Cord prolapse is among the obstetric emergencies that will lead to fetal death or low APGAR score. There are several risk factors that can predispose the woman to have cord prolapse. The factors include multiparity, low birth weight less than 2.5 kg, prematurity less than 37 weeks, fetal congenital anomalies, breech presentation, transverse, oblique lie, second twin, polyhydramnios, low-lying placenta, artificial rupture of membranes with unengaged presenting part.
There are several studies that concur with the above details as the risk factors for cord prolapse
In most of the developing countries the cases of cord prolapse ended up with fetal demise or very low APGAR score. This is due to lack of facilities like theatres and human resources to enable fast delivery of the fetus. This case shows the other means that can be done in order to save the babies while making sure the women are safe.
A 30 years Old Gravida 4 Para 3 living 3 who could not remember her date of last menstrual period hence gestation age was approximated from gestation age of the first visit on the antenatal card. She started ANC at 20 weeks gestation hence her gestation age was approximated to be 40 weeks. She was admitted for 3 days.
She was admitted due to Lower abdominal pain for 8 hours and per vaginal mucoid bloodish discharge for 6 hours.
The woman reported to have lower abdominal pain radiating to the back, on and off increasing in intensity and frequency with time, no relieving factors, no per vagina leakage, no per vagina bleeding. She reported positive fetal movements; she had no fever, no headache, no vomiting, no blurred vision, no awareness of heart beats, no pain during urination.
The woman started antenatal clinic at 20 Weeks gestation and visited 4 times, with normal weight increase and normal blood pressure. Investigations done during ANC were HIV and syphilis which were negative. She was given hematenics, mebendazole, SP for presumptive treatment of malaria. There were no complications during antenatal period. Her past 3 vaginal deliveries were normal with no complications.
Upon examination the woman was conscious; not pale, afebrile and no edema of lower limbs,
The Blood pressure was 100/70 mmHg, Pulse rate 88 beats per minute, Temperature 36.6˚C, Respiratory rate 22 cycles per minute. Examination of all other the systems was done and all parameters were normal.
Asymmetrical distension of the abdomen was noted. She had 3 contractions in 10 minutes lasting for 30 seconds. The fundal height was equivalent to 36 weeks, lie was longitudinal with cephalic presentation. The fetal heart tones were detected and were 140 beats per minute.
She was 8 cm dilated; thin, anterior, fully effaced, fetal membranes were intact, no active bleeding and the pelvis was adequate.
Active phase of first stage of labor.
She was sent to labor room for Labor monitoring using partograph.
Hb: 12 g/dL, blood group and Rhesus factor: O positive and cross matching, repeated HIV test which was Negative.
After 10 min she reported spontaneous rupture of membrane and vaginal assessment was done where she still had 8 cm cervical dilatation, clear amniotic fluid, cord prolapse was detected which was pulsating. Fetal heart rates were present 132 beats per minute.
Cord prolapse and a live fetus.
The woman was placed in Knee chest position to minimize the cord compression by the fetal head; intravenous 1 liter of RL was given to improve circulation and hence blood flow to the placenta. The woman had very strong contractions this time (3 contractions lasting for more than 40 seconds).
The woman told and counseled on the new diagnosis of cord prolapse and the mode of delivery after the diagnosis. She was planned for emergency caesarian section and she consented for the operation. She was prepared for emergency caesarian section. The hospital had one theatre room and there was another caesarian section being done hence there was delay to perform the procedure. During the waiting time urinary catheter was inserted, 400 mls of Normal saline was added. We clamped the catheter with small artery forceps for the purpose of continuous collection of urine in the bladder as this mechanism helps to decrease decent of the fetus head. She was still kept in knee chest position.
The theatre room was available 30 minutes from the diagnosis. This time she was screaming that she has the urge to push.
The assessment of the cervix was done, she had full dilatation with pulsating cord but this time weak pulsations, head at station 1. The amniotic fluid was thick meconium stained hence the decision to deliver the woman vaginally with the use of vacuum extractor was made. The patient was also involved in every decision. This was done because of the presence of signs that showed compromise of the fetus like weak pulse on the prolapsed cord and thick meconium stain of the amniotic fluid. We also anticipated the preparations of the theatre room for the next caesarian section would take longer time hence the decision to speed up the process using vacuum was reached. If she would have delivered vaginally without vacuum assistance there was fear of continuous cord compression during the process leading to severe birth asphyxia or fetal death.
The woman in knee chest position, aseptically a soft vacuum cup was placed at vacuum pressure of 15 mmHg extraction of the fetus was done.
At 12.40 pm baby was delivered using vacuum, the first minute the APGAR score was 6, the baby was dried and kept warm, suction of the meconium was done and then resuscitation with bag and mask was done. After resuscitation the fifth minute Apgar score became 10.
Active management of the third stage of labor was done and the placenta was removed. Estimated blood loss was 300 mls. She got second degree vaginal tear which was repaired. The woman and the baby were kept for observation for four hours while breast feeding the baby and were transferred to the postnatal ward. The following day after review the woman and the baby were discharged in good condition. She returned after 10 days for follow up. The woman and the baby had no complications hence was discharged from the clinic and was told to continue follow up clinics at the health center near her village.
Occult cord prolapse is the descent of the umbilical cord through the cervix alongside the presenting part (membrane intact) and overt cord prolapse is the descent of the umbilical cord through the cervix past the presenting part, in the presence of ruptured membranes
Risk factors for cord prolapse include multiparity, low birth weight less than 2.5 kg, prematurity less than 37 weeks, fetal congenital anomalies, breech presentation, transverse, oblique lie, second twin, polyhydramnios, low-lying placenta, artificial rupture of membranes with unengaged presenting part
In order to improve fetal outcome some interventions can be done like putting mother in knee-chest position or lateral position, instillation of fluid into the bladder, giving tocolytics to mothers in labor with cord prolapse and intrauterine resuscitation
When cord prolapse is diagnosed there should be immediate delivery of the fetus. The mode of delivery of the fetus needs to be in the fastest and safe way
In a woman with fully dilated cervix vaginal delivery in most cases operative (vacuum or forceps delivery) can be attempted if it is anticipated that the delivery will be accomplished quickly and safely
In our case we anticipated that doing operative vaginal delivery would take less than 10 min rather than doing caesarian section which would take longer time and there was an experienced Obstetrician Gynecologist to perform the vacuum delivery. In the under resourced areas like our hospital at that particular time that had one theatre room and inadequate manpower the operative vaginal delivery seemed right in order to reduce fetal loss.
There are several factors that can predict the outcome of the fetus that include location of the cord prolapse, decision to delivery interval, birth weight and mode of delivery
Women at risk of umbilical cord prolapse should be treated as high-risk patients. Once the diagnosis is made, measures to reduce compression of the cord should be applied to prevent hypoxia to the fetus. The best mode of delivery in these cases is the caesarian section. In cases where a woman has full cervical dilatation with features of fetus compromise, the operative vaginal delivery can be attempted if it is anticipated to take short time and will not compromise the safety of the woman.
Authors are sincerely thankful to the patient involved in this case, staff members in the Department of Obstetrics and Gynecology as well as the Theatre team for their support. Authors are also thankful to their families for their continuous support.