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Umbilical Cord Prolapse

Transcript: Umbilical Cord Prolapse Christabel Chan GW School of Medicine Class of 2022 Question 1 A 30-year-old woman, gravida 3 para 2, at 37 weeks gestation comes to labor and delivery for regular, painful contractions. The contractions started an hour ago and are now 3-4 minutes apart. She has had no leakage of fluid or vaginal bleeding. Fetal movement has been normal. At her prenatal visit last week, examination showed a cephalic fetal presentation; group B Streptococcus rectovaginal culture was negative. Today temperature is 36.7C, bood pressure is 110/80 mmHg, and pulse is 88/min. Fetal heart rate tracing shows moderate variability, multiple accelerations, and no decelerations. Tocodynamometer shows contractions every 3-4 minutes. The abdomen is nontender when contractions subside. On digital cervical examination, the cervis is 4cm dilated, 90% effaced, and a taut, bulging bag is palpable with no presenting fetal part. Which of the following is the best next step in management of this patient? A) Amniotomy B) Cesarean delivery C) External cephalic version D) Terbutaline tocolysis E) Transabdominal ultrasound Question 2 In occult umbilical cord prolapse (contained within the uterus), the umbilical cord is often compressed by a shoulder or the head. A fetal heart rate pattern that suggests cord compression and progression to hypoxemia may be the only clue. Which of the following characterizes that heart rate pattern? a) Episodic accelerations b) Fibrillation c) Moderate tachycardia d) Severe variable decelerations Introduction Presentation of umbilical cord prior to fetal parts Rare obstetric emergency Overt prolapse = cord exits prior to presenting fetal part Occult prolapse = cord exits with presenting fetal part Introduction Kumar A., George N. (2020) Cord Prolapse and Transverse Lie. In: Sharma A. (eds) Labour Room Emergencies. Springer, Singapore. https://doi.org/10.1007/978-981-10-4953-8_33 Question 3 Overt prolapse (protruding from the vagina) occurs with ruptured membranes and is more common with which of the following? a) Breech presentation b) Fetopelvic disproportion c) Multifetal pregnancy d) Vertex presentation Risk Factors Obstetric Risks Risk Factors Iatrogenic Risks Amniotomy SROM + high presentation External Cephalic Version Cervical ripening balloon IUP catheter Rotation of fetal head Poor prenatal care AMA Multiparity Non-cephalic (36.5%) Preterm labor SGA Polyhydramnios Non-engaged presenting part PPROM Male Pathophysiology Pathophysiology Etiology of cord prolapse typically unknown Potentially 2/2 rapid velocity of amniotic fluid carrying umbilical cord forward Cessation of blood flow to fetus resulting in hypoxia and asphyxiation Potential brain stem damage due to high metabolic rate Mechanical compression of Umbilical Cord by Fetal Presenting Part + Vasospasm Epidemiology Epidemiology 1.4-6.2 per 1000 Majority in single gestation Increased incidence in second twin in twin gestations Downtrend in incidence 1932: 0.6% 1990: 0.2% 2016: 0.018% Increased rates of C-section for breeched presentation contribute to downtrend Mean cervical dilation: 5.8cm Mean position: -1 Perinatal Outcomes Outcomes Perinatal mobidity: Low 5-min APGAR Ventilation requirement Acidotic cord blood gas Meconium aspiration Hyaline membrane disease Neonatal seizure Neonatal encephalopathy Cerebral Palsy Decreasing perinatal mortality & morbidity 1940s: 48% rate of stillbirth 2000s: 2.1% rate of stillbirth Predictors of favorable outcome Location of prolapse Diagnosis to delivery time period Birth weight Mode of delivery Question 4 A 30 year old woman, gravida 1 para 0, at 42 weeks gestation comes to the hospital with regular and painful uterine contractions. On admission, temperature is 36.1C, blood pressure is 110/70 mmHg, and pulse is 92/min. Estimated fetal weight is 3.8 kg (8.4lb). Digital cervical examination shows the cervix to be 4cm dilated and 100% effaced with the fetal vertex at 0 station. Fetal heart rate monitoring shows a baseline of 140/min, moderate variability, spontaneous accelerations, and no decelerations. An hour later, the patient is noted to have grossly ruptured membranes. Temperature is 37.2 C, blood pressure is 100/62 mmHg, and pulse is 100/min. ON repeat digital cervical examination, the cervix is 7 cm dilated and 100% effaced with the fetal vertex at +1 station. Fetal heart monitoring is showin in the exhibit. Which of the following is the most likely cause of this patient’s fetal heart rate pattern? A) Fetal head compression B) Placental abruption C) Postterm pregnancy D) Umbilical cord compression Evaluation Clinical dx: fetal bradycardia +/- sudden recurrent variable decelerations Evaluation Less commonly can present as palpation by provider of pulsating cord or visual appreciation of prolapsed cord prior to fetal presenting part US can show cord presentation between cervical os and fetus Differential Placental abruption (painful) Uterine rupture (painful) Vasa previa Management Management

Cord Prolapse

Transcript: Cord Prolapse Lizzie Stanton What is Cord Prolapse? What is it? Descent of the umbilical cord through the cervix either alongside (occult) or past (overt) the presenting part in the presence of rupture membranes. When the membranes are intact, it is called CORD PRESENTATION Types of Cord Prolapse Types • Cord is adjacent to the presenting part. • Cannot be palpated during pelvic examination. Might lead to variable decelerations or unexplained fetal distress • Cord is adjacent to the presenting part. • Cannot be palpated during pelvic examination. Might lead to variable decelerations or unexplained fetal distress (Funic cord presentation) • Prolapse of the umbilical cord below the level of the presenting part before the rupture of fetal membranes. • Cord can often be easily palpated through the membranes. Incidence • 0,1% to 0,6% of all births • 1% in breech presentations Incidence How can we reduce the likelihood of CP occuring? 1 Prevention 2 3 Risk Factors What risk factors can you think of? Risk Factors Intrapartum: Amniotomy Unengaged presenting part Prematurity Breech presentation Internal Podalic Version Second twin Disempactation of head during operative birth Large balloon cathether (IOL) Antenatal: Breech Presentation Multiparity Congenital Abnormailities Unstable Lie Polyhydramnious ECV Low birth weight Recognition Recognition • Umbilical cord visible/protruding from vagina • Cord palpable on vaginal examination • Abnormal FHR on auscultation/CTG (e.g. bradycardia, decelerations, prolonged deceleration) in the presence of ruptured membranes • Prompt vaginal examination is the most important aspect of diagnosis. Management What is important when dealing with this emergency? Management C O R D CALL FOR HELP! Calling For Help S O A N S Relieving Pressure from the Cord Relieve pressure Relieving Pressure from the Cord (continued) Consider tocolysis (terbutaline 0.25 mg subcutaneously). Stop oxytocin infusion if in progress. Consider Bladder Filling if Delay (500ml normal saline ) Fetal Wellbeing Fetal Monitoring • Continuous fetal monitoring should be performed. • If not audible fetal heart, an ultrasound scan should be performed. • If fetal compromise is suspected a grade one caesarean section should be performed. Expedite Delivery! • Emergency transfer to hospital labour ward. • Consider general or regional anaesthesia • IV Cannula and take blood for FBC and G+S EXPEDITE DELIVERY! • Cervix not fully dilated: Ceaserean Section immediately. • Cervix fully dilated: Consider assisted vaginal birth. • Breech extraction (i.e. after podalic version for the second twin). What type of delivery? • Experienced neonatal team must be present at birth. • Paired umbilical cord gases should be taken after birth to aid assessment of the neonatal condition. Post Birth Post Birth Document Debrief Datix (DoC) Professional Responsibilities

CORD PROLAPSE

Transcript: CORD PROLAPSE Contact Info Contact Info Sales Model More Explaining Use subtopics to make your point A Create a Subtopic B Customize the Cover C Insert Your Content Describe a Process: How it Works How does it all come together? Present visual materials Add Your Content Customer Overview Text Videos Images Symbols Where? What? Why? Global Issues Present Business Data Business Reports Q1 Q2 Q3 Q4 Contact Info Connect with Clients and Partners Contact Info Contact Info What's your prezi about? Introduction First Topic Contact Info Contact Info

Umbilical cord prolapse

Transcript: Because of the risk of low oxygen to the fetus it must be dealt with right away. This means that the baby may have to be delivered immediately by cesarean section. umbilical cord prolapse can cause a lot of danger to the fetus. during the delivery of the baby the fetus can put stress on the cord and this can result in a loss in oxygen to the fetus and could possibly cause stillbirth. Image by Tom Mooring Umbilical cord prolapse can be detected in a few different ways. During the delivery of the baby the doctor will use a fetal heart monitor to measure the baby's heart rate, if the cord is prolapsed then the baby could have bradycardia (a heart rate that is less than 120 beats per minute). The doctor may also do a pelvic examination where they would be able to see and feel the prolapse. Consequences there are no current ways to prevent umbilical cord prolapse. During delivery when the baby passes threw the vagina, this puts pressure on the cord which can cut slow down or cut off the baby's blood supply. Umbilical cord prolapse is a complication that occurs prior to or during the delivery of a baby. In a prolapse the cord drops threw the open cervix into the vagina ahead of the baby, the cord can then become trapped against the baby's body during delivery What is umbilical cord prolapse? If the problem can be solved immediately there may be no permanent harm or injury to the baby. Longer delay means it is a greater risk and a greater chance of problems such as brain damage or death of the baby. Causes when is fetus affected during pregnancy? *Happens in approximately 1 in every 300 births Umbilical cord prolapse Prolapse in a breech delivery How is it managed? -premature delivery of the baby -delivering more then one baby per pregnancy (twins, triplets, ect...) -breech delivery (baby comes out feet first) -a umbilical cord that is longer than usual Feeling the baby's umbilical cord before the baby's delivery is a symptom How it is detected Symptoms Effects on the baby Prevention

Cord prolapse

Transcript: Cord BEH2421 Paramedic Management of Maternal & Nonatal Health prolapse Introduction Student: Afra Saeed AlBaloshi ID : A0032778 (First semester) Submitted to : Scott Cottam The Scope of presentation 1 Physiology and pathophysiology Risk factor & signs & symptoms History taking & resources Time factors during the management Clinical practice guidelines management 2 3 4 How important is cord prolapse to Paramedic Management of Maternal and Neonatal Health? Important About Cord prolapse is an obstetric complication which puts the fetus’s life in danger and is seen in 1 of 300 births (Cleveland Clinic, 2014). Physiology & pathophysiology Risk Factors 1.A long umbilical cord. 2.Malposition of the fetus and small size. 3.Condition called “poly hydramnios”, where the amniotic fluid is more than required in amniotic sac. 4.Pelvic malformations. 5.Multiparty. 6.Cephalopelvic disproportion where the head of the baby is larger than the pelvis ( Woolard, Simpson, Hinshaw and Wieteska, 2010). Sign & Symptoms Only vaginal inspection during the physical examination. If the cord is seen descending the cervix at the vaginal opening, then it is cord prolapse (Queensland Ambulance Service, 2016). History History taking 1. If the delivery is imminent or not? 2. If so, then it is important to know if there are any complications. 3. What the actual date of the delivery and gestation age. 4. Ask if it the first delivery and about any complications faced during previous childbirths. 5. Assessment should be continued on monitoring maternal vital signs 6. SAMPLE (Pollak, Elling & Smith, 2016). Resources available 1. Pillow position 2. Oxygen 3. Sterile dressing 4. Two fingers gently cord can be replaced if it is recommended 5. Caesarean section Time factor Clinical practice Time factors to be considered during the management of cord prolapse Clinical practice guidelines for the prehospital management of cord prolapse The amount of time to be spent on scene depends on the condition of the patient based on the history and physical. If the delivery is not imminent and there is time to reach hospital, transport should be initiated while continuously monitoring the patient. Most of the time, complicated deliveries need caesarean section.(Pollak, Elling & Smith, 2016). 1.TIME CRITICAL transfer. 2. Rapid removal of the patient and quick transfer needs. 3.During transport, main goal is to preserve the blood supply to the fetus. 4. If replacing the cord is not done, cover it with dry paddings to keep it warm and moist within the vagina. 5. Position the mother on the left lateral side with raised pelvis by keeping pillows or pads under the hips. 6.Entonox has to be administered (Brown, Kumar and Millins, 2016). Clinical practice guidelines Video Conclusion https://www.youtube.com/watch?v=df1KR2PC6Ik Questions Brown,S.N., Kumar, D., and Millins,M. (2016). UK Ambulance Services Clinical Practice Guidelines 2016. Bridgwater, TA: Class Professional Publication. Cleveland Clinic. (2014). Umbilical cord Prolapse. Retrieved from https://my.clevelandclinic.org/health/diseases/12345-umbilical-cord-prolapse Pollak,A.N., Elling,B., & Smith,M. (2016). Nancy Caroline’s Emergency Care in the Streets (7th ed.). Burlington, MA: Jones and Bartlett Learning. Queensland Ambulance Service (2016). Clinical Practice Guidelines: Obstetrics/Cord Prolapse. Retrieved from https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Cord%20prolapse.pdf Woolard,M., Simpson,H., Hinshaw,K. and Wieteska,S. (2010). Pre-hospital Obstetric Emergency Training. United Kingdom: Wiley- Blackwell. References

PowerPoint Game Templates

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CORD PROLAPSE

Transcript: by: OB-GYNE AND L &D DEPARTMENT INTRODUCTION AND LEARNING OBJECTIVES CORD PROLAPSE INTRODUCTION AND LEARNING OBJECTIVES 1.Define cord prolapse and the related terms. 2. Understand the patient data. 3.Explain the disease condition and risk factors. 4. Describe the maternal and fetal complications. 5. Explain the nursing management given to the patient. 6. Provide health education to the patient PATIENT DATA ON 14/12/2019 AT:-1730 HRS Mrs. Xxxx. 29 Years old, Syrian female non eligible,G5 P4 A0, 39 weeks of gestation came to E.R in active labor pain, breach presentation and cord prolapse as per the doctor in duty. AT:-1745 HRS Patient was admitted direct to labor and delivery room for further observation & management. Routine Admission procedure and Laboratory examination done. She was conscious, coherent with cardiotocography showing decrease in variability from ER to L & D With the following Vital Signs: BP= 110/70 mmHg PR= 75 bpm RR= 20 /bpm Temp= 37⁰C FHR = 148bpm weight = 63 kg. Height = 150cm BMI = PAIN SCORE=7/10 CONT History of Present illness She is diagnosed case of breech in presentation, cord prolapse. Chief Complaint 39 week pregnancy with lower abdominal pain. CONT Obstetric history: Gravida 5 Para 4 Abortion 0 Living 4 Menstrual history: LMP:13/03/2018 EDD:- 18-12-2018 CONT Not hypertensive , Not diabetic, no history of thyroid disorders PAST MEDICAL/SURGICAL HISTORY: CONT Family history: Insignificant PSYCHO SOCIAL HISTORY : Insignificant PHYSICAL ASSESSMENT : Head, Neck, Eyes: NAD Chest: NAD Breast: NAD Heart : Regular rhythm ABDOMEN • Abdomen is soft Fundal height - 39 cm,lie longitudinal, breach presentation. FHR 148bpm with contraction. GENITOURINARY VAGINAL EXAMINATION fully dilated. Bilateral extremities : no edema, no varicosities CONT At 1755 hrs:- Patient delivered AN ALIVE BABY GIRL DELIVERED BY NVD FOOTLING BREECH, CORD PROLAPSE, CONDUCTED BY DRA. GHAZALA. BABY NOT CRIED IMMEDIATELY AT BIRTH. KEPT WARM UNDER PREHEATED RADIANT WARMER. BABY ATTENDED BY PEDIATRICIAN DR. ABDUL AZIZ. BABY WT - 2.33 KG , APGAR OF 3 IN 1 MINUTE, 5 IN 5 MINUTES AND 6 IN 10 MINUTES ADMITTED TO NICU FOR OBSERVATION. BABY HAS CONGENITAL ANOMALY AS PER PEDIATRICIAN. 1815H-UTERINE MASSAGE GIVEN. WELL CONTRACTED UTERUS. NORMAL LOCHIA NOTED. VITALS SIGNS MONITORED. STABLE. . CONT AT 2040H: shifted patient to ob/gyne ward . As post normal vaginal delivery with intact perineum CONT B.P 126/75 mmofHg, Pulse- 64bpm, Respiration-18 bpm, Temperature 37c. Spo2- 100%. Normal lochea. Well contracted uterus voiding freely. 15/12/2018 AT 0840H- Mother discharge in good condition. Where? What? Why? DEFINITION OF TERMS Present visual materials Add Your Content ANATOMY & PHYSIOLOGY Text Videos Images Symbols Describe a Process: How it Works How does it all come together? Present Business Data Business Reports Q1 Q2 Q3 Q4 Contact Info Sales Model More Explaining Use subtopics to make your point A Create a Subtopic B Customize the Cover C Insert Your Content Contact Info What's your prezi about? Introduction First Topic Contact Info Connect with Clients and Partners Contact Info 1 Contact Info

Umbilical Cord Prolapse

Transcript: Resources Unique Facts posibility of emergency c-section Possible complications Non-preventable Possible causes -preterm premature ROM/ROM -Malpresentation -Multiple gestation -Hyperactivity Diagnostic Tests/Monitoring Goal: reduce fetal hypoxia The fall of the umbilical cord through the cervix. The cord is squeezed between the fetal presenting part and the soft tissue or the bony pelvis, which can lead to fatal hypoxia. insert 2 fingers, they are to be placed between the pelvic inlet and the cord use a foley cath and an IV infusion kit and insert 500-750 ml of normal saline into the bladder. do this until you can see it distended above the pubic symphysis. This takes pressure off the cord because it allows the presenting part to move away from the cord. Assesment Interventions Types Occult : the cord goes through the cervix beside the fetal presenting part. It can not be seen or palpated. Overt : the cord is able to be seen and is palpable. It is presented before the fetal presenting part. Membrane rupture (often found after) Monitor fetal heart rate - can lead to variable decelerations (irregular, jagged dips in the fetal heart rate) - HR = <115 bpm, last no more than 15 sec. but less than 10 min. vaginal examination Patient Teaching done through vaginal examination - palpate the umbilical cord doppler ultrasound transvaginal ultrasond * occult diagnosis is very uncommon it can not be determined definitively even when using ultrasound. Potential Outcomes Umbilical Cord Prolapse reposition client - place in knee-chest - place in Trendelburg postions UPC neonates often do well. More than likley if they are delivered within 30 minutes. Can lead to brain damage due to decrease in oxygen reaching the fetus. the severity depends on how long the fetus went with decreased oxygen levels. Death Administer 10ml oxygen to the mother to help increase oxygenation to the fetus amniofusion - add sterile fluid to the uterus to supplement amniotic fluid to reduce pressure c-sections keep cord from drying by applying sterile saline Tocolytics (anti-contraction meds) are not used as a primary form of care. They are usually used only when decelerations still continue after implementing other forms of primamry care such as repositioning. If the cord protrudes through the vaginal opening it should be reinserted into the vagina. A tampon soaked in sterile saline or 4x4 gauze should be placed below the cord to prevent it from drying. Definition

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