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