Espresso: Cord Prolapse

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What is cord prolapse? 

  • Definition 

    • When the cord moves out of the cervix in front of the fetal presenting part; can usually only happen when rupture of membranes has occurred 

      • Otherwise, it is called funic presentation (cord presenting with intact membranes)

    • Uncommon: 1.4-6.2/1000 

    • Majority of them happen in singleton gestation, but there is an increased risk in twin pregnancies of the second twin 

  • Risk Factors

    • PPROM - especially if the fetus is not in the cephalic position 

    • Multifetal gestation 

    • Polyhydramnios 

    • Fetal growth restriction 

    • Preterm labor 

    • AROM when fetal head is not well engaged 

      • Nearly half of cases are attributed to iatrogenic causes 

      • 57% occur within 5 minutes of membrane rupture, and 67% occur within 1 hour of rupture 

  • Why do we care? 

    • Compression of the cord → vasoconstriction and → fetal hypoxia 

    • Can lead to fetal death or brain damage if not rapidly diagnosed and managed 

How can I recognize cord prolapse? 

  • Exam 

    • Palpation of a pulsatile mass in the vaginal vault or at the cervix 

    • No need for radiographic or laboratory confirmation 

  • Fetal heart tracing 

    • Usually can see recurrent variable decelerations or fetal bradycardia 

  • Differential diagnosis 

    • Another mass in the vagina could be fetal malpresentation 

    • Other causes of fetal bradycardia/decelerations should also be considered 

How do I manage cord prolapse if it is found? 

  • Reduction of the cord – if possible 

    • This is usually not possible if there is large amount of cord in the vagina, and not recommended 

    • However, if there is small amount of cord at the internal cervical os, at times, it is possible to reduce it back beyond the present part 

    • However, if there is recurrent prolapse … 

  • Expedient delivery

    • Usually via cesarean delivery 

    • Prior to getting to the operating room, the goal should be decompression of the umbilical cord 

      • Elevate the fetal presenting part as interval to umbilical cord decompression can be associated with worse outcomes than interval to delivery 

        • Decompression can be done manually: place finger or hand in the vagina and gently elevate the head or presenting part off of the umbilical cord 

        • Do not put additional pressure on the cord → can lead to vasospasm 

      • Another way of decompression 

        • Place pregnant patient into steep Trendelenburg or knee-chest position 

        • Usually if there is not a provider who is able to do manual decompression or if there is prolonged interval to delivery (ie. transfer to hospital) 

      • If there is visible cord protruding from the introitus, try to place a warm, moist sponge or towel over the cord to prevent vasospasm

        • Or can replace into vagina 

What are the outcomes, and how do I prevent prolapse? 

  • Prognosis 

    • Fetal mortality is <10% now that we are able to complete cesarean sections in a timely manner 

    • In earlier studies, the range was 32-47% 

    • Gestational age and location of prolapse (in or out of hospital) can significantly determine outcomes 

      • Cord prolapse outside of hospital carries 18x increased risk of fetal mortality 

  • Prevention 

    • For patients who are at increased risk of cord prolapse (ie. PPROM, malpresentation), they should be encouraged to deliver at a hospital 

    • Early recognition training by both patient and providers

      • SIM! 

    • ACOG recommend against routine amniotomy in normally progressing labor unless needed for fetal monitoring 

      • AROM - if needed, make sure that there is engagement of the fetal head 

      • If AROM is needed, but there is polyhydramnios or high fetal station, can use a fetal scalp electrode to rupture the amniotic sac to slowly release fluid