Cord Prolapse True Prolapsed Cord

UMBILICAL CORD PROLAPSE

A loop of the umbilical

cord slips down in front of the presenting fetal. Prolapse may occur at any time after the membranes rupture if the presenting part is not fitted firmly into the cervix.

Definition
Cord prolapse

It has been defined as descent of the

umbilical cord through the cervix alongside (occult) or pass the presenting part (overt) in the presence of ruptured membranes.

Definition
Cord presentation It is the presence of one or more loops of

umbilical cord between the fetal presenting part and the cervix, without membrane

rupture.

Incidence
The overall incidence of cord prolapse

ranges from 0.1 to

0.6 %.
With breech presentation, the incidence

is just above

1%.
Male fetuses seem to be predisposed. The incidence is higher in multiple gestations.

Risk factors for cord prolapse

Risk factors for cord prolapse

Predisposing Factors: Premature Rupture of Membranes Fetal Presentation other than Cephalic Placenta previa Intrauterine tumors Small fetus Cephalopelvic Disproportion Multiple Gestation

Prolapsed Cord Fetus moves downward into the pelvis Cord compressed Diminished oxygen and Blood supply to fetus

Fetal distress

Pathophysiology
Fetomaternal Factors Fetal malpresentation Prematurity Multiple gestation Multiparity Rupture of membranes Polyhydramnios Obstetrical Interventions Artificial rupture of membranes Vaginal manipulation of the fetus with ruptured membranes External cephalic version Internal podalic version Stabilising induction of labor Insertion of uterine pressure transducer

Umbilical cord prolapses

Frank cord presentation cord prolapsed through cervix

Occult cord presentation Cord trapped alongside presenting part

Drop in temparature of prolapsed cord

Rupture of membrane and amniotic sac occurs when presenting part is ill fitting Footling Breech Presentation CPD Fetal Abnormaliy

Compression Bet. Pelvic brim And presenting part

Vasospasms Of Umbilical vessels

Fetal blood supply obstructed when cord out of the uterus as the fetus Moves downward into the pelvis

Oxygen and blood Supply diminishes Or cut-off

ASSESSMENT: On initial vaginal examination, cord may be felt as the presenting part during labor and also be identified on a sonogram. Assess fetal viability by checking for a palpable pulse in the cord. Assess for fetal heart sounds.
SIGNS AND SYMPTOMS: Exposed umbilical cord Rapid deceleration of FHR (Normal: 120-160bpm)

Assessment
Speculum and/or a digital vaginal examination

should be performed when cord prolapse is suspected, regardless of gestation.

Prompt vaginal examination is the most important

aspect of diagnosis.

It is important to avoid digital vaginal examinations in

women with preterm labour, but suspicion of cord prolapse was regarded as an exception to that rule.

Umbilical Cord Prolapse

Management
When cord prolapse is diagnosed dilatation :
1. Assistance should be immediately called 2. Venous access should be obtained, 3. Consent taken and 4. Preparations made for immediate delivery in theatre.

before full

 THEAPEUTIC AND MEDICAL MANAGEMENT:

Relieve pressure on the cord by placing a glove hand in the vagina

and manually elevate fetal head of the cord. Place woman in a knee chest or trendelenburg position Administer oxygen at 10 liters per minute via face mask to mother Administer tocolytic agent (Magnesium sulfate) to reduce uterine activity and pressure on the fetus

Cont..
When prolapsed cord is exposed to room air do not

attempt to push any exposed cord back in to the vagina instead cover any exposed portion with a sterile saline compress to prevent drying When cervix is fully dilated at the time of prolapse physician may choose to deliver infant quickly possibly by forceps SUGICAL MANAGEMENT: Cesarian Section

When cord prolapse is diagnosed before full dilatation, assistance should be immediately called and preparations made for immediate delivery

Initial management of cord prolapse in hospital setting:

To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina. To prevent cord compression, it is recommended that the presenting part be elevated either manually or by filling the urinary bladder.

NURSING DIAGNOSES:
(prioritized)
Impaired gas exchange Ineffective tissue perfusion Risk for infection Anxiety Fatigue

Relieve cord compression Replace cord gently into vagina Place hand in vagina, cord cradled in palm Tips of fingers elevating presenting part Mother in trendelenburg or kneechest position Fill bladder (16 Foley catheter, 500800ml of saline)

Management
If the decision-to-delivery interval is likely to be prolonged,

particularly if it involves ambulance transfer, elevation through bladder filling may be more practical. Bladder filling can be achieved quickly by inserting the cut end of an intravenous giving set into a Foleys catheter. The catheter should be clamped once 500-750 ml have been instilled. It is essential to empty the bladder again just before any delivery attempt, be it vaginal or caesarean section.

Nursing Interventions
Position pt. in Trendelenburg or knee-chest posn.

Manually raise the presenting part aseptically

Administer Oxygen 10L/min via face mask Strictly follow proper handwashing and aseptic

techniques for all healthcare providers Monitor pts. temp. Maintain sterility of equipments Identify clients perception of the threat presented by the situation.

Nursing Interventions
Monitor physical response for example,

palpitations/rapid pulse Show openness and availability as a healthcare provider Note nutritional status and fluid balance Assess psychological and physical factors that may affect reports of fatigue level Evaluated aspect of learned helplessness that may be manifested by giving up