During transfer to theatre, the woman should adopt either the exaggerated sims or the knee-chest position on the bed and the member of staff pushing up the presenting part should resume this once the woman has been safely transferred to the theatre table. It may be necessary to swap the member of staff performing the manoeuvre to prevent muscular strain or injury.
As an alternative to prevent compression of the cord, bladder filling with 500ml Normal Saline through a No. 16 Foley catheter can be considered. This allows a longer delivery interval especially in cases where general anaesthesia poses a high risk. The urinary catheter should be unclamped before the peritoneal cavity is open for caesarean delivery.
Anaesthesia: The usual anaesthetic for caesarean section with cord prolapse is general anaesthesia. With modern techniques, the complications of general anaesthesia are rare, but still higher than for regional anaesthesia. The use of temporary measures, as described above, can reduce cord compression, making regional anaesthesia the technique of choice if there is no evidence of severe fetal compromise. However, repeated attempts at regional anaesthesia should be avoided. Degree of urgency should be clearly communicated to the anaesthetist.
Fetal Continue fetal monitoring in order to confirm viability immediately prior to monitoring: planning mode of delivery.
Cord Prolapse – Guideline for Management Page 4 of 7 Authors: Original Working Party - updated by N Ling Written: February 2001 Contact: L Matthews, Clinical Risk and Quality Standards Midwife Last Review: April 2019 Approved by: Maternity Service Governance Group Next Review: April 2022 Guideline Register No: C226/2016 Please note that this may not be the most recent version of the document. A definitive version is in the Policy and Guidelines Library.
Paired cord blood samples: Take paired cord blood samples for acid base, document results and communicate them to the Neonatal Team.
Initial Order Ambulance 999 to avoid delay Management in Advise woman to be in the knee-chest position until the ambulance the Community: arrives During transfer the woman should adopt the exaggerated Simms position with pillows under the left hip, as the knee – chest position is potentially unsafe during ambulance transfer. Transfer to the nearest consultant led unit for delivery, unless an immediate vaginal examination by a competent midwife reveals that a spontaneous vaginal delivery is imminent. Preparation for transfer should still be made. Auscultation of the fetal heart during transfer is of no benefit in this situation and could increase anxiety Inform NICU
Debriefing: Postnatal debriefing should be offered to all women with cord prolapse as this can reduce the incidence of post-traumatic stress disorder, fear of further childbirth and postnatal depression.
Documentation: Complete a clinical incident form where local incident data relating to cord prolapse will be reviewed, with appropriate action taken if applicable.
References:
Royal College of Obstetricians and Gynaecologists Green Top Guideline No 50. Umbilical Cord Prolapse 2014
Perinatal Institute for Maternal and Child Health: Obstetric Emergencies: Cord Prolapse. Update Feb. 2006.
Katz Z. Management of labour with umbilical cord prolapse: a 5 year study. Obstetrics & Gynaecology. 1988; 72(2):278-81.
Chetty RM. Umbilical cord prolapse. South African Medical Journal. 1980;57(4):128-9.
PROMPT Course Manual (2nd ed) 2012. Eds White C, Crofts J, Loxton C, Barnfield S and Draycott T. RCOG Press: London
Kingusa M et al. Antepartum detection of cord presentation by transvaginal ultrasonography for term bree presentation: potential prediction and prevention of cord prolapse. Journal of Obstetrics anf Gynaecology Res. 2007;33(5):612
Cord Prolapse – Guideline for Management Page 5 of 7 Authors: Original Working Party - updated by N Ling Written: February 2001 Contact: L Matthews, Clinical Risk and Quality Standards Midwife Last Review: April 2019 Approved by: Maternity Service Governance Group Next Review: April 2022 Guideline Register No: C226/2016 Please note that this may not be the most recent version of the document. A definitive version is in the Policy and Guidelines Library.
Algorithm for the management of cord prolapse
NO IS THE FETUS ALIVE?
Confirm IUFD with YES ultrasound
Is the cervix fully dilated? Await spontaneous delivery
YES NO Alternative
Consider ventouse/forceps Keep fingers in vagina and delivery or breech push weight of PP off cord Place Foley catheter extraction
Transfer to theatre in Fill bladder with 500ml supine position with wedge Normal Saline
Monitor fetal heart rate Monitor fetal heart rate on CTG
Caesarean section within Transfer to theatre for 15 minutes caesarean section
Release catheter clamp at skin incision
Cord Prolapse – Guideline for Management Page 6 of 7 Authors: Original Working Party - updated by N Ling Written: February 2001 Contact: L Matthews, Clinical Risk and Quality Standards Midwife Last Review: April 2019 Approved by: Maternity Service Governance Group Next Review: April 2022 Guideline Register No: C226/2016 Please note that this may not be the most recent version of the document. A definitive version is in the Policy and Guidelines Library.
DEVELOPMENT AND APPROVAL RECORD FOR THIS DOCUMENT Author / Lead Original Working Party Job Title: Obstetric Officer: Consultants, Consultant Anaesthetists and Midwives
Reviewed by: N Ling
Approved by: Guidelines Group Date Approved: 17.04.19 Maternity Service Governance Group
REVIEW RECORD Date Issue Reviewed By Description Of Changes (If Any) Number July 2014 As above No change April 2019 V2 N Ling Safety measures inserted to prevent injury to staff
DISTRIBUTION RECORD: Date Name Dept Received
Cord Prolapse – Guideline for Management Page 7 of 7 Authors: Original Working Party - updated by N Ling Written: February 2001 Contact: L Matthews, Clinical Risk and Quality Standards Midwife Last Review: April 2019 Approved by: Maternity Service Governance Group Next Review: April 2022 Guideline Register No: C226/2016 Please note that this may not be the most recent version of the document. A definitive version is in the Policy and Guidelines Library.