Cord prolapse

I. Epidemiology A. Incidence

1. Vertex presentation: 0.4% 2. Frank Breech: 0.5% 3. Complete Breech: 4-6% 4. Footling Breech: 15-18%

II. Pathophysiology A. Umbilical cord prolapses

1. Frank cord presentation a. Cord prolapsed through cervix

2. Occult cord presentation a. Cord trapped alongside presenting part

B. Follows Rupture of Membranes C. Occurs when presenting part is ill fitting

1. Footling Breech Presentation 2. Cephalopelvic Disproportion 3. Fetal abnormality

D. Fetal blood supply obstructed when cord out of uterus 1. Drop in temperature of prolapsed cord 2. Vasospasm of umbilical vessels 3. Compression between pelvic brim and presenting part

III. Risk factors A. Multiparity B. Prematurity C. Macrosomia D. Breech Presentation E. Polyhydramnios F. High Fetal Station

IV. Signs A. Ill-fitting or non-engaged presenting part B. Prolapsed umbilical cord

1. Umbilical cord visualized in vagina or at vulva 2. Umbilical cord palpated on pelvic exam

C. Fetal Distress on Fetal Heart Tracing 1. May follow Rupture of Membranes

V. Management: General A. Emergent Cesarean Section

1. Vaginal delivery only if imminent B. Deliver as Intrauterine Fetal Demise if fetus has died

1. Check for cord pulsations 2. Check for fetal heart sounds 3. Obstetric Ultrasound to assess heart activity

C. Pre-hospital cord prolapse noted at home by patient 1. Patient assumes deep knee-chest position 2. Emergent transport to hospital

VI. Management: Temporizing measures to relieve cord pressure A. Tocolysis with Terbutaline 0.25 mg SC B. Push cord back into vagina and maintain with gauze pack

C. Vaginal retrograde pressure applied to presenting part 1. Hand in vagina elevates presenting part

D. Consider filling bladder with 500-700 cc Saline E. Minimize handling of the cord

1. Do not attempt to replace cord back into uterus F. Adjust maternal position to reduce cord pressure

1. Raise foot of the bed (Trendelenburg's Position) 2. Sims' position

a. Mother in left lateral decubitus position 3. Genu-pectoral position

a. Mother in knee-chest position VII. Prognosis

A. High perinatal mortality for delayed delivery >40 min VIII. Prevention

A. Do not AROM if fetal head at high station