Seminar
On
Cord Prolapse
On
Cord Prolapse
Submitted to :
Mrs. Padmavathi
Lecturer , N.C.O.N. ,Raichur
Submitted by:
Felix Joseph
IVth B.Sc Nursing ,N.C.O.N ,Raichur
Mrs. PadmavathiLecturer , N.C.O.N. ,Raichur
Submitted by:
Felix JosephIVth B.Sc Nursing ,N.C.O.N ,Raichur
Introduction
Umbilical cord prolapse is an obstetric emergency during pregnancy or labour that endangers the life of fetus. It occurs when the umbilical cord presents itself outside of the uterus while the fetus is still inside. It can happen when the water breaks- with the ush of water the cord comes along. Usually, thereafter the fetus will engage & squash the cord, cutting off oxygen supplies & leading to brain damage of he fetus or still birth. Before that happens, the baby must be delivered quickly by caesarean section.
Definition
“Cord prolapse” is when the umbilical cord exits the birth canal prior to baby. If cord prolapse occurs, the blood and oxygen flow to the baby can be interrupted or severed, which can cause tissue, oxygen or brain damage.
Incidence:
1 in 200 pregnancies
A cord prolpse can occur 20 times more often with a transverse lie than with an oblique or cephalic.
It ranges from 0.14 – 0.62%
Etiology
2 major etiologic categories are:
1. Fetomaternal factors
2. Obstetric factors
The main fetomaternal factors are:-
Obstetric intervention
Risk factors
Breech presentation
PROM (Premature rupture of the amniotic sac)
Large fetus
Multiple gestations
Long cord
Preterm labor
Abnormal presentations:-
Footling breech in particularly risk
Cephalo-pelvic disproportion
Pelvic tumours
Placenta praevia
Low lying placenta
Macrosomia
Overt Cord Prolapse:
If the presenting part of the fetus does not fix the pelvis snugly after membrane rupture, there is a risk that the umbilical cord can slip past & present at the cervix or descend into the vagina. This is known as overt cord prolapse. Depending on its duration and degree of compression, fetal hypoxia, brain damage and even death can occur.
Occult prolapse:
Occur when the cord descends alongside, but not past, the presenting part. It can occur with intact or ruptured membranes. The diagnosis should be considered in the setting of a sudden, prolonged fetal heart rate deceleration. An occult prolapse often cannot be diagnosed with certainty, but is suggested by clinical features (eg. Fetal bradycardia) & findings at cesarean delivery.
Funic Presentation:
Where the cord can be felt to prolapse below presenting part before the membranes have ruptured. The cord may slip to one side of the head and disappeared as the membranes rupture.
Diagnostic evaluation:
History collection
Physical examination
Ultra sound – It has been used as an adjustment to diagnose cases where cord presentation is suspected. When cord presentation is identified as an incidental finding, follow-up scans have been recommended to determine the mode of delivery.
Visual sight of cord prolapse in vagina or cord felt on vaginal examination.
Overt > Overt can be scan protruding from the introits or loops of cord can be palpated within the vaginal canal. If the cord is pulsating, the fetus is alive.
Occult > It rarely felt on pelvic examination and the only indication may be fetal heart rate changes.
Funic > loops of cord are palpated through the membrane.
Colour Doppler studies
Clinical features:
9 An ill fitting or non-engaged presenting part should alert one of the possibilities of the cord.
9 Variable fetal heart rate decelerations are seen during uterine contractions that promptly return to normal after contraction subsides.
9 With prolonged and complete compression bradycardia occurs.
9 With deteriorating fetal status activity diminishes and eventually stops.
Management :
1. Immediate vaginal examination to replace the cord into vagina. Confirm presence of fetal heart. (Palpate the presence or absence of pulsation in the cord.)
2. To relieve cord compression :-
a. If the cord is outside of the introitus, replace the cord gently into the vagina. This is important to reduce spasm of umbilical vessels due to colder temperature outside the vagina & to prevent rough handling of cord.
b. The cord is cradled in the palm of the hand with the tips of the fingers try to elevate the presenting part to relieve or prevent cord compression.
Treatment :
Asses & support maternal ABC’s
Rapid transport
Refer to the obstetrics protocol
To prevent fetal esphyxia, if the cord is visible or palpable in the vagina.
Position the mother with hips, elevated as much as possible
OR
In TRENDDENSBURG position
OR
In a knee-chest position
Administer supplemental oxygen to the mother.
Instruct the mother to “plant” with each contraction to prevent bearing down.
Assess fetal viability by checking for a palpable pulse in the cord.
Apply moist ssterile dressings to the exposed cord; handle the cord carefully.
With a gloved hand, gently push the fetus back into the vagina and elevate the presenting part off the cord. If the cord spontaneously retracts, do not attempt to reposition it.
Periodically reassess fetal viability by confirming the presence of a palpable pulse in the cord.
This position must be maintained in route and until the infant can be delivered by emergency C-section.
Prevention:
Treat high-risk patient with constant fetal monitoring during delivery.
Do not artificially rupture membranes if presenting part is high.
Identifying patients at risk for cord prolapse and avoiding unnecessary obstetric interventions in these at risk patients may prevent some cases of cord prolapse.
Nursing Management:
Nursing diagnosis1.
Acute pain related to disease condition
Assess the severity of pain.
Provide comfortable position.
Advice the patient to take rest.
Encourage the patient to take analgesics as per order.
---------> Patient will get relief from pain
Nursing diagnosis2 :
High risk of injury to fetus related to cord compression and uteroplacental insufficiency
Assess the condition of fetus.
Check the vagina for cord.
Provide knee- chest position.
Prepare the patient for immediate delivery.
----------> Injury to the fetus will be reduced
Nursing diagnosis 3
Knowledge deficit related to life threatening condition of fetus.
Assess the knowledge level of patient.
Record fetal heart rate.
Explain normal pre-operative procedures.
Explain about the causes of prolapsed cord.
Clear the doubt about the condition.
-------Patient will understand about cord prolapse.
Nursing diagnosis 4 :
Fear and anxiety related to potential loss of fetus.
Assess the patient’s awareness and understanding of situation.
Explain all actions taken.
Encourage patient to verbalize concerns.
Observe non-verbal signs of fear and anxiety.
-------> Patient’s fear will reduce.
Nursing diagnosis 5:
Altered family process related to hospitalization.
Provide emotional and psychological support to family members.
Advice about post partum checks up.
Provide self care and infant care and infant care based on learning needs.
Encourage verbalization of feelings related to delivery and hospitalization.
---------> Family members will make realistic plans for self and infant care.
Reference Links
What is it?
Reference at WHO
Management of a Prolapsed Cord
Guidelines for management of cord prolapse (pdf)
Powerpoint presentation on Cord prolapse can be downlaoded from the folllowing link!!
Please click here to open/download the presentation
Thank you
(felixwings@gmail.com)
Umbilical cord prolapse is an obstetric emergency during pregnancy or labour that endangers the life of fetus. It occurs when the umbilical cord presents itself outside of the uterus while the fetus is still inside. It can happen when the water breaks- with the ush of water the cord comes along. Usually, thereafter the fetus will engage & squash the cord, cutting off oxygen supplies & leading to brain damage of he fetus or still birth. Before that happens, the baby must be delivered quickly by caesarean section.
Definition
“Cord prolapse” is when the umbilical cord exits the birth canal prior to baby. If cord prolapse occurs, the blood and oxygen flow to the baby can be interrupted or severed, which can cause tissue, oxygen or brain damage.
Incidence:
1 in 200 pregnancies
A cord prolpse can occur 20 times more often with a transverse lie than with an oblique or cephalic.
It ranges from 0.14 – 0.62%
Etiology
2 major etiologic categories are:
1. Fetomaternal factors
2. Obstetric factors
The main fetomaternal factors are:-
- Fetal malpresentation
- Prematurity
- Multiple gestation
- Multiparity
- Rupture of membranes
- Polyhydramnios
Obstetric intervention
- Artificial rupture of membranes
- Internal scalp electrode application
- Intra uterine pressure
- Catheter replacement
- Forceps or vacuum application
- Manual rotation of fetal head
- Amnio infusion & external cephalic version.
Risk factors
Breech presentation
PROM (Premature rupture of the amniotic sac)
Large fetus
Multiple gestations
Long cord
Preterm labor
Abnormal presentations:-
Footling breech in particularly risk
Cephalo-pelvic disproportion
Pelvic tumours
Placenta praevia
Low lying placenta
Macrosomia
Types
Overt prolapse
Occult prolapse
Funic presentation
Overt prolapse
Occult prolapse
Funic presentation
Overt Cord Prolapse:
If the presenting part of the fetus does not fix the pelvis snugly after membrane rupture, there is a risk that the umbilical cord can slip past & present at the cervix or descend into the vagina. This is known as overt cord prolapse. Depending on its duration and degree of compression, fetal hypoxia, brain damage and even death can occur.
Occult prolapse:
Occur when the cord descends alongside, but not past, the presenting part. It can occur with intact or ruptured membranes. The diagnosis should be considered in the setting of a sudden, prolonged fetal heart rate deceleration. An occult prolapse often cannot be diagnosed with certainty, but is suggested by clinical features (eg. Fetal bradycardia) & findings at cesarean delivery.
Funic Presentation:
Where the cord can be felt to prolapse below presenting part before the membranes have ruptured. The cord may slip to one side of the head and disappeared as the membranes rupture.
Diagnostic evaluation:
History collection
Physical examination
Ultra sound – It has been used as an adjustment to diagnose cases where cord presentation is suspected. When cord presentation is identified as an incidental finding, follow-up scans have been recommended to determine the mode of delivery.
Visual sight of cord prolapse in vagina or cord felt on vaginal examination.
Overt > Overt can be scan protruding from the introits or loops of cord can be palpated within the vaginal canal. If the cord is pulsating, the fetus is alive.
Occult > It rarely felt on pelvic examination and the only indication may be fetal heart rate changes.
Funic > loops of cord are palpated through the membrane.
Colour Doppler studies
Clinical features:
9 An ill fitting or non-engaged presenting part should alert one of the possibilities of the cord.
9 Variable fetal heart rate decelerations are seen during uterine contractions that promptly return to normal after contraction subsides.
9 With prolonged and complete compression bradycardia occurs.
9 With deteriorating fetal status activity diminishes and eventually stops.
Management :
1. Immediate vaginal examination to replace the cord into vagina. Confirm presence of fetal heart. (Palpate the presence or absence of pulsation in the cord.)
2. To relieve cord compression :-
a. If the cord is outside of the introitus, replace the cord gently into the vagina. This is important to reduce spasm of umbilical vessels due to colder temperature outside the vagina & to prevent rough handling of cord.
b. The cord is cradled in the palm of the hand with the tips of the fingers try to elevate the presenting part to relieve or prevent cord compression.
Treatment :
Asses & support maternal ABC’s
Rapid transport
Refer to the obstetrics protocol
To prevent fetal esphyxia, if the cord is visible or palpable in the vagina.
Position the mother with hips, elevated as much as possible
OR
In TRENDDENSBURG position
OR
In a knee-chest position
Administer supplemental oxygen to the mother.
Instruct the mother to “plant” with each contraction to prevent bearing down.
Assess fetal viability by checking for a palpable pulse in the cord.
Apply moist ssterile dressings to the exposed cord; handle the cord carefully.
With a gloved hand, gently push the fetus back into the vagina and elevate the presenting part off the cord. If the cord spontaneously retracts, do not attempt to reposition it.
Periodically reassess fetal viability by confirming the presence of a palpable pulse in the cord.
This position must be maintained in route and until the infant can be delivered by emergency C-section.
Prevention:
Treat high-risk patient with constant fetal monitoring during delivery.
Do not artificially rupture membranes if presenting part is high.
Identifying patients at risk for cord prolapse and avoiding unnecessary obstetric interventions in these at risk patients may prevent some cases of cord prolapse.
Nursing Management:
- Acute pain related to disease condition
- High risk of injury to fetus related to cord compression and uteroplacental insufficiency.
- Knowledge deficit related to life threatening condition of fetus.
- Fear and anxiety related to potential loss of fetus.
- Altered family process related to hospitalization.
Nursing diagnosis1.
Acute pain related to disease condition
Assess the severity of pain.
Provide comfortable position.
Advice the patient to take rest.
Encourage the patient to take analgesics as per order.
---------> Patient will get relief from pain
Nursing diagnosis2 :
High risk of injury to fetus related to cord compression and uteroplacental insufficiency
Assess the condition of fetus.
Check the vagina for cord.
Provide knee- chest position.
Prepare the patient for immediate delivery.
----------> Injury to the fetus will be reduced
Nursing diagnosis 3
Knowledge deficit related to life threatening condition of fetus.
Assess the knowledge level of patient.
Record fetal heart rate.
Explain normal pre-operative procedures.
Explain about the causes of prolapsed cord.
Clear the doubt about the condition.
-------Patient will understand about cord prolapse.
Nursing diagnosis 4 :
Fear and anxiety related to potential loss of fetus.
Assess the patient’s awareness and understanding of situation.
Explain all actions taken.
Encourage patient to verbalize concerns.
Observe non-verbal signs of fear and anxiety.
-------> Patient’s fear will reduce.
Nursing diagnosis 5:
Altered family process related to hospitalization.
Provide emotional and psychological support to family members.
Advice about post partum checks up.
Provide self care and infant care and infant care based on learning needs.
Encourage verbalization of feelings related to delivery and hospitalization.
---------> Family members will make realistic plans for self and infant care.
Reference Links
What is it?
Reference at WHO
Management of a Prolapsed Cord
Guidelines for management of cord prolapse (pdf)
Powerpoint presentation on Cord prolapse can be downlaoded from the folllowing link!!
Please click here to open/download the presentation
Thank you
(felixwings@gmail.com)
