CORD PROLAPSE

•	Definition.
•	Aetiology. 
•	Management.

Definition

1.	Umbilical cord presentation: presence of a segment of umbilical cord at the cervical os as the presenting part.

2.	Cord prolapse: the membranes have ruptured and the segment of cord may be at any level from the upper vagina to outside the introitus.

3.	Incidence: 1:500 deliveries.

4.	The stage preceding cord presentation is the presence of cord beside the presenting part and may manifest as variable decelerations of the fetal heart. 

Aetiology

1.	Malpresentations:

a.	Flexed or footling breech.

b.	Transverse lie.

c.	Brow, face presentation or OP position.

2.	Multiple pregnancies.

3.	Prematurity.

4.	Contracted pelvis.

5.	Multiparity.

6.	Polyhydramnios.

7.	Preterm rupture of membranes.

Management

1.	Cord prolapse is an indication for immediate Caesarean section if the baby is alive and vaginal delivery cannot be effected immediately.

2.	VE to decide mode of delivery:

a.	os full: forceps or vacuum.

b.	os not full: LSCS.

3.	NVD or AVD with forceps if the following exist:

a.	Cervix is fully dilated.

b.	Cephalic presentation.

c.	No complications.

4.	Criteria before LSCS:

a.	Baby is alive.

b.	Baby is viable.

5.	While preparations for LSCS are being made,

a.	Reduce cord into vagina to maintain warmth and moistness of cord which prevents cord arterial spasm.

b.	Keep warm moist pad at introitus.

c.	Bolus dose of terbutaline 0.25mg in 5cc saline over 5 mins if LSCS is planned.

d.	Knee-chest position: pillows beneath buttocks to raise pelvis higher than abdomen.

e.	Introduce Foley’s catheter and fill bladder with 500cc of normal saline after draining the urine: this will reduce pressure of presenting part of the cord at the pelvic brim.

f.	Listen to fetal heart by fetal stethoscope or doptone or monitor electronically till time of LSCS.

6.	Preparation for LSCS:

a.	Administer oxygen.

b.	I/V line with a large bore cannula.

c.	Group and cross match blood.

d.	Prepare patient for delivery.

7.	In the OT,

a.	Listen to fetal heart:

i.	if fetal heart is present and os not full: emergency LSCS.

ii.	if fetal heart absent, confirm by U/S and aim for NVD.

b.	Bolus does of I/V terbutaline 0.25mg in 5cc saline abolishes uterine contractions to prevent cord compression between presenting part and pelvis during contractions.

c.	At time of LSCS, consider giving propranolol 1mg I/V to reverse the action of terbutaline and to enable oxytocic drugs to act and prevent PPH.