Cord Prolapse and Cord Presentation

Cord prolapse occurs when the umbilical cord descends in respect to the fetal presenting part, usually during labour. It is most commonly seen following a membrane rupture, with a loop of cord visible at the vulva; it is most common in multiparous women.

There are three clinical kinds of aberrant umbilical cord descent by the side of the presenting section. All of these are classified as cord prolapsed.

1. Occult prolapsed: On the internal examination, the cord is located by the side of the presenting part and is not touched by the fingers.
2. Cord presentation: The cord is inserted beneath the presenting section and is felt lying in the intact bag of membranes.
3. Cord prolapse: Following membrane rupture, the chord is either inside or outside the vagina.

etiology

Foetal causes:

• Malpresentations: e.g. complete or footling breech, transverse, and oblique lie.
• Prematurity.
• Anencephaly.
• Polyhydramnios.

Maternal causes:

• Contracted pelvis.
• Pelvic tumours.

Predisposing factors:

• Placenta praevia.
• Long cord.
• Sudden rupture of membranes in polyhydramnios.

Risks:

There is no danger as long as the membranes are intact. The foetal perinatal mortality rate from hypoxia caused by cord prolapse is 25-50 per cent.

• When subjected to cold or manipulations, the cord is mechanically compressed between the presenting section and the bony pelvis, and the cord vessels spasm.

When the chord is more prone to compression, the prognosis is worse, as in:

• Primigravida is preferable to multipara.
• Cephalic presentation is preferable than breech or transverse lay.
• The cervix is somewhat dilated rather than totally dilated.
• In general, a constricted pelvis is preferable over a flat pelvis.
• The cord is positioned anteriorly rather than posteriorly.

Signs and Symptoms

1. The umbilical cord loop may be seen on the vulva or palpable during a P.V exam.
2. FHS changes, notably bradycardia.
3. Fetal movement is excessive.
4. Meconium-coloured liquor

Diagnosis

• A vaginal examination is used to diagnose it. If the cord is prolapsed, it is vital to determine if it is pulsing, indicating a living foetus, or not, indicating a dead foetus, but this must be validated by auscultating the FHS.
• Ultrasound can occasionally be used to diagnose cord presentation.

Management

Cord presentation

Caesarean section is used to treat a constricted pelvis. Treatment for other disorders is determined by the degree of cervical dilatation:

• Partially dilated cervix: delay membrane rupture as long as possible by:
  • putting the patient in the Trendelenburg posture, avoiding high enema, and avoiding repeated vaginal exams
  • When the cervix is fully dilated, proceed as described later.
• Fully dilated cervix: the foetus should be delivered as soon as possible by:
  • Membrane rupture and forceps delivery: engaged vertex presentation
  • Membrane rupture and breech extraction: in breech presentation.
  • Rupture of the membranes + internal podalic version + breech extraction: may be attempted in a transverse lie; otherwise, Caesarean section is needed for non-engaged vertex and other cephalic malpresentation.

Cord prolapse

Management is determined by the foetal state:

• Living foetus:
  • If the cervix is partially dilated, an immediate caesarean section is recommended. To reduce the risk to the fetus during theatre preparation, do the following:
    • Placing the patient in the Trendelenburg position, manually moving the presenting section higher up, and, if the chord protrudes from the vulva, gently handling it and wrapping it in a warm wet pack.
    • providing the mother oxygen
  • When the cervix is fully dilated, the foetus should be delivered quickly, as in cord presentation.
• Dead foetus:
  • It is permissible to deliver unexpectedly.
  • As damaging surgeries are no longer used in modern obstetrics, Caesarean section is the safest technique in obstructed labor.