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    Umbilical cord prolapse

    A plan for an ob emergency

     

     

    Funic reduction. Another method that has been used to treat cord prolapse is funic reduction, replacement of the cord back into the uterus by sliding it above the fetal presenting part. This is performed by placing the entire hand in the vagina and gently elevating the fetal head. The cord is then lightly elevated above the fetal head, preferably at its widest point, and replaced back into the uterus; the goal is that the cord should stay in the fetal nuchal region.

    Before cesarean delivery became commonplace, funic reduction was a major part of management in cases of UCP. It is now rarely performed, however, because outcomes were worse than cesarean delivery. There has been some discussion of renewed interest in funic reduction, and Dr. Barrett notes that overall, he has had very good outcomes with this strategy.13 In our experience, the technique is difficult but it can sometimes be successful and is certainly worth an attempt. Nevertheless, we would not recommend delaying preparations for cesarean delivery while attempting to replace the cord.7

    Tocolysis. Although not a primary treatment for UCP, tocolysis has also been described and it appears to be a useful adjunct.9 It is likely not necessary in cases in which urgent delivery can be performed, but it can certainly be employed if FHR decelerations persist after the primary procedures have been performed.

    Other considerations. Another important consideration is keeping the cord moist. When delivery is imminent, this is less of a concern. But with a prolonged interval to delivery, the cord could dry out, which could lead to vasospasm and thus, potentially worse outcomes. Therefore, if the cord prolapses through the introitus, it should be gently replaced into the vagina. A moist tampon or 4 x 4 gauze can then be inserted gently into the vagina below the cord to help hold it in place.

    In rare cases of UCP, contraindications to immediate delivery may exist. In cases of lethal fetal anomalies or absent fetal heart tones, exposing the mother to the risk of urgent cesarean delivery will lead to no benefit to the fetus and thus, should not be performed. Delivery at a previable gestational age falls into this same category, although the definition of previability will vary based on the capabilities of a neonatal intensive care unit (NICU) as well as institutional policies.

    It is important to note that there are case reports of UCP at a previable gestational age that were managed expectantly and successfully prolonged pregnancy to viable gestational age.2,14 Cases of multiple gestations with prolapse of one cord at a periviable gestational age present difficult clinical dilemmas; the risks to each fetus must be discussed in detail but quickly with the patient to make the best management decision.

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    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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