1. Dr.Suresh Babu Chaduvula
Professor
Department of Obstetrics & Gynecology
King Khalid University
Abha, Saudi Arabia

2. 
To provide information and practical guidance to
enable early diagnosis and efficient initiation of
emergency procedures to ensure the best
possible neonatal outcome

3.  Umbilical
cord presentation: Presence of
cord in front of presenting part before the
rupture of membranes.
 Umbilical
cord prolapse: Descent of
umbilical cord following rupture of the
membranes, through the cervix so that it lies
either along side the fetal part or in front of
presenting part into the cervix/ and into or
out of vagina.

6.  Occult
prolapse – Cord lies adjacent to the
presenting part, but not beyond the
presenting part in the presence of intact or
without intact membranes.
 Overt
prolapse – cord which is visible or
palpable with naked eyes following rupture
of membranes.

8.  Identify
predisposing risk factors
 Enable prompt diagnosis and institute
immediate action
 Initiate correct emergency procedures
 Raise awareness of the neonatal implications

9.  Over
all incidence – 0.1% -0.6%
 Primi gravida – 0.4 %
 Multi gravida – 0.6 %
 Cephalic presentation – 0.3 %
 Breech - Frank – 0.9 %
- Complete – 5 %
- Footling – 10 %
 Shoulder presentation – 15 %
 Contracted pelvis – 4-6 times more.

10.  Non
engagement of fetal head:
1.Unengaged or poorly applied presenting part
2. High parity - weak muscles
3. Unstable lie – weak muscles
4. Malpresentations
5. Breech presentations

11.  Related
1.
2.
3.
4.
to Uterine and Pelvic factors:
Polyhydramnios
Long umbilical cord
Low lying placenta
Contracted Pelvis

12.  Related
to Fetal factors:
1. Prematurity
2. Low Birth Weight
3. Second twin
4. Congenital malformations

13.  Related
to clinical procedures:
1. ARM in high presenting part
2. External cephalic version
3. Stabilizing induction of labor
4. Manual rotation of fetal head in OP position
5. Application of fetal scalp electrode
6. Internal podalic version of second twin

14.  Other
causes
1. PROM
2. Male fetuses
3. Anomalies of uterus

15.  Neonatal
morbidity and Mortality – as high
as 50 % due to
1. Hypoxia - is due to cord compression by
the presenting part and also due to
vasospasm of umbilical vessels
2. Operative trauma
3. Delay in transport
4. Congenital malformations
5. Prematurity
 Maternal morbidity :

16.  Overt
cord can be seen in the vagina or
outside the vagina- feel pulsations
 Variable deceleration and bradycardia on
CTG following rupture of membranes.
 Fetal bradycardia – following fundal pressure
 Meconium stained liquor

17.  Ultrasound
examination for malpresentation
and cord presentation.
 Avoid ARM in unengaged head
 Routinely doing PVE following spontaneous
rupture of membranes.
 Controlled ARM in poly hydramnios –
Stabilizing induction.
 Bradycardia and variable decelerations - do
either vaginal examination or speculum
examination

18.  Depends
upon viability of the fetus and
absence of fetal malformations.
 Quick action should be taken to expedite the
delivery.
 Survival of fetus depends on swift action
Prepare for Emergency interventions like
Cesarean section and or Instrumental
delivery.
 Multidisciplinary approach or Team work is
required

19.  Discontinue
 Oxygen
 CORD
IV oxytocin infusion
by mask – 15 lits/ mt
– C – call for help
- O – organize for delivery
- R – Relieve pressure
- D – Delivery
Funic repositioning: with soaked warm saline
reposition into vagina

20.  Avoid
presenting part pressure over cord by
digital or manual pressure.
 Instruct the patient to not to exert pressure
or pushing.
 Bladder filling with 500 700 ml of saline.
 Tocolysis? Inj.Terbutaline 250 microgams SCly
 Positioning of the patient:
1. Knee chest position
2. Trendelenburg position
3. Exaggerated Sims or lateral position

24. Do’s –
 Replace the cord into the vagina to prevent
from vasospasm with saline soaked pad
 Continuous monitoring of FHR
 Inform the patient
 Minimal handling of cord
Don'ts –
Replace inside the uterus
Excessive handling of the cord.

25.  Knee
chest face down position
 Bladder filling with saline
 In Ambulance – left lateral position
 Manual elevation – if a nurse or family
physician there
 Urgent transfer to center with cesarean
facilities and neonatal care.

26.  Stage
I of Labor
 Prepare for Emergency Cesarean section
 Inform the senior pediatrician
 Delivery should be done within 30 minutes
 If fetal death occurs, try for vaginal delivery.
Stage II Labor:
 Expedite delivery with liberal episiotomy and
instrumental delivery.
 If there is fetal heart disturbance and not in
favor of vaginal delivery plan for Emergency
Cesarean section.

27.  Extreme
prematurity with cord prolapse:
1. Below or around 24 weeks – counsel the
patient.
If she wishes to continue pregnancy if FHR is
normal and patient willing for up to 3 weeks
If patient does not agree allow for vaginal
delivery with or without oxytocin infusion

28.  Overall
– 50 %
 First stage of labor – 75 %
 Second stage – 50 %
 Neonatal death – 4 %
 Perinatal mortality – 20 %
 Asphyxia – Hypoxic ischaemic encaephlopathy
- Cerebral palsy

29.  Good
with vertex presentation than Breech.
 Good in Primigravida than in multi.

31. 
MEDLINE and NHS databases

RCOG Green Top Guidelines

Women’s Hospitals Australasia

Lin MG (2006). Umbilical cord prolapse. Obstetrical and Gynecological Survey
61(4):269-77.
Mapp T (2005). Feelings and fears post obstetric emergencies-2. British Journal of
Midwifery 13(1):36-40.
Mapp T, Hudson K (2005). Feelings and fears during obstetric emergencies-1. British
Journal of Midwifery 13(1):30-5.
Murphy DJ, MacKenzie IZ (1995). The mortality and morbidity associated with
umbilical
cord prolapse. British Journal of Obstetrics and Gynaecology. 102(10):826-30.
National Collaborating Centre for Women’s and Children’s Health (2007).
Intrapartum
care: care of healthy women and their babies during childbirth. London: RCOG
Press
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Afolabi BB, Lesi FE, Mera NA (2006). Regional versus general anaesthesia for caesarean
section. Cochrane Database of Systematic Reviews, issue 4.
Boyle JJ, Katz VL (2005). Umbilical cord prolapse in current obstetric practice. Journal
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Clinical Negligence and Other Risks Scheme (CNORIS 2009). http://www.cnoris.com
[Accessed 26 March 2010].
Crofts JF, Ellis D, Draycott TJ et al (2007). Change in knowledge of midwives and
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local hospital, simulation centre and teamwork training. BJOG: An International Journal
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Draycott T, Winter C, Crofts J, et al, eds (2008). Module 8. Cord prolapse in: PROMPT:
Practical Obstetric MultiProfessional Training Course Manual. London: RCOG Press:117-24.
Goswami K (2007). Umbilical cord prolapse. In: Grady K, Howell C, Cox C eds.
Managing Obstetric Emergencies and Trauma. The MOET course manual 2nd ed.
London: RCOG Press: 233-7.
Houghton G (2006). Bladder filling: an effective technique for managing cord prolapse.
British Journal of Midwifery 14(2):88-9.
Katz Z, Shoham Z, Lancet M et al (1988). Management of labor with umbilical cord
prolapse: a 5-year study. Obstetrics and Gynecology 72(2):278-81.
Koonings PP, Paul RH, Campbell K (1990). Umbilical cord prolapse. A contemporary
look. Journal of Reproductive Medicine 35(7):690-2.

33. Thank You