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Obstetrics Simplified - Diaa M. EI-Mowafi

Cord Presentation and Prolapse

Definitions

In both conditions a loop of the cord is below the presenting part. The difference is in the condition of the membranes; if intact it is cord presentation and if ruptured it is cord prolapse.

Incidence: 1:200.

The Risk

As long as the membranes are intact there is no risk. In cord prolapse, the foetal perinatal mortality is 25-50% from asphyxia due to:

  • mechanical compression of the cord between the presenting part and bony pelvis and
  • spasm of the cord vessels when exposed to cold or manipulations.

The prognosis is worse when the cord is more liable for compression as in:

  • Primigravida than multipara.
  • Cephalic than breech presentation or transverse lie.
  • Partially than fully dilated cervix.
  • Generally contracted than flat pelvis.
  • Anterior than posterior position of the cord.

Aetiology

The presenting part is not fitting in the lower uterine segment due to:

  • Foetal causes:
    • Malpresentations: e.g. complete or footling breech, transverse and oblique lie.
    • Prematurity.   
    • Anencephaly.     
    • Polyhydramnios.    
    • Multiple pregnancy.
  • Maternal causes:
    • Contracted pelvis.   
    • Pelvic tumours.

Predisposing factors:

  • Placenta praevia. 
  • Long cord.   
  • Sudden rupture of membranes in polyhydramnios.

Diagnosis

  • It is diagnosed by vaginal examination . If the cord is prolapsed it is necessary to detect whether it is pulsating i.e. living foetus or not i.e. dead foetus but this should be documented by auscultating the FHS.
  • Ultrasound: occasionally can diagnose cord presentation.

Management

Cord presentation

Caesarean section: for contracted pelvis.

In other conditions the treatment depends upon the degree of cervical dilatation:

  • Partially dilated cervix: prevent rupture of membranes as long as possible by:
    • putting the patient in Trendelenburg position,
    • avoiding high enema,
    • avoiding repeated vaginal examination.
    • When the cervix is fully dilated manage as mentioned later .
  • Fully dilated cervix: the foetus should be delivered immediately by:
    • Rupture of the membranes and forceps delivery: in engaged vertex presentation.
    • Rupture of the membranes and breech extraction: in breech presentation.
    • Rupture of the membranes + internal podalic version + breech extraction: may be tried in transverse lie otherwise,
    • Caesarean section: is indicated as well as for non-engaged vertex and other cephalic malpresentations.

Cord prolapse

Management depends upon the foetal state:

  • Living foetus:
    • Partially dilated cervix: Immediate caesarean section is indicated. During preparing the theatre minimise the risk to the foetus by:
      • putting the patient in Trendelenburg position,
      • manual displacement of the presenting part higher up,
      • if the cord protrudes from the vulva, handle it gently and wrap it in a warm moist pack.
      • giving oxygen to the mother.
    • Fully dilated cervix: the foetus should be delivered immediately as in cord presentation.
  • Dead foetus:
    • Spontaneous delivery is allowed.
    • Caesarean section: is the safest procedure in obstructed labour as destructive operations are out of modern obstetrics.

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