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King Edward Memorial Hospital
Obstetrics & Gynaecology
Contents
Cord prolapse quick reference guide (>23 weeks) .............................
Background information .......................................................................................... 3 Definitions^5 .............................................................................................................. 3
Cord prolapse in hospital / Family Birth Centre .................................
Key points ............................................................................................................... 4 Management of cord prolapse ................................................................................ 4
Cord prolapse in the community (Community Midwifery Program)..
Management ........................................................................................................... 8
References ............................................................................................
CLINICAL PRACTICE GUIDELINE
Cord prolapse: Umbilical
This document should be read in conjunction with this Disclaimer
Cord prolapse quick reference guide (>23 weeks)
Management algorithm for cord prolapse >23 weeks gestation
Perform a vaginal examination
- Replace the cord in the vagina
- Apply digital pressure to elevate the presenting part
- Assess the cervical dilatation
Call for assistance
Dial 55 - ask for appropriate Code blue- Caesarean or medical as required Call 000 if in the Community (CMP)
Transfer the woman to theatre
Position the women
In the exaggerated
SIM’s position
Catheterisation
Consider filling the bladder with 500 mL of Normal Saline 0.9% if delay to theatre is expected
Note the time
If the woman is fully dilated consider operative delivery
Consider Terbutaline 250 MICROGRAMS subcutaneous
Turn off Syntocinon
Monitor the fetal heart
Prepare for theatre
Cord prolapse in hospital / Family Birth Centre
Key points
- The Registrar should be informed of all women presenting to MFAU/LBS in labour at high-risk for umbilical cord prolapse.
- All women who are high risk for cord prolapse should immediately have a speculum examination and / or digital vaginal examination following spontaneous rupture of membranes.^6
- Management of cord prolapse depends on parental/medical consultation which includes fetal gestation and viability.
- If no cord pulsation or fetal heart is heard, the presence or absence of a fetal heart beat should be confirmed by Ultrasound Scan.
- Manual elevation of the fetal presenting part decompresses cord occlusion.4, 6
- Reduce potential umbilical cord spasm by minimal handling of the cord,^6 and prevention of the cord becoming cold or drying.^7
- If delay in birth is expected, catheterisation of the bladder should be performed. 500mL of Sodium Chloride 0.9% is infused into the bladder and the catheter is clamped. This elevates the presenting part^6 and may reduce contractions.^4
- Expectant management should be considered in cases with associated risks of fetal prematurity.^4
- Delay in delivery time interval may increase the risk of perinatal morbidity and mortality.^4 The measures described on the following pages, whilst potentially useful, should not result in unnecessary delay.^6
Management of cord prolapse
PROCEDURE ADDITIONAL INFORMATION
1 Call for assistance^6 Press the emergency assist bell. Dial 55, call a CODE BLUE MEDICAL as required If the fetus is potentially viable, call a Code Blue – Caesarean Section. The type of code depends on the gestation.
Management for cord prolapse is as follows: Less than 23 weeks gestation: The gestation is below viability – do NOT call an emergency code. Notify the obstetric medical team. Unless a previous management plan has been confirmed by the obstetric team transfer the woman to the Labour and Birth Suite for ongoing care.
PROCEDURE ADDITIONAL INFORMATION
23 to 25 weeks gestation: Dial 55, CODE BLUE MEDICAL should be called. This allows medical and midwifery staff to assess the situation on the ward and make a management decision in consultation with the parents. A decision is made by senior medical staff if a caesarean section is to be performed.^6 If the decision is made for a Caesarean Section birth, then dial 55, call a Code Blue – Caesarean Section.
Equal to or more than 25 weeks gestation: Dial 55, CODE BLUE - CAESAREAN SECTION should be called. This informs the anaesthetic, obstetric, paediatric, and Labour and Birth Suite staff to go immediately to theatre rather than the ward. Prepare and take the woman to theatre.^6 Verbal consent is appropriate in this situation.^6
2 Note the time the code is called
3 Position the woman
Place the woman into the exaggerated Sims position.^6
The woman lies on her left side in a semi-prone position, with her right knee and thigh drawn up: her left arm lies along her back while the hips and buttocks are elevated on a wedge or pillow. This relieves pressure on the umbilical cord.^5
PROCEDURE ADDITIONAL INFORMATION
5 Fetal assessment
Auscultate the fetal heart rate as soon as possible.
Continuous fetal heart rate monitoring should be initiated to allow constant assessment of fetal well-being. An ultrasound should be done immediately if: No cord pulsation can be felt Fetal heart rate cannot be found on auscultation.
6 Intravenous therapy (IVT)
If intrapartum, cease Syntocinon infusion immediately
Ceasing oxytocin may decrease contractions which cause pressure on the cord.^5 Insert intravenous cannula – commence Compound Sodium Lactate Solution intravenously.
7 Administering Terbutaline
Consider administration of Terbutaline 250 micrograms subcutaneously for women in established labour.
Tocolysis may be advocated to inhibit uterine activity.^6 Contractions can exacerbate cord compression.^1
8 Urinary catheterisation
Consider catheterisation of the bladder if delay to theatre is expected: Attach a standard infusion set to a 16 g indwelling catheter Instil a Sodium Chloride 0.9% infusion into the catheter until the distended bladder is visible above the symphysis pubis Clamp the catheter and attach to a drainage bag Remove the clamp and allow urine to drain when the time is appropriate in theatre
A full bladder can inhibit uterine activity and reduce compression on the cord by raising the presenting part.^1
500 – 700 mL of solution (warmed or at room temperature) is generally enough to fill an empty bladder.^5 Caution is advised if the woman has not recently voided.
The infusion clamp should be removed and the bladder emptied just before entering the peritoneal cavity during caesarean section.^4
PROCEDURE ADDITIONAL INFORMATION
9 Documentation Detailed notes of the incident should be documented in the medical record. 10 Support and Debriefing Explanation of the management should be given to the woman and support people during the incident as appropriate.
Follow up discussion after the birth by medical and midwifery staff is essential to reduce adverse psychological outcomes.^5
Cord prolapse in the community (Community Midwifery
Program)
Management
- Call 000 and the support midwife if not already present
- Follow Management of Cord Prolapse >23 weeks as applicable to the community setting from point 2.
- Inform the support hospital of the imminent transfer for cord prolapse. Ensure immediate transfer on arrival of ambulance
- Explain the circumstance to the woman in a calm manner, and reassure her.
