PROLAPSE AND PRESENTATION OF THE CORD

PROLAPSE

ALWAYS do a vaginal examination immediately a mother’s membranes rupture spontaneously, unless: (1) She is <36 weeks and is not having contractions, and you are considering non-operative management. Or, (2) her baby’s head is well down (not more than 2/5 above the brim).

If you find a prolapsed cord, DON’T take your hand out of her vagina! Instead, push the fetal head (or breech) off the cord. While you are holding his head, ask an assistant to insert a Foley catheter and fill her bladder with 500 ml of Ringer’s lactate or normal saline. A full bladder will keep his head away from the cord and inhibit the contractions of her uterus.

Listen to the fetal heart, to find out if he is still alive. It may still be beating, even if his cord is not (cord spasm). Assess his size, and try to exclude gross congenital abnormalities, particularly hydrocephalus.

Remove your fingers, and apply a pad to her perineum, so that the cord remains in her vagina. Turn her on to her side with the foot of her bed raised. Or put her into the knee–elbow position (23-2). Set up an isoprenaline infusion. Do a Caesarean section as soon as possible. Don’t pass a stomach tube; instead give her an antacid. Don’t empty her bladder until you are ready to incise her parietal peritoneum.

Always do a Caesarean section unless: (1) She is fully dilated and the head is only 2/5 or less above the brim (unusual). If so, apply forceps (if you are experienced with them because they are quicker), or a vacuum extractor. (2) Prolapse of the cord complicates the delivery of a second twin with a cephalic presentation. If there is no CPD, you can usually apply a vacuum extractor, or do a breech extraction preceded by internal version if necessary.

Figure 19.6: TREATING PROLAPSE OF THE CORD BY FILLING THE BLADDER. A, the head pressing on the cord. B, the patient’s bladder has been filled through a catheter, and the cord is now free. A full bladder also inhibits contractions of the uterus.

PRESENTATION OF THE CORD

If you feel the cord vaginally when she has intact membranes, observe carefully for the fetal heart changes which indicate cord compression: (1) Put her into the head–down or knee–chest position. Nurse her with the foot of her bed raised for 24 hours. This will nearly always allow it to rise above his head. Or, (2) before 37 weeks, try external version. Turning the fetus may draw the cord from under the presenting part. Or, (3) do a Caesarean section, unless he is dead or too small to survive.