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Abnormal Positions of the Umbilical Cord POSTGRAD. MED. J. (1966), 42, 20 Postgrad Med J: first published as 10.1136/pgmj.42.483.20 on 1 January 1966. Downloaded from ABNORMAL POSITIONS OF THE UMBILICAL CORD A discussion of some perinatal hazards IAN A. DONALDSON, M.B., B.S., F.R.C.S., M.'R.C.O.G., D.A. Consultant Obstetrician & Gynaecologist City of London Maternity Hospital, London, N.4. ABNORMAL positions of the umbilical cord are The duration of the prolapse is not always difficult to define anatomically. The normal or known. usual positions are not demonstrable at present. In 1958 a prolapsed cord occurred in a gravida 3 At Caesarean Section the cord is usually in the in early labour at home. Pulsation in the cord was reported as absent and the foetal heart not heard. upper segment and only seen in the lower On admission the foetal heart was heard and pulsation segment in the minority of cases; however, that was present. The 'baby was delivered by Caesarean is the impression given by memory and not by Section and cried at birth some 3 hours after the a statistical survey. declared prolapse. Functionally an abnormal position could be As has long been known, it is the degree of defined as one in which the cord is liable to pressure on the cord which matters and deter- compression, torsion, stretching or other mines the prognosis, and the cervix which con- mechanical alteration Which might interfere trols the treatment. Possibly the best, though impracticable, emergency treatment would be with the free passage of blood through the Protected by copyright. vessels. Like a diver's air-pipe there may be to suspend the patient vertically by the ankles certain positions which constitute a hazard. On and so allow the extruding contents to fall back the one hand the hazard may remain potential into the uterus, which so resembles a purse but on the other hand it may become danger- string bag being carried strangely, mouth down- ous or even fatal. The flow of blood may be wards, even when the contents are most valu- impeded by compression of the vessels or by able. The acceptable postural methods all in- spasm in their walls, and is normally or ab- voke the aid of gravity to relieve cord pressure. normally altered by the pumps and their asso- Something else may be achieved simultaneous- ciated blood vessels at either end. It is clear ly: - the uterine contractions may become that here is an enormous subject for research. temporarily weaker. This can be seen in normal labour after favourable progress in the second stage when in the dorsal position, the head may Some Abnormal Positions of the Umbilical regress then the patient is put in the left lateral Cord position. There then may'be a delay before the http://pmj.bmj.com/ head reaches its previous station. The delay (1) Prolapse of the cord. may seem interminable if there had been some This is the grossest, most obvious and well- foetal bradycardia. An alternative emergency documented abnormal position. measure frequently employed for prolapse of Frank prolapse of the cord is not always the cord does not evoke the life-saving gravita- so lethal to the baby. The cases occurring from tional effects but consists of pushing the pre- 1957 to 1962 at the City of London Maternity senting part away from the cervix to relieve the Hospital are shown in Table 1. pressure on the cord. However, the hand in the on September 27, 2021 by guest. In this small series 68.4% of the baibies sur- vagina may suffer from cramp, partly due to vived. If the babies dead before delivery was the increased force of the contractions produced commenced together with the one neonatal by the manipulation. This method could make death of a premature baby are subtracted from matters worse for the baby and should be the series, then the baby survival rate would be replaced whenever and as soon as possible by 86.6%. All the babies delivered by Caesarean effective postural methods. In certain circum- Section survived. Two 'babies died during stances it may be the only method conveniently delivery by forceps. available. Prolapse of the cord may be discovered for An example ,occurred in 1964. A safe gravida 2 was booked for home confinement. In early labour the the first time on examination prior to a forceps cord prolapsed. Pressure on the cord was relieved by delivery, the Ibaby crying at ibirth, with no pre- the midwife by continuous vaginal manipulation. As viously recorded alteration of the foetal heart. the patient was being put in the amnbulance a message January, 1966 DONALDSON: Abnormal Positions of the Umbilical Cord 21 Postgrad Med J: first published as 10.1136/pgmj.42.483.20 on 1 January 1966. Downloaded from TABLE 1 CITY OF LONDON MATERNITY HOSPITAL CASES OF PROLAPSED CORD AND CORD PRESENTATION PUBLISHED IN REGISTRARS' REPORT. _1957 1958 1959 1960 1961 1962 Total NO. OF CASES 2 3 3 1 3 7 19 Booked 1 Not 3 Not 2 3 9 Emergency 1 Noted 0 Noted 1 4 6 INCIDENCE 0.14% 0.20% 0.20% - 0.18% 0.4% TREATMENT Normal delivery 1 0 0 0 0 1 2 Breech extraction 0 0 1 1 0 2 4 Forceps delivery 1 1 1 0 0 1 4 Caesarean Section 0 2 1 0 3 3 9 Stillbirth 2 1 1 0 0 1 5 Stillbirth of these 5 those 2 0 0 0 0 1 3 dead before treatment Live birth 0 2 2 0 3 6 13 Neonatal death 0 0 0 1 0 0 1 2 lbs. 9oz.__ = Perinatal deaths 6 31.5% Protected by copyright. Of these, possible avoidable perinatal deaths 2 =10.5% Surviving babies 13 = 68.4% was received at hospital that a hand was prolapsing. the baby's head. It may be an incidental finding On admission the patient was put in the Trendelen- with no of burg position whilst preparations for abdominal prior alteration the foetal heart or be delivery were completed. The cervix was barely half suspected as in the following case in 1964. dilated. The baby was delivered by Caesarean Section The Ipatient was a primigravida, 20 years old. She and cried at bith. was admitted on 25th April, 1964 at the forty-first In all cases of of the cord it must week for induction of labour because of oedema. prolapse Vague uterine contractions commenced 22 hours after be remembered that this is the last stage of a artificial rupture of the hindwaters. A Syntocinon in- journey and we have no idea when the journey fusion was given. After ten and a half hours despite commenced nor how many incompleted strong contractions, ,the cervix was thick, only ad- journeys occur. mitting one finger, the blood pressure had Ibeen rising and was 160/1190 mm hg, and the foetal heart which http://pmj.bmj.com/ (2) Forelying cord and occult prolapse of had been varying between 144 and 150 a minute the cord. developed a bradycardia of 110 after contractions Sometimes a loop of cord may lie beside the head and only slowly recovered. The head was in the left My attention was drawn to this fact dramatically at occipitolateral position and was felt easily tper abdo- Oxford in 1940. I was giving an anaesthetic for a men; pressing the Ihead into the pelvis evoked brady- forceps delivery. The experienced general practitioner cardia. The baby was delivered by Caesarean Section, had known the patient all her life. This child born there was a little liquor; there was a loop of cord after an orthodox, leisurely and easy extraction was confined between the left side of the head and the dead. The feeling was conveyed that the inexperienced lower uterine segment. The Ibaby boy cried at birth anaesthetist was somehow to blame. On examining and weighed six pounds seven ounces. (2.91 kg.). on September 27, 2021 by guest. the cord closely I noticed two areas of flattening The cord was 20 inches (50.8 cm.) long. If the cord fairly close together. Illustrations in DeLee's book had been found frankly prolapsed there would be no (1940) of a forelying cord and of occult prolapse, debate about the mode of delivery. As it was, it where the cord is higher, gave the answer. About a could be argued whether baby would have been week later I was performing a forceps delivery and healthy if expectancy had been adopted, but as the discovered an occult prolapse and was careful in the definitive treatment had been taken the question could application of the blades and delivered the baby in not be answered scientifically. a shorter time. It cried at birth. How often in obstetrics would we like a In my mind I formulated the dictum that it problem all over again, treated differently to was safer for the cord to be round the neck evaluate scientifically the results! An occult rather than dangling beside the baby's head. prolapse of the cord could Ibe more common An occult prolapse of the cord is sometimes than generally accepted, it could kill a baby seen at Caesarean Section, either lying lateral to during labour without leaving a trace of evi- the baby's head or less commonly posterior to dence at vaginal delivery-unless the whole 22 22POSTGRADUATE MEDICAL JOURNAL January, 1966 Postgrad Med J: first published as 10.1136/pgmj.42.483.20 on 1 January 1966. Downloaded from cord was carefully examined possibly micro- with no improvement, arrangements were made to scopically.
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