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    Umbilical cord prolapse

    A plan for an ob emergency

     

    Outcomes

    Despite the potential for extremely poor outcomes, most neonates born after experiencing UCP do very well, especially if delivery is achieved within 30 minutes.5 The literature shows improved outcomes for cases of UCP that occur when the patient is already in the hospital, even if the fetus is not being monitored.3

    One study has shown team training exercises to be beneficial in decreasing the mean diagnosis-to-delivery interval in cases of UCP.15 In addition, although this study was small and the results did not reach statistical significance, there was a trend toward improved Apgar scores and fewer NICU admissions. It appears that such exercises may lead to improved neonatal outcomes. These drills should stress both the steps taken prior to arrival in the operating suite and the role of all members of the team in facilitating an efficient and safe urgent/crash cesarean delivery.

    Summary

    Umbilical cord prolapse is a well-known obstetric emergency that requires prompt delivery to avoid potentially devastating fetal outcomes. Diagnosis is made by the presence of a palpable, pulsating mass within the vagina or visibly extruding from the introitus. It is often accompanied by sudden, severe FHR decelerations. Risk factors for UCP include malpresentation, prematurity, low birth weight, polyhydramnios, and a number of iatrogenic causes related to routine labor interventions. There is no evidence that UCP can be prevented, but rapid diagnosis and delivery have been shown to be advantageous.

    Once UCP is diagnosed, the fetal presenting part should be manually elevated off the cord, the patient placed in knee-chest or steep Trendelenburg position, and preparations made for cesarean delivery, unless vaginal delivery is imminent. In cases in which the time to delivery is anticipated to be prolonged, backfilling the bladder with approximately 500 mL of saline can safely be substituted for manual elevation of the presenting part. Figure 2 presents an algorithm for management of UCP. Team training exercises have been shown to shorten the interval between diagnosis and delivery and may lead to improved neonatal outcomes.

    If managed improperly, UCP can lead to significant fetal morbidity or mortality. Prompt, appropriate management of this condition, however, has been shown to have favorable overall outcomes.

     

    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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