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
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
Transcript: second twin Reduce contractions Stop any Oxytocin infusion immediately Terbutaline 0.25mg S/C as a tocolytic to reduce contractions and improve outcomes breech Megan Blease March 2017 theatre team Malpresentation Monitoring oblique/transverse lie Cord presentation Malpresentation & unstable lie Unstable lie continuous CTG polyhydramnious TIME! Shoulder Immediate transfer Good communication & Clear discussion Monitoring on route- in the ambulance? FBC/Group & Save IV Access Caesarean section if the cervix is not fully dilated Assisted vaginal birth if birth is imminent Breech extraction/internal podalic version for a second twin Be prepared to resuscitate the cord presenting in front or at the side of the presenting part with membranes intact DO NOT RUPTURE THE MEMBRANES Carries a high risk of cord prolapse High risk of fetal distress High risk of damage to vessels in the cord with ARM VE Bladder Filling RECOGNISE ?FBS Resuscitation & Cord Gases Communication Birth by quickest means ECV Neonatal Team Obstetrician RELIEVE Elevate Presenting Part disimpaction of the fetal head during assisted rotation CALL FOR HELP Maternal Position Consider Tocolytics Relieve What do these terms mean? Possible instrumental birth RECOGNISE! Anesthetist internal podalic version FSE application Ambulance- Time Critical neonatal team Malpresentation, Unstable lie & Cord Prolapse unstable lie presentation of any part other than the occiput ruptured membranes Senior Midwife Who is more at risk? Theatre Team Scribe feet senior midwife Caesarean if not fully dilated RCOG recommends women with transverse, oblique or unstable lie should be offered elective admission to hospital at 37 weeks- or sooner in the presence of ruptured membranes or suspected labour management of unstable lie References unpredictable Call for Help! Remove Remember: Any obstetric intervention after ruptured membranes carries a risk of cord prolapse Fetal Scalp Electrode Fetal Blood Sampling Artificial Rupture of Membranes Manual rotation Internal Podalic Version AVOID ALL WHERE POSSIBLE REMOVE Quick Transfer Fetal Heart? Exaggerate Sim's position: woman in left lateral with a pillow under left hip- with or without head tilt OR knee chest, face down position (less suitable for transportation) Relieve a common feature is a poorly applied presenting part 1% in breech birth Antenatal Risk Factors Documentation arm premature labour anesthetist Relieve why is this a problem?? VE Centre for Maternal and Child Enquiries (CMACE) (2010) Perinatal Mortality 2008 [Online] http://www.publichealth.hscni.net/sites/default/files/Perinatal%20Mortality%202009.pdf Centre for Maternal and Child Enquiries (CMACE) (2011) Perinatal Mortality 2009 [Online] http://www.publichealth.hscni.net/sites/default/files/Perinatal%20Mortality%202009.pdf Royal College of Obstetricians & Gynecologists (2014) Management of Cord Prolapse [Online] https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-50-umbilicalcordprolapse-2014.pdf Vago, T (1970) 'Prolapse of the umbilical cord: a method of management' American Journal of Obstetrics & Gynaecology. 107: 967-969 Winter, C; Crofts, J; Laxton, C; Barnfield, S & Draycott, T (2012) PROMPT course manual. 2nd Ed. Cambridge University Press. Cambridge oblique Empty Bladder just before birth if full elective caesarean section recommended at term Buttocks USS unstable lie Amniotomy with a high head Breech knee Is there an audible FH? previous cord prolapse To be used if diagnosis to birth is likely to be prolonged Vago 1970 Raises the presenting part for an extended period of time A Foley's catheter is placed into the bladder 500-750mls of sterile saline is ran through the catheter using a blood giving set The catheter should then be clamped Remember to empty the bladder before delivery! senior obstetrician Definition: the umbilical cord presenting below the presenting part after membranes rupture (either spontaneously or artificially) The descent of the umbilical cord past or alongside the presenting part in the presence of ruptured membranes transverse scribe- documentation is key! The continuous change of position of the fetus in the womb at 37 weeks onwards 0.1%- 0.6% of all births Perinatal mortality rate is approx 9% Consistency within the perinatal mortality reports (CMACE 2010, CMACE, 2011) Interval between diagnosis and birth impacts stillbirth and perinatal death significantly Asphyxia due to cord compression OR arterial vasospasm due to exposure to fluids or air Babies may be at risk of hypoxic-ischaemic encephalopathy, cerebral palsy or death Can be due to predisposing causes such as prematurity or LBW rather than the event CTG Stop Oxytocin visually To recap on knowledge of malpresentation To understand unstable lie and the associated risks & management To understand the risk factors for cord presentation/prolapse To recognise the emergency situation of cord prolapse To manage a cord prolapse situation Fill Bladder Intrapartum risk factors
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
Transcript: fetal malpresentation fetal anomalies prematurity cord abnormalities spotaneous movements multiple pregnancies amniotomy amnioinfusion attempting to rotate the fetal head premature rupture of membranes birth injury, trauma emergency c-section: risk for infection, bleeding stillbirth intrauterine bleeding Cord Prolapse Thank You! placenta previa http://www.mayoclinic.org/diseases-conditions/placenta-previa/basics/risk-factors/con-20032219 http://my.clevelandclinic.org/health/articles/umbilical-cord-prolapse http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/content/tags/bradley-holbrook-md/umbilical-cord-prolapse?page=full http://www.medbroadcast.com/condition/getcondition/placenta-previa https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/labor-and-delivery-complications-and-errors/placenta-previa/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4081886/ https://www.glowm.com/section_view/heading/Umbilical%20Cord%20Prolapse%20and%20Other%20Cord%20Emergencies/item/136 http://americanpregnancy.org/pregnancy-complications/placenta-previa/ http://americanpregnancy.org/pregnancy-complications/placenta-previa/ http://my.clevelandclinic.org/health/articles/umbilical-cord-prolapse serious, life-threatening bleeding that can result in maternal hemorrhaging during labor, delivery, and even post partum preterm birth of the neonate prompting an emergency C-section hypovolemic shock from blood loss infection blood clots death cord prolapse Umbilical Cord Prolapse - Complication that happens prior to or during birth of a baby. This is when the umbilical cord drops through the open cervix into the vagina before the baby comes out. This can make the cord become trapped against baby's body during delivery (occult cord prolapse) or when the cord comes out before the baby's head (overt cord prolapse). It occurs in about 1 in 300 births. Mother cord prolapse Placenta Previa and Cord Prolapse Placenta Previa Cord Prolapse C-section delivery surgery to remove uterine fibroids, benign uterine tumors dilation, curettage; removal of uterine tissue over 35 years of age use of tobacco use of cocaine carrying more than one fetus more than one delivery previous history of placenta previa cord prolapse placenta previa Complications Ilyana Gonzalez Blaire Hammer Victoria Kaspar - Mother will be put on bed rest after diagnosis - Depending on gestational age, mother will recieve steroid shots - If mother starts to bleed and it cannot be controlled, immediate cesarean section will be performed placenta previa delayed fetal growth due to lack of blood supply fetal anemia fetal distress due to lack of oxygen severe hemorrhagic bleeding birth injury birth asphyxia, lack of oxygen to brain and organs during birth hypoxic ischemic encephalopathy, permanent brain damage due to lack of oxygen Placenta Previa - A condition when the placenta lies low in the uterus and partially or completely covers the cervix. The placenta may separate from the uterine wall as cervix begins to dilate during labor. It occurs in about 1 in 200 births. 3 Types: - Complete previa: the cervical opening is completely covered. - Partial previa: a portion of the cervix is covered by the placenta - Marginal previa: extends just to the edge fo the cervix. fetal death fetal distress and asphyxia decreased "health" at birth, low APGAR scores small incidence of long-term neurological defects developmental delays and impairments cerebral palsy hypoxic brain injury Placenta Previa Cord Prolapse Signs & Symptoms - Amniofusion: a process that involves introducing a saline solution, at room temperature, into the uterus during labor in order to relieve pressure that can potentially lead to the umbilical cord becoming compressed - Oxygen therapy - If baby becomes distressed, the provider will preform a cesarean section Risk Factors - Can be diagnosed before labor by doctor either by fetal doppler or ultrasound - Fetal heart monitor can show this because usually the baby will have bradycardia (hr rate lower than 120) - Doctor may also conduct a pelvic examination to detect the prolapsed cord Infant Placenta Previa - The most common sign would be painless bleeding during the 3rd trimester - Premature contractions - Baby is breech, or in transverse position - Uterus measures larger than it should be according to gestational age Resources http://www.pregmed.org/umbilical-cord-prolapse.htm Treatment https://nurseslabs.com/placenta-previa/
Transcript: Being the baby of the family, my parents and I are very close. My mother and I have always had the same interests, and have become who I am because of her; a bug and animal lover who will stand up to any injustice. Many people call my home a farm, having pet chickens among other things, and I simply love it. I am born and raised in California, and I don't plan on leaving anytime soon. What are my strengths? Courses in musical education, formal training through an instructor, and a B.A degree in that field are usually required. Natural talent, and the capability to deal with criticism is also a must have. Who am I? Lessons I have learned. My skill set Within this pathway, there are many possible careers such as; performing on broadway, becoming a dance teacher or vocal coach, choreographing for groups, or even a dancer through a professional studio. Salary for these are all near minimum wage, unless fame is achieved. I am great at focusing on the job at hand, without paying attention to outside distractions. No matter what obstacle that must be overcome, I always work to my fullest. Being a very determined individual, the job will never be left uncompleted. Sawyer Knieriem Personal Insight Possible careers within my Pathway I'm a singer, an artist, a right brainier. I have been performing for as long as I can remember, and am grateful that I can continue to do so. I also love to draw, and always find time to fit it in. An avid reader, I have a large collection of books in my house, but often go to the library to pick up ten at a time. I love riding horses, even though it's difficult to even get on. I love to care for animals. My mother and I will always take care of an animal in need I have learned that although this field is very enjoyable, a job through performing is very unstable, and scarce to come by at all. What am I about? Graduating 2013 Pathway:Arts and Communication Pathway Cord: Performing Arts I am a dancer, and excel on pouring my soul out on stage. The stage is my second home, a place where I feel completely comfortable, a trait found in those who can make it professionally. I have always been singing, and have won many honors for this. A classical style of singing combined with dancing will enable me to possibly one day work on Broadway. Is this the Career Path I plan to pursue? Educational/Training requirements to obtain a career within your pathway This experience showed me that in this field you will come across many different personalities and stressful situations that require critical problem solving skills in very public settings, while always worrying about the companies image. No, I will not be pursuing this career path as my overall career. A possible minor in this field would be the farthest, as the publicity of all of it would be too stressful, and I would be far too worried about the availability of a job with this career.
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
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
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