In which position would the nurse place the patient who has a prolapsed cord?
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Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt, [email protected] Show
Find articles by Waleed Ali Sayed Ahmed Mostafa Ahmed HamdyDepartment of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt, [email protected] Find articles by Mostafa Ahmed Hamdy Disclaimer Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt, [email protected] Correspondence: Waleed Ali Sayed Ahmed Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Round Road, Ismailia 41111, Egypt, Email [email protected] Copyright © 2018 Sayed Ahmed and Hamdy. This work is published and licensed by Dove Medical Press Limited The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. AbstractUmbilical cord prolapse (UCP) is an uncommon obstetric emergency that can have significant neonatal morbidity and/or mortality. It is diagnosed by seeing/palpating the prolapsed cord outside or within the vagina in addition to abnormal fetal heart rate patterns. Women at higher risk of UCP include multiparas with malpresentation. Other risk factors include polyhydramnios and multiple pregnancies. Iatrogenic UCP (up to 50% of cases) can occur in procedures such as amniotomy, fetal blood sampling, and insertion of a cervical ripening balloon. The perinatal outcome largely depends on the location where the prolapse occurred and the gestational age/birthweight of the fetus. When UCP is diagnosed, delivery should be expedited. Usually, cesarean section is the delivery mode of choice, but vaginal/instrumental delivery could be tried if deemed quicker, particularly in the second stage of labor. Diagnosis-to-delivery interval should ideally be less than 30 minutes; however, if it is expected to be lengthy, measures to relieve cord compression should be attempted. Manual elevation of the presenting part and Vago’s method (bladder filling) are the most commonly used maneuvers. Care should be given not to cause cord spasm with excessive manipulation. Simulation training has been shown to improve/maintain all aspects of management and documentation. Prompt diagnosis and interventions and the positive impact of neonatal management have significantly improved the neonatal outcome. Keywords: umbilical cord prolapse, neonatal outcome, obstetric emergency, simulation training IntroductionUmbilical cord prolapse (UCP) is an uncommon but potentially fatal obstetric emergency. Its incidence has decreased over the years and significant advances in its management have led to improved perinatal outcome. This article reviews the risk factors, perinatal outcomes, prevention and the optimal management of UCP. DefinitionsCord presentation (fore-lying cord) is the presence of the umbilical cord (UC) between the fetal presenting part and the cervix, regardless of the membrane status (intact or ruptured). Descent of the UC through the cervix is essential for diagnosing cord prolapse. It can be either overt (past the presenting part) or occult (alongside the presenting part). IncidenceUCP is an uncommon obstetric emergency but with potentially significant neonatal adverse outcomes. The overall incidence is reported at 0.1%–0.6% with higher incidences in non-cephalic presentations, multiple gestations, and earlier gestational ages. However, a lower incidence (0.018%) has been reported recently and there is a trend toward decreasing incidence throughout the years: 0.6% in 1932, 0.2% in 1990, and 0.018% in 2016. The decreasing incidence has also been documented by Gibbons et al in their retrospective review of 69 years. Liberal use of cesarean section (CS) for some of the most important risk factors of UCP, eg, breech presentation, may explain such decreasing trends. In addition, the decreasing occurrence of grand multiparity, better diagnosis, and improved obstetric care is linked to the falling incidence. DiagnosisUCP is diagnosed by seeing or palpating the prolapsed cord in addition to the presence of abnormal fetal heart (FH) tracings. In overt UCP, the diagnosis is straightforward as the UC is seen coming out of the vagina or palpated as a soft pulsating mass during vaginal examination. However, the diagnosis of occult UCP may be more difficult. Abnormal fetal heart rate (FHR) tracings in the form of recurrent, variable, sudden severe, and/or prolonged (lasting a minute or more) decelerations may be the first sign of UCP, especially the occult type. These FHR abnormalities may occur in up to 67% of cases. Fore-lying umbilical cord can be diagnosed by ultrasound scan. Lange estimated an antenatal incidence of approximately 1:167 (0.6%) live births; however, with the increased use of antepartum obstetric ultrasound, especially with color flow Doppler, the incidence could be higher. Cord presentation is transient and usually insignificant prior to 32 weeks. Large studies showed that the presence of cord presentation does not necessarily lead to cord prolapse during delivery,, and that antenatal ultrasound diagnosis has a poor sensitivity and is a poor predictor of cord prolapse. However, when diagnosed in the third trimester, cord presentation requires follow up scans in addition to intrapartum assessment to finalize the mode of delivery. A significant percentage of UCP cases are diagnosed at the time of amniotomy (24%) or spontaneous rupture of membranes (SROM) (35%). Attention should be paid to this complication at these times especially when abnormal FHR tracings follow membrane rupture. Differential diagnosis of these presentations – soft mass in the vagina and sudden FHR decelerations – must be considered. The presence of fetal limb, caput succedaneum and face presentation should be excluded. In addition, numerous causes of sudden fetal bradycardia such as maternal hypotension, placental abruption, uterine rupture should be carefully evaluated. Risk factorsSeveral risk factors for UCP have been identified (Table 1). Clinicians should be aware of these risk factors as this would represent the first step in anticipating this obstetric emergency and decreasing the perinatal morbidity/mortality. Table 1Identified risk factors for umbilical cord prolapse ObstetricIatrogenicMaternal age ≥35yearsAmniotomy/SROM + high presenting partMultiparityECVNon-cephalic presentationsPlacement of cervical ripening balloonPreterm labor (< 37 weeks)Placement of intrauterine pressureLow birth weightcatheterPolyhydramniosAttempted rotation of the fetal headMultiple pregnanciesInadequate prenatal careNon-engaged presenting part PPROMMale sex of the newborn Open in a separate window Abbreviations: ECV, external cephalic version; PPROM, preterm premature rupture of membranes; SROM, spontaneous rupture of membranes. Almost half of the risk factors are iatrogenic. Artificial rupture of fetal membranes (ARM) especially in a multiparous case with high non-engaged head, attempted rotation of the fetal head in cases of abnormal positions, placement of intrauterine pressure catheter or fetal scalp electrode and external cephalic version are the most common examples of iatrogenic risk factors. Interventions that may cause elevation of the fetal presenting part predispose to UCP. Other obstetric risk factors that may lead to UCP include multiparity, especially grand multiparity (75% of cord prolapse events in the 1940s), malpresentations, polyhydramnios, multiple gestations particularly in the second twin, preterm labor, and preterm premature rupture of membranes (PPROM). The relationship between malpresentations including breech and transverse lie and UCP is well documented and is due to the poor engagement/non-engagement of the presenting part into the maternal pelvis allowing the space for the cord to prolapse. In one study, breech presentation accounted for 36.5% of UCP cases. Multiple gestation is another risk factor and can lead to UCP due to the abnormal fetal presentation, and it may occur with both first or second twin. The use of cervical ripening balloon may predispose to UCP especially when filled with a large amount of fluid, and it may occur after insertion, removal or spontaneous expulsion of the balloon. Although prematurity is associated with increased risk of UCP as a result of poor application of the presenting part to the cervix, most UCP cases occur in term pregnancies. PathophysiologyCompression of the UC can lead to either profound or total acute asphyxia or subacute hypoxia with different neonatal outcomes. It has been suggested that the pathophysiology of cord prolapse is almost an “all or none event”, either causing overwhelming neurological injury and death or causing little or no cerebral injury, and this is supported by the very low incidence of stillbirth/neonatal death, neonatal encephalopathy, and cerebral palsy. The mechanism of fetal demise is through near-total or total acute asphyxia, which occurs when the umbilical cord is compressed between the fetal head and bony pelvis. This results in failure of the normal autoregulatory mechanisms of the brain resulting from hypotension and bradycardia and leads to the failure of cerebral blood redistribution, with cell death of the brainstem – the most metabolically active area of the brain. This is unlike cases of subacute hypoxia where blood can be distributed to the more vital areas of the brain, sparing the brainstem and resulting in minimal or short-lasting neurological manifestation. ManagementUmbilical cord prolapse is an acute obstetric emergency that is associated with increased perinatal morbidity and mortality, thus requiring rapid identification and intervention. Once diagnosed, the most rapid method of delivery should be carried out. If delivery is not imminent, alleviation of cord compression should be contemplated by elevating the presenting part either manually or by bladder filling in addition to repositioning of the patient. Prior knowledge of risk factors as well as regular simulation training that helps develop team work, DDI and documentation will benefit those unfamiliar with the condition to improve their management and hence the neonatal outcome. What is the safest position for a woman in labor when the nurse notes a prolapsed cord?If the fetus is viable, place the mother in the knee-chest position (patient facing the bed, chest level to bed, knees tucked under chest, pelvis and buttocks elevated) or head-down tilt in the left lateral position and apply upward pressure against the presenting part to lift the fetus away from the prolapsed cord.
What are interventions for cord prolapse?Management and Treatment
Umbilical cord prolapse is an acute obstetric emergency that requires immediate delivery of the baby. The route of delivery is usually by cesarean section. The doctor will relieve cord compression by manually elevating the fetal presentation part until cesarean section is performed.
In what position should the mother be transported if a prolapsed cord is present?If prolapsed cord is present during delivery, place mother in knee/chest position or elevate hips with pillows or folded blankets. Insert hand into vagina and attempt to gently push the presenting part upward to release pressure on the cord. Do not damage the cord by attempting to push it back into the vagina.
Which of the following is an appropriate nursing action if the cord is already exposed in the introitus?When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal introitus for possible cord prolapse. If there is part of the cord that has prolapsed into the vaginal opening the correct nursing intervention is: Push back the prolapse cord into the vaginal canal.
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