Cord presentation and cord prolapse
Cord presentation: the cord lies below the presenting part with intact membranes. Cord prolapse: the cord lies in front of the presenting part (or in the vagina) after rupture of membranes. Prolapse occurs in about 1–6 per 1,000 births; the cord is compressed and goes into spasm, so the fetus becomes hypoxic within minutes.
Risk factors
- Anything that leaves room above the pelvis: malpresentation (breech, especially footling; transverse lie), high head, preterm or small fetus, polyhydramnios, multiple pregnancy (second twin), multiparity.
- Artificial rupture of membranes with a high head, external version, long cord.
Diagnosis
- Sudden fetal bradycardia or variable decelerations after rupture of membranes; the cord is felt or seen.
Emergency management
- Call for help; note the time; do not handle the cord (spasm) more than needed.
- Relieve compression: push the presenting part up with a hand in the vagina, or fill the bladder with 500 ml saline; knee–chest or exaggerated Sims position (Trendelenburg).
- Tocolysis (terbutaline) if contractions continue.
- Fastest delivery: category 1 caesarean section, unless the cervix is fully dilated and vaginal birth can be achieved quickly (instrumental or breech extraction).
- A neonatal team at the delivery.