II. Epidemiology
-
Incidence
- Vertex presentation: 0.4%
- Frank Breech: 0.5%
- Complete Breech: 4-6%
- Footling Breech: 15-18%
III. Pathophysiology
- Umbilical Cord Prolapses
- Frank cord presentation
- Cord prolapsed through Cervix
- Occult cord presentation
- Cord trapped alongside presenting part
- Frank cord presentation
- Follows Rupture of Membranes
- Occurs when presenting part is ill fitting
- Footling Breech Presentation
- Cephalopelvic Disproportion
- Fetal abnormality
- Fetal blood supply obstructed when cord out of Uterus
- Drop in Temperature of Prolapsed Cord
- Vasospasm of umbilical vessels
- Compression between pelvic brim and presenting part
IV. Risk factors
- Multiparity
- Prematurity
- Macrosomia
- Breech Presentation
- Polyhydramnios
- High Fetal Station
V. Signs
- Ill-fitting or non-engaged presenting part
- Prolapsed Umbilical Cord
- Umbilical Cord visualized in vagina or at vulva
- Umbilical Cord palpated on pelvic exam
-
Fetal Distress on Fetal Heart Tracing
- May follow Rupture of Membranes
VI. Management: General
- Emergent Cesarean Section
- Vaginal Delivery only if imminent
- Deliver as Intrauterine Fetal Demise if fetus has died
- Check for cord pulsations
- Check for fetal heart sounds
- Obstetric Ultrasound to assess heart activity
- Pre-hospital cord prolapse noted at home by patient
- Patient assumes deep knee-chest position
- Emergent transport to hospital
VII. Management: Temporizing measures to relieve cord pressure
- Adjust maternal position to reduce cord pressure
- Raise foot of the bed (Trendelenburg's Position)
- Sims' position
- Mother in left lateral decubitus position
- Genu-pectoral position
- Mother in knee-chest position
- Vaginal retrograde pressure applied to presenting part
- Hand in vagina elevates presenting part
- Mother should stop pushing
- Tocolysis with Terbutaline 0.25 mg SC
- Consider filling Bladder with 500-700 cc Saline
- Minimize handling of the cord
- Do not attempt to replace cord back into Uterus
- Cover cord with moist towel
VIII. Prognosis
- High perinatal mortality for delayed delivery >40 min
IX. Prevention
- Do not AROM if fetal head at high station