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33. Cord Prolapse and Transverse Lie
33.1 Cord Prolapse
33.1.1 Definition
Umbilical cord (funic) presentation—when the cord felt alongside the presenting part or below it in labor and membranes not ruptured
Occult cord prolapse—when the membrane ruptured and the cord felt alongside the presenting part
Overt cord prolapse—when the cord felt below the presenting part with membranes ruptured; the cord may be in the vagina or outside the introitus (Fig. 33.1)
Types of cord prolapse
33.1.2 Incidence
0.6% of all deliveries
33.1.3 Etiology
- 1.
Breech, transverse, oblique, unstable lie, face, brow
- 2.
A high head at the onset of labor
- 3.
Multiple gestation—second of the twins
- 4.
Grand multiparity
- 5.
Abnormal placentation
- 6.
Preterm labor, rupture of membranes
- 7.
Polyhydramnios
- 8.
Obstetric manipulations such as ARM, ECV, IPV, manual rotation of fetal head, forceps delivery, application of scalp electrode, and IUPC
- 9.
CPD, contracted pelvis
- 10.
Long umbilical cord
- 11.
Fetal anomalies
- 12.
Male fetus
33.1.4 Pathophysiology
Cord compression or spasm of the cord (handling cord, atmospheric temperature) leads to hypoxia which is manifested as prolonged abrupt bradycardia or repetitive variable decelerations in CTG and meconium passage, low APGAR, and birth asphyxia leading to sudden IUD, neonatal death, or morbidity.
33.1.5 Diagnosis
The diagnosis is commonly made during a vaginal examination; the examiner feels a soft, usually pulsatile structure through the membranes or with membranes ruptured. The absence of pulsations and meconium passage are ominous signs.
CTG in cord prolapse
33.1.6 Prevention
- 1.
ARM should be avoided when the presenting part is high or mobile. A stabilizing induction should be done in polyhydramnios with high head. A controlled ARM with a spinal needle can be done in cases of high head where contractions have been established and fixity of the head is yet to occur. Facilities for a crash CS should be available in every labor room.
- 2.
Transverse, oblique, or unstable lie patients should be offered ECV after 34 weeks after informed consent. Oblique or transverse lie patients persisting after 37 weeks can be offered repeat ECV if no contradiction for the same.
- 3.
PROM/PPROM patients with mobile head should be restricted till the head is fixed.
- 4.
Upward pressure on the presenting part should be kept to minimum during per vaginum and ARM.
- 5.
If the cord presentation persists after the established labor, CS is indicated.
- 6.
Beware of cord prolapse, during amnioinfusion.
33.1.7 Management
(a) Retrofilling the bladder (b) Position for prolapse cord
33.1.8 Fetal Complications
Among fetal complications prematurity and congenital malformations are the major adverse outcomes associated with cord prolapse in our hospital settings, but one cannot forget birth asphyxia which is also associated with cord prolapse. Asphyxia further results in hypoxic–ischemic encephalopathy and cerebral palsy. The cause of asphyxia is cord compression, and umbilical arterial vasospasm prevents venous and arterial blood flow to and from the fetus.
33.1.9 Summary and Recommendations
The first sign of cord prolapse is usually severe, prolonged fetal bradycardia or moderate to severe variable decelerations after a previously normal tracing. The prolapse may be overt or occult.
Standard obstetrical management of cord prolapse is prompt cesarean delivery to avoid fetal compromise or death from compression of the cord. However, vaginal delivery may be a reasonable option in select cases when delivery is imminent and can be safely assisted.
Intrauterine resuscitation using maneuvers such as elevation of the presenting part manually or by retrofilling the bladder, placing the patient in a Trendelenburg or knee-chest position, and administering a tocolytic may reduce pressure on the cord while preparations are being made for delivery.
Reported perinatal mortality related to cord prolapse varies widely, from 0% to 3% for events occurring among patients monitored on a labor and delivery unit. Asphyxia and complications related to prematurity and congenital anomalies are the major causes of poor outcome. The degree of cord compression, the interval between cord prolapse and delivery, and the successful use of intrauterine resuscitation maneuvers all impact the risk of asphyxia.
Awareness of patients at high risk of prolapse may help facilitate prompt diagnosis and delivery when prolapse occurs.
Transverse, oblique, or unstable lie patient should present to the hospital urgently when they begin labor or rupture membranes.
In high-risk patients, the risk of cord prolapse may be reduced by minimizing the use of obstetric interventions that may disengage the presenting part and by performing controlled amniotomy.
We do not routinely perform ultrasound examinations to assess umbilical cord position near term, but would order an ultrasound examination to confirm cord position when there is a clinical suspicion of funic presentation.
For patients with a funic presentation that has not resolved before labor at term, management depends on the risk of cord prolapse.
Patients with a floating vertex, cervical dilation >2 cm, and persistent funic presentation at ≥39 weeks are at very high risk of cord prolapse with rupture of membranes and unlikely to benefit from expectant management, especially if polyhydramnios is present. The authors offer these women induction of labor by “needling” the membranes in a controlled environment, with the anesthesia team ready for an emergency cesarean delivery in the event of cord prolapse.
Patients in whom the vertex has descended, the cervix is not significantly dilated, and amniotic fluid volume is normal are at an increased risk of cord prolapse, but not the highest risk group. Advise these women to come to labor and delivery as soon as labor begins so that the cord position can be evaluated. The patient can continue to labor with a goal of vaginal delivery if the funic presentation has resolved. If the funic presentation is confirmed, we monitor the patient/fetal heart rate continuously and perform a controlled amniotomy, with the anesthesia team ready for an emergency cesarean delivery in the event of cord prolapse. Cesarean delivery without a trial of labor is also reasonable.
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