Prolapsed Umbilical Cord

• Prolapse of the umbilical cord

  Where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus

  
• During delivery, the prolapsed cord


  Can become compressed by baby's body

  
• Umbilical cord


  Delivers blood from the placenta to the baby, cord prolapse can compromise a baby's oxygen supply

  
• It must be dealt with immediately so the fetus doesn't put pressure on the cord, cutting off oxygen

  
• Fetal hypoxia occurs via two main mechanisms


  1. Occlusion - The presenting part of the fetus presses onto the umbilical cord, occluding blood flow to the fetus

  2. Arterial vasospasm - The exposure of the umbilical cord to the cold atmosphere results in umbilical arterial vasospasm, reducing blood flow to the fetus

  
• Pregnancy complications that may increase the risk of cord prolapse

  • Breech delivery
  • Delivering two or more babies vaginally (the second baby is more likely to experience cord prolapse)
  • Preterm labor
  • Polyhydramnios
  • Prolonged labor
  • Low-lying placenta
  • Intrauterine tumors preventing the presenting part from engaging
  • CPD

  
• Pelvic Exam/Vaginal Examination


  Seeing or palpating the prolapsed cord + The fetus may have an abnormal fetal heart rate (Bradycardia - a heart rate of less than 120 beats per minute)

  
• Preparation for vaginal examination

  1. The bladder must be empty

  2. The procedure must be carefully explained to the patient

  3. The patient is put in the dorsal or lithotomy position (the dorsal position is more comfortable and less embarrassing than the lithotomy position and does not require any equipment)
• Fetal attitude


  Describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other
• Good attitude


  Is in complete flexion "Universal flexion"
• Fetal engagement


  Refers to the settling of the presenting part of a fetus far enough into the pelvis to be at the level of the ischial spines

  
• Floating


  Presenting part that is not engaged
• Dipping


  One that is descending but has not yet reached the ischial spines
• Fetal station


  Refers to the relationship of the presenting part of a fetus to the level of the ischial spines
• Station 0


  When the presenting fetal parts is at the level of the ischial spine, synonymous with Engagement
• Above the ischial spine

  The distance is measured & described as minus stations
• Below the ischial spine

  The distance is stated as plus stations
• Fetal position


  Relationship of the chosen portion of the fetal presenting part to 1 of the 4 quadrants or transverse diameter of birth canal
• Determining points used in defining fetal position

  • O - Occiput (Cephalic/Vertex Presentation)
  • M - Mentum or Chin (Face Presentation)
  • S - Sacrum (Breech Presentation)
  • A - Acromion or Scapula (Shoulder Presentation)
• Fetal position abbreviation


  The middle letter denotes the fetal landmark (O, M, Sa, A)

  The first letter defines whether the landmark is pointing to the mother's right (R) or left (L)

  The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T)
• Fetal positions


  • LOA
  • LOP
  • ROA
• Posterior occiput (OP)


  Occiput - The back of the head or skull, caused by the adaptation of the fetal head to a pelvis having a narrow fore pelvis
• Before labor, 15-20% of term fetuses in cephalic presentation are OP, but only 5% are OP at vaginal delivery
• Most OP fetuses spontaneously rotate to an anterior position (OA) during labor, some persistent OP positions may be due to an android maternal pelvis which can inhibit rotation to the occiput anterior (OA) position
• Why posterior position matters in labor

  The head is angled so that it measures larger, the top of the head molds less than the crown
• Left Occipito Posterior (LOP)


  Is the most common fetal malposition, can lead to more back pain, slow progression of labor

  
• Right Occipito Posterior (ROP)


  The fetus is facing forward and slightly to the right, may slow labor and cause more pain, forceps are often used to deliver babies in this position

  
• Right Occipital Anterior (ROA)


  The back of the baby is slightly off center in the pelvis with the back of the head toward the mother's right thigh
• Left Occipito Anterior (LOA)


  The baby's head is slightly off center in the pelvis with the back of the head toward the mother's left thigh, usually the easiest position for the fetal head to traverse the maternal pelvis
• Transverse Occiput (OT)


  A type of fetal cephalic malposition in which the sagittal suture and fontanels align in the transverse plane of the maternal pelvis or are <15 degrees from the transverse plane

  
• Left Occipito Transverse (LOT)


  When facing out toward the mother's right thigh, is an ideal starting position for labor
• Right Occipito Transverse (ROT)


  When the baby is facing outward toward the mother's left thigh, is halfway between a posterior and anterior position
• Fetal malpresentations


  Refers to abnormal fetal vertex positions in relation to the maternal pelvis
• Vertex position


  The position your baby needs to be in for you to give birth vaginally (Head down)
• Breech


  A breech baby has their buttocks coming into mother's pelvis before the head, usually the buttocks will be born first, less often the feet or knees emerge first
• Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester

  • Placenta previa - As the placenta is occupying the inferior portion of the uterine cavity, therefore the presenting part cannot engage
  • Uterine myoma - Mainly larger myomas located in the lower uterine segment, often intramural or submucosal, that prevent engagement

  
• Fetal Presenting Part


  The part of the fetus which is the first to proceed into and through the pelvic inlet
• Breech


  A breech baby has their buttocks coming into mother's pelvis before the head. Usually, the buttocks will be born first, less often the feet or knees emerge first (Closest to the cervix)
• Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester

  • Placenta previa
  • Uterine myoma
  • Oligohydramnios
  • Polyhydramnios
  • Fetal neuromuscular disorders
  • Prematurity

  
• 3 Main Breech Positions

  • Frank breech
  • Complete breech
  • Footling breech