Obstetric emergency

Emergencies can happen suddenly as with a convulsion or they can develop as a result of a
complication that is not properly managed or monitored. Obstetric emergencies are life
threatening situations which requires urgent action and immediate referral and transfer to an
equipped hospital. They can occur suddenly without warning during pregnancy, delivery and up
to 6 weeks postpartum.
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Presentation and prolapse of cord

Ruptured uterus/ scarred uterus
Shoulder dystocia
Placenta previa
Amniotic fluid embolism
Acute inversion of the uterus

1. Presentation and prolapse of cord

Definition:
When the umbilical cord lies alongside or below the presenting part after rupture of membrane is
called umbilical cord prolapse.
When the umbilical cord lies alongside or below the presenting part with the membrane intact is
called umbilical cord presentation.

Types
There are three types of abnormal descent of the umbilical cord by the side of presening part.
1. Occult prolapsed: The cord is placed by side of the presenting part and is not felt by the
fingers on internal examinations.
2. Funic presentation (cord presentation): The cord is slipped down below the presenting
part and is felt lying in the intact bag of membranes. The cord may slip to one side of the
head and disappear as the membrane rupture.
3. Overt cord prolapse: If the presenting part of the fetus does not fit the pelvis snugly
after membrane rupture, there is a risk that the umbilical cord can slip past and present at
the cervix or descend into the vagina. This is known as overt cord prolapse. The
prolapsed exposes cord to intermittent compression compromising the fetal circulation.

Depending on its duration and degree of compression, fetal hypoxia, brain damage and
even death can occur. Exposure of the cord to air causes irritation and cooling resulting in
vasospasm of the cord.

Incidence
The over all incidence of overt prolapsed cord is between 1 and 6 per 1000 deliveries. Overt cord
prolapse occur in more than 1 % breech deliveries.

For cephalic presentation it is 0.5%

For breech presentation depends on the type of breech
- Frank breech it is 0.5 %
- Complete breech 5%
- Footling breech 15%
For transverse lie 20%

Causes:
1. High fetal station
2. Multiparity
3. Prematurity
4. Malpresentation
5. Low birth weight
6. Fetal congenital anomalies
7. Macrosomia
8. Multiple pregnancy
9. Polyhydramnios
10. Pelvic contraction
11. Premature rupture of membrane
12. Surgical induction of labour
13. Placenta previa
14. Abnormally long cord
15. Obstetric intervention including amniotomy (before presenting part engaged), use of
scalp electrode or intrauterine pressure catheter and attempted external cephalic or
internal podalic version.
16. Pelvic tumors.

Signs
The cord prolapse may occur with no outward physical signs and a normal fetal heart rate.

1. The cord can be seen protruding from the introitus or loops of cord can be palpated
within the vaginal canal with overt cord prolapse. If the cord is pulsating fetus is alive.
2. Occult prolapse are rarely felt on pelvic examination and the only indication may be fetal
heart rate changes.
3. The loops of cord are palpated through the membrane with funic presentation.
4. Whilst the fetus remains in good condition, variable fetal heart rate decelerations are seen
during uterine contraction.
5. Bradycardia occurs with prolonge and complete compression.
6. The fetal activity diminishes and eventually stops with deteriorating fetal status

Diagnosis
A loop of cord may be visible at the vulva in cord prolapse. It is easly recognized by its
pulsation. If the fetus is dead and pulsation has ceased. The posibilities of cord prolapse is
always kept in mind in the high risk categories of malpresentation and pelvic disproportion.
i)
ii)
iii)
iv)

Sign of fetal distress in labour may lead one to suspect cord prolapse or presentation.
Vaginal examination
Ultrasounds occasionally can diagnosis cord presentation.
Occult prolapsed is rarely palpated during pelvic examinations. It may be diagnosed
simply by palpating loops of the cord in the vaginal canal during vaginal

v)

examinations.
Cord presentation is also diagnosed by feeling loops of cord through the membranes.

Any fetal bradycardia or decelerations that may indicate compression of a prolapsed cord
should be confirmed/ruled out with a vaginal examination.

Management
Principles of management are:

To relieve pressure on the cord.

To findout the fetus is alive or dead.
If alive, to deliver expeditiously.
If dead, pelvis and presentation are favourable wait spontaneous delivery.

Management
i) If an oxytocin infusion is on, this should be stopped.
ii) Give oxygen 4-6 L/min by mask or nasal canula.

iii) Ensure continue fetal monitoring until in theater and commencing caesarean section or
until vaginal delivery birth.
iv) Whether the fetus is alive or dead. Cord pulsation is the best guide. If the fetus is alive, it
must be delivered immediately. It there is no cord pulsation allows labour to progress
normally.
v) Examine the cervix for fully dilated or not.
vi) With an overt cord prolapse:

If the fetus is viable, place the mother in the knee chest position or head down tilt in the
left lateral position and apply upward pressure against the presenting part to lift the fetus

away from the prolapsed cord.

Replacement of umbilical cord: Wear the sterile gloves on two hands and insert hand into

the vagina and push upward the presenting part to decrease pressure on the cord.
Once the presenting part is above the pelvic brim, apply continuous suprapubic pressure

in an upward direction or by filling the urinary bladder.

Manual replacement of the prolapsed cord above the presenting part is not currently

recommeded. Avoid handling the cord outside the vagina as this induces vasospasm.
Proceed to emergency caesarean section as soon as possible.
If available, give terbutaline 0.25 mg subcutaneously to reduce contractions when there
are persistent fetal heart rate trace abnormalities, despite attempts to prevent cord
compression manually, and there may be delays in achieving delivery.
Only proceed with vaginal delivery if delivery is imminent, the cervix is fully dilated and
there are no contra-indications. This can be expedited with episiotomy/vacuum extraction
or forceps.
Ensure resuscitation is available for the baby post-delivery.
If the fetus has died, deliver in the manner that is safest for the woman.

vii) If an occult prolapsed is suspected:

Place the mother in the left lateral position.
If the fetal heart rate returns to normal, allow labour to continue with the mother
receiving O2 and fetal heart rate being continuously monitored.

 If the fetal heart rate remains abnormal, expedite a rapid Caesarean section.
viii) With funic presentation:
A decision needs to be made between prompt elective Caesarean section prior to
membrane rupture or artificial rupture of membranes (AROM) with full preparations for
an emergency Caesarean section, in case the cord does become an overt prolapse on
rupture.
Management of cord prolapsed in community
In the community, cord prolapsed is associated with a tenfold increase in perinatal mortality rate,
compared with that occurring in hospital.
Emergency community management of cord prolapsed:

Arrange 999 ambulance transfers to the nearest consultant-led obstetric unit for delivery,
unless spontaneous vaginal delivery is assessed as imminent by a competent
professional's VE. Even then, still ensure urgent transport is on its way in case delivery is
delayed or the baby requires resuscitation.

Advise knee-chest, face-down position whilst awaiting the ambulance.

Elevate the presenting part whilst awaiting transfer and during transfer to hospital.

Use the left lateral position for transfer in the ambulance.

Prognosis
The perinatal mortality rate (associated with cord prolapsed) is 91/1,000. Prematurity and
congenital abnormalities are underlying factors in many cases. Even congenitally normal, fullterm babies can die as a consequence of cord prolapse - home birth and delay in transfer to
hospital

have

been

identified

as

particular

risks

in

these

cases.

The most common serious morbidities associated with cord prolapsed relate to asphyxia, hypoxic

brain injury and cerebral palsy. There are few long-term studies looking at long-term sequelae of
cord prolapse.

Prevention

Consider admission of all pregnant women with transverse, oblique or unstable lie from
37 + 6 weeks of gestation. Cord prolapses occurring in hospital have better outcomes
than those occurring within the community. Advise these women that they will require
rapid assessment if they start labour or have a spontaneous rupture of membranes and
should seek help as soon as possible.

Similarly, admit women with premature rupture of membranes and a non-cephalic

presentation.

Avoid artificial rupture of membranes (AROM) where possible. If an AROM is

performed with a mobile presenting part, ensure arrangements have been put in place for
an immediate emergency section should a cord prolapse occur.

Whenever a VE or other obstetric procedure is performed following rupture of

membranes with a high presenting part, avoid any upward pressure on the presenting
part.

Treat high-risk patients with constant fetal monitoring during delivery.