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    Umbilical cord prolapse

    A plan for an ob emergency

     

    Management

    Cord prolapse results in fetal hypoxia, and if not rapidly treated, can lead to long-term disability or death.2,3,8 Prompt delivery has been shown to improve outcomes.5 This means that cases of UCP should be delivered as quickly as possible, which generally means cesarean delivery. In rare cases, however, UCP can occur when delivery is near. If the provider believes that a vaginal delivery can be performed more rapidly than a cesarean delivery, it is certainly appropriate to proceed with vaginal delivery. Operative delivery should be considered if the FHR tracing shows concerning findings.

    The mainstay of management for UCP is urgent cesarean delivery. From the time of diagnosis until cesarean can be performed, the fetal presenting part should be elevated to relieve pressure on the cord and arrangements should be made for urgent cesarean delivery. Specifics of management will vary depending on whether an operative delivery can be accomplished within 30 minutes (typically an in-hospital event) or there will be a delay of more than 30 minutes (an out-of-hospital event). Table 2 lists variations to consider in management, depending on location.

     

    Elevation of the presenting fetal part. The key first step after identifying a UCP is to elevate the presenting fetal part off the prolapsed cord. This is generally performed manually, with the physician placing 2 fingers or an entire hand into the vagina to elevate the fetus off the cord. Care should be taken to avoid palpation of the cord because that may cause vasospasm, potentially leading to a worse outcome.2 Placing the patient in steep Trendelenburg or in knee-chest position is believed to be helpful by taking advantage of gravity to further relieve pressure on the cord.9

    In cases in which the interval to delivery is likely to be prolonged (that is, requiring maternal transport to a facility where cesarean delivery can be performed), bladder filling may be a better option. With this technique—commonly called Vago’s method, in reference to the physician who first described the technique—a Foley catheter is placed and the bladder is filled with 500 to 750 mL of saline, and then clamped. 10 The patient’s enlarging bladder provides upward pressure on the fetus, thus alleviating the compression on the cord. Vago described this as an alternative to manual elevation, which he described as “effective, but . . . unpleasant for the mother and wearying for the doctor.” He also noted that in his experience, filling the bladder tends to calm uterine contractions, which would certainly further relieve pressure on the cord. Over the years, studies have shown Vago’s method to be effective.10,11 To employ this strategy requires that a cord prolapse tray be immediately available (Figure 1). Comparison of manual elevation of the presenting part versus bladder filling shows essentially equal outcomes between the 2 groups.12 It should be noted that the combination of the 2 methods does not lead to any improvement over using either alone.

     

    Sharon T. Phelan, MD
    Dr. Phelan is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.
    Bradley D. Holbrook, MD
    Dr. Holbrook is a senior resident in the Department of Obstetrics and Gynecology at the University of New Mexico School of Medicine, ...

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