Launceston General Hospital Clinical Guideline SDMS ID: P2010/0497-001 2.

10/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: Umbilical cord prolapse is an obstetric emergency demanding immediate attention. Delay in management is associated with significant perinatal morbidity and mortality, due mainly to complications associated with preterm birth and birth asphyxia. Definition: Cord Prolapse: Where the umbilical cord lies in front or beside the presenting part in the presence of rupture membranes. Cord Presentation: Where the umbilical cord lies in front of the presenting part and the membranes are intact. Risk factors: Multiparity Low birth weight (less than 2.5kg) Prematurity Fetal congenital anomalies Breech presentation Transverse, oblique and unstable lie Second twin Polyhydramnios Unengaged presenting part Low lying placenta, other abnormal placentation Procedure related risk factors: Artificial rupture of membranes Vaginal manipulation of the fetus with ruptured membranes External cephalic version Internal podalic version 50% of cord prolapse are preceded by obstetric manipulations (RCOG 2008). Diagnosis: Visible cord at introitus Cord maybe unexpectedly palpated during vaginal examination (on diagnosis take note of whether the cord is pulsating or not). Cord prolapse should be suspected where there is a non-reassuring fetal heart rate pattern (bradycardia, variable decelerations etc), particularly if such changes commence soon after membrane rupture, spontaneously or with amniotomy.
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Umbilical Cord Prolapse Umbilical Cord Prolapse WACSClinProc2.10/06 Management of umbilical cord prolapse with a viable fetus Midwives and medical officers Umbilical cord prolapse

Management: This is dependent on the presence of fetal heart rate or cord pulsation. Call for help Explain to woman and support people nature of the emergency Position woman in knee chest or left lateral. Attempt to keep pressure of the presenting part off the cord by pushing the presenting part up and away from the cord. This needs to be maintained until the baby is born. To prevent vasospasm there should be minimal handling of loops of cord lying outside the vagina. Discontinue oxytocics Continuous fetal monitoring Administer maternal oxygen Consider tocolysis - Terbutaline 250 micrograms administered subcutaneously Plan for delivery of fetus as soon as possible. o If fully dilated expedient vaginal birth by maternal effort or assisted vaginal delivery o Immediate caesarean section if not fully dilated and/or vertex above spines and/or malpresentation and/or malposition Where there is a delay for transfer to theatre, elevation of the presenting part can also be achieved by filling the maternal bladder. Insert a Foleys catheter and then use a giving set to instil 500 to 750ml of normal saline. Clamp the catheter. It is essential to empty the bladder prior to any delivery attempts.

If the fetus is not viable, labour should proceed to vaginal birth.

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Attachments
Attachment 1

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 3/09/09

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APPENDIX 1 REFERENCES American Academy of Family Physicians 2000 Advanced life support in obstetrics (ALSO) course syllabus (4th edn). American Academy of Family Physicians, Kansas Enkin M, Keirse J, Neilsen J et al 2000 A guide to effective care in pregnancy and childbirth. Oxford University Press, London Lim M 2006 Umbilical cord prolapse Obstetrical and Gynaecological Survey 2006 61(4): 269 -277. Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia Royal College of Obstetricians 2008 Guideline Umbilical cord prolapse Online: http://www.rcog.org.uk/index.asp?PageID=2384 Womens Hospital Australasia Clinical Practise Guidelines 2005 Cord Prolapse Online: http://www.wcha.asn.au/index.cfm/spid/1_47.cfm

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