Espresso: Cord Prolapse

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 

Espresso: Uterine Rupture

What is uterine rupture? 

• Definition

• Spontaneous tearing of the uterine muscles which can lead to expulsion of the fetus into the peritoneal cavity

• In the literature, uterine rupture can also incorporate less catastrophic phenomena, like uterine window or asymptomatic scar dehiscence without expulsion of the fetus

• Focus today: intrapartum uterine rupture.

• The true incidence of uterine rupture across all populations in pregnancy is likely very low.

• With no history of surgery, the risk is 1/8000-17,000 deliveries 

• With one prior low transverse cesarean, the incidence has been reported to be between 0.2-1.5%, though usually quoted as <1% 

• With two prior low transverse cesareans, the incidence is reported to be between 0.8-3.9%, usually quoted as just over 1% 

• However, there are things that can modify this risk: 

• History of prior successful VBAC → reduce the risk of rupture from 1.1% to 0.2% 

• In other types of incisions such as T-incisions and classical incisions, the rate of rupture can be as high as 4-9%

• What are some other risk factors? 

• By far, the biggest one is previous uterine surgery,

• Other risk factors: 

• Uterine scar presence

• Uterine anomalies

• Prior invasive molar pregnancy

• History of placenta accreta spectrum

• Malpresentation

• Fetal anomaly

• Obstructed labor

• Induction of labor with use of prostaglandins

  • These other risk factors are much less significant than prior uterine surgery/presence of scar  

How do I recognize uterine rupture?

• Again — only be discussing uterine rupture in labor 

• There are a few studies looking at thinning of the myometrium on ultrasound, but this is controversial.

• It is much more likely that you will encounter uterine rupture at time of labor and birth than during other times 

• Diagnosis

• High index of suspicion - know your patient’s risk factors and be on the lookout for uterine rupture given how catastrophic it can be for both maternal and fetal wellbeing 

• Some of the classical signs: 

• Sudden, tearing uterine pain

• Vaginal hemorrhage

• Cessation of contractions 

• Destationing of the fetal head 

• However, these classical signs are actually not necessarily reliable and not always present! 

• The most reliable presenting clinical symptom is actually fetal distress 

• One study of 99 patients with uterine rupture showed: 

• Only 13 patients reported pain and 11 had vaginal bleeding 

• However, bradycardia or signs of fetal distress (decelerations) were present in the majority.

• Ultrasound examination 

• Not necessarily reliable and if you are truly suspicious of uterine rupture, this should prompt immediate delivery 

• Why do we need to diagnose uterine rupture promptly? 

• Maternal complications

• Maternal circulatory system delivers 500 cc of blood to the uterus every minute 

• Uterine rupture increases the risk of hemorrhage, with studies showing that about 50% of cases result in EBL of 2000cc or greater 

• This can lead to need for blood transfusion, and in more dire circumstances, hysterectomy  

• Fetal complications 

• Depends on how quickly the neonate is delivered after recognition of uterine rupture 

• One study showed a neonatal mortality rate of 2.6%, and increases to 6% if uterine rupture occurs outside of the hospital

• Older literature report rates as high as 13%  

• Many neonates will require resuscitation and admission to the NICU 

Management

• The best form of management is prevention or setting expectations - ie. counseling 

• All patients who desires a trial of labor after cesarean section should be counseled about the risks and benefits of TOLAC 

• Patients should deliver at a location where labor and delivery staff, anesthesia staff, and neonatal staff are available 24 hours in order to facilitate prompt delivery if needed. 

• Patients who are at high risk of uterine rupture (ie. classical cesarean, T-incision, prior uterine rupture, >2 cesarean sections, history of prior fundal surgery) should be counseled against TOLAC 

• We did a whole episode on TOLAC counseling back in 2019, so check it out here: https://creogsovercoffee.com/notes/2019/9/22/trial-of-labor

• Note that the VBAC calculator we included in those notes is outdated! 

• There is a new VBAC calculator available that does not include race as a predictor: https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator

• What if it happens? The answer is prompt delivery via cesarean delivery 

• Urgent delivery - as quickly as possible, but within 30 minutes generally 

• Patient can be under general anesthesia or if they already have working regional anesthesia, this can also be used 

• Cesarean delivery should be performed, and if there is a uterine rupture, the neonate can often be delivered via the area of rupture without creating a new hysterotomy 

• However, if there is just a uterine window, a hysterotomy may be needed 

• Once the neonate is delivered, pediatrics should be there immediately to facilitate resuscitation 

• If uterine rupture is confirmed, a full exam of the uterus should be done to assess for other injury 

• Ie. bladder injury, broad ligament hematoma 

• If possible, the area of rupture should be repaired 

• However, if it is not possible to repair the rupture due to significant damage, patient is not stable, or significant hemorrhage, then the next step should be hysterectomy 

• Follow-up 

• Debriefing - this should occur with the team who was present for uterine rupture 

• But also, should discuss with your patient when they are at a place when they can discuss what happened 

• Counsel patient that if they desire future pregnancy, TOLAC should not be attempted due to increased risk of repeat rupture 

Babies on a Plane: Air Travel, Pregnancy, and In-Flight Emergencies

Depending on your perspective, the idea of delivering a baby on a plane might be exciting… or your worst nightmare! Today we’ll talk about what to think about in this scenario, and familiarize you with what you have available for this in-flight emergency.

First of all… what recommendations are there for air travel (i.e., can we prevent this??)

• There is an ACOG Committee Opinion on Air Travel During Pregnancy (reaffirmed 2019)

• Highlights:

• Air travel is safe for pregnant folks, and there’s no increased risk of adverse events following occasional air travel.

• Most airlines will allow for air travel up until 36 weeks.

• The Points Guy blog had a recent post comparing airline policies, if you’re interested! 

• If travel is necessary after 36 weeks, most airlines will require a doctor’s note clearing the patient to fly.

• Remind patients traveling to reduce VTE risk with compression stockings, frequent movement/ambulation (at least 1x/hr), and adequate hydration.

• Risk of radiation for occasional air travelers is fairly minimal.

How common is the scenario of a birth on a plane?

• It’s not very common – but also hard to find estimates.

• One publication estimated a birth once in every 26 million air travelers. 

So if I’m on a 1 in 26 million flight… 

• First – we’ll plug a paid app called AirRx that’s written for physicians to know about what in-flight emergencies are common, and what you can expect to have access to in a flight.

• Information is destination/origin specific, so also useful for international air travel.

• We’ll focus on US-origin (mostly domestic) flights.

• Every flight has first aid kits:

• If under 50 passenger seats, minimum 1 kit.

• If 51-150, minimum 2.

• If 151-250, minimum 3 - this is a Boeing 737 size.

• If 251+, minimum 4. 

• First aid kits on planes have some basic equipment, including antiseptic swabs, bandages, adhesive tape, and bandage scissors.  

• Separately, all commercial aircraft in the USA are required to carry a separate “emergency medical kit” that contains more advanced equipment:

• Stethoscope and BP cuff

• Airway supplies

• PPE for you (gloves, gown, etc).

• IV tubing set with at least 500cc bag of NS 

• Tylenol, benadryl, aspirin

• Epinephrine, nitroglycerin, and atropine

• Automatic external defibrillator

• And some basic instructions for use of drugs in the kit.

• You will also have access to oxygen and masks.

Who can help?

• It’s good to keep in mind you have a team, and you’re never alone if you’re helping the crew respond to an in-flight emergency.

• Always share with flight crew yourself, your level of training, and show a medical ID if you have it.

• If someone has already volunteered, don’t be shy about volunteering, too – you never know who might have good skills to assist (especially if you’re an OB on a plane where a baby might be coming!).

• Also if you’re the only one who has responded – feel free to ask the crew to keep asking for additional assists if you need more folks to help.

• On board, you’ll have a flight crew:

• Ask them to bring the emergency medical kit and first aid kit.

• Ask one flight attendant to be an assist throughout the event (usually one will be assigned).

• The crew will notify a ground medical support team, who is well-trained in a wide variety of scenarios as well as specific physiology of flight.

• Talking to your ground medical crew:

• Be explicit about your impression of what’s going on.

• Keep what you say simple.

• Keep talking and keep everyone informed – your pilot and crew are often trying to help with weighing a decision about whether emergency landing is warranted.

• This is more than the medical decision – part of this is airport choice, whether the plane is safe to land (i.e., is the extra fuel of landing early making the plane too heavy for a safe landing), and whether resources are available to assist the patient where landing is considered.

• Especially if there is concern for communicable disease, flight crew needs to be aware for themselves and to alert ground medical crew for transport considerations.

• Be professional – all conversations with medical ground crew are recorded!

Starting your assessment

• Get basic vitals - vital signs are vital!

• Get your history.

• Do what you do best as an OB – assess labor or not in labor!

• You are limited in the air - you have your physical exam, and that’s about it.

• Your goal is to promote safety of the patient and passengers with your professional assessment. 

• You’ll have assistance from ground medical staff on what to do in specific scenarios regarding flight diversion.

• Pregnant folks also have a lot of other things that can be occurring – keep your differential diagnosis broad and reassure folks if labor is not occurring. You may be the best person to limit panic in assessing a pregnant person on board a plane, regardless of the complaint.

• If delivery is occurring, get help!

• You know you need assistants, even if not trained.

• Be prescriptive and talk out loud – think about how you simulate a shoulder dystocia. Now imagine that on a plane with no nurses, no backup, no anesthesia – you have to be directive in making sure you get what you need to succeed.

What about weird / crazy / undesirable scenarios in the air?

• Preterm labor:

• Remember these babies need breathing and warmth primarily!

• In your emergency medical kit, you have equipment for PPV and oxygen that can be administered to babies.

• Skin-to-skin, layers, and blankets are readily available on planes for warmth.

• For super premature kids, we often will put them in plastic bags to help with heat retention… and on planes, there’s often several of those! Ask for a gallon Ziploc bag from volunteering passengers.

• Malpresentation (i.e., breech or cord prolapse).

• Don’t encourage pushing in these scenarios! Be clear with ground crew an emergent cesarean is needed and landing the plane needs to be a top consideration. 

• Get patient into all fours for a cord prolapse, with chest down and butt up – this will help presenting parts stay off the cord.

• If the baby is coming – go through our breech delivery episode and simulate breech deliveries while you can in training! 

• Postpartum hemorrhage

• You’re limited in what you can do here – bimanual massage, examination, pressure, and bandages. 

• You have a limited amount of IV crystalloid on a plane you can give. 

• Remember that nipple stimulation can help with oxytocin production – starting breastfeeding or doing nipple stim can get the uterus contracting.

• Consider delaying placental delivery until the plane is landed – remember you have 30 minutes in an active management scenario. If there’s no active bleeding and baby is delivered, without oxytocin, it may be prudent to wait to not provoke bleeding.

What about medicolegal implications?

• There is no relevant international law for assisting in-flight medical emergencies.

• In the US, the Aviational Medical Assistance Act (aka, “Good Samaritan Act”) of 1998 states:

• An individual shall not be held liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency, unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.

• The standard for malpractice here is significantly higher than it is in usual malpractice cases.

• There is no example of a medical professional anywhere in the world who has been sued successfully for assisting an ill traveler

• Actually - successful lawsuits have only occurred against airlines; and airlines will normally accept liability associated with requests for in-flight assistance. 

• There likewise is no standard protocol for documentation of in-flight events and assistance; but individual airlines may have forms or policies.

• It is advisable for you to create a secure document of your exam, assessment, and plan, or get a photo of a completed airline documentation form, for your own records in case you are asked to comment on the case later for any reason.

What about compensation?

• The Good Samaritan law only applies to true “good samaritan” actions, so where no compensation is provided. Because of this, it’s not advisable to take any monetary compensation for assisting in an in-flight emergency.

• These laws do not address non-monetary compensation (i.e., frequent flyer miles, seat upgrade, bottle of wine, etc.). 

• However, just because they are not addressed doesn’t mean they may not be targeted, so most folks advise not accepting these gifts.

• Lawsuits have been brought against assisting physicians; just none of them have succeeded in US courts to date.

Final Fun Facts

• If a baby is born in flight, most of the time the child is given citizenship status of the parents.

• If in US airspace, the child can also be given US birthright citizenship.

• Sometimes, citizenship is awarded based on the country of registration of the plane.

• The most recent baby we could find born on a plane occurred in Oct. 2022:

• American Airlines flight from NYC to the Dominican Republic!

Espresso: The Emergency Department Consult

Why do patients come to the ER with GYN complaints?

• A whole host of reasons! But some of the most common:

  • Bleeding irregularities – heavy bleeds, mistimed bleeds, unusual bleeding

  • Pain – PID, ovarian cysts, ectopic pregnancy, ovarian torsion, endo, non GYN pain issues

  • Infections – Bartholin’s and other cysts, UTIs, PID

  • Urinary complaints – most often retention or incomplete voiding

  • OB - patients who haven’t established prenatal care, or otherwise sick OB patients (trauma, medical issues) may be first evaluated in the ED

  • Sexual assault and injuries, such as lacerations

Before the Consult: What the EM Clinician Should Do

• Normal EM things – obtaining your acute history and HPI, vital signs, physical exam, and getting the “sick vs not sick” intuition.

  • Consider pregnancy test and pelvic exam as part of your basics.

    • Pregnancy tests should mostly be protocolized for appropriate patients in EDs, but also frequently missed in the evaluation of reproductive-aged patients.

      • If positive – be sure that your labs include a type-and-screen for Rh status, and likely plan on an ultrasound (especially if the diagnosis of pregnancy is new).

    • Pelvic exams are controversial, and we see the argument:

      • OBs are specialized in performing the exam, and we’re likely to repeat it.

      • However, particularly with bleeding – having a sense of whether the bleeding is light, moderate, or heavy/rapid helps us triage the consult urgency and a differential! 

        • Contraindications to digital pelvic exam –

          • Suspected rupture of membranes at 34 weeks or less (unless laboring);

          • Bleeding in pregnancy without confirmation of placental location.

        • OB residents – this is a long-standing controversial issue and training / advice will differ based on region and one’s own biases.

          • If it hasn’t been done and you can’t go to evaluate immediately, ask kindly for it to be performed and for a call back if the bleeding is concerning. 

      • EMs, consider bouncing back with your OB/GYN colleagues when they do a pelvic exam!

        • Getting to do these exams and then comparing your findings will help you to gain comfort with making calls when you’re in the community on your own!

What constitutes an emergency consult?

• Sometimes, things can’t wait!

  • If you have clinical suspicion of ovarian torsion or ruptured ectopic pregnancy, those are surgical emergencies and so merit a rapid response from your GYN colleagues.

  • Heavy vaginal bleeding (>1 maxipad per hour) and/or hemodynamically unstable patient – can range from ectopic pregnancies to gynecologic cancers - need an expert in exam present to help triage.

  • Major OB traumas – ideally, this should prompt OB to be present at the time of patient arrival or rapidly.

  • The “sick” OB patient – this should also prompt OB to be present rapidly, especially if the patient is “viable” or the uterus is at/above umbilicus. Considerations for delivery might need to be made.

    • Common reasons for this could be DKA in pregnancy, sepsis in pregnancy or septic abortion, or other decompensated illness.

Framing the ED Consult

• For our EM colleagues, we love the mnemonic BLUF: bottom line, up front.

  • “This is a consult for possible ectopic and hemodynamic instability” immediately grabs our attention.

  • Follow with that history though so we can help:

    • Gs and Ps – even we mess these up, so just sharing some important pregnancy history can be more helpful (i.e., G3P0020 is less helpful than “two prior ectopics.”)

    • Nature of presenting complaint: as you normally would

    • Vitals / hemodynamic status

    • Laboratory and imaging evaluation done or ongoing

  • In the less-emergent patient, lead off with your BLUF by starting with the specific question or ask:

    • I.e., “This is a consult for a pregnancy of unknown location, and we need your assistance in confirming the findings and coordinating follow up.”

• For our OB colleagues, help facilitate this conversation:

  • Ask for the BLUF – “before we get to her history, can you tell me what your primary clinical concern or question is? That just helps me to triage more appropriately.” 

  • Recognize you’re not going to always get a history or question on a silver platter.

  • Formulate your differential even if it seems like a slam dunk – and make sure you’re asking the right questions to get there

    • For instance, common misses include pregnancy tests, Rh status.

  • When in doubt, go see the patient faster! You’re the expert here and your expertise is being requested. 

  • Follow up with colleagues after you see the patient, or even better as you are getting ready to see them – particularly at training facilities, your EM resident colleagues may want to go see the patient again with you to get confirmatory findings, pearls of wisdom for their independent practice, and help with counseling.