Umbilical Cord Prolapse in Obstetrics, Essays (university) of Medicine

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PROLAPS OF THE UMBILICAL

CORD

2.1 Definitions Umbilical cord prolapse is the umbilical cord in the birth canal under presentation of the fetus after the rupture of the membranes. Umbilical cord prolapse is an emergency case in obstetrics because the incidence of perinatal death is high. Umbilical cord prolapse is a complication in labour. Although cord prolapse is not a malpresentation, it is more likely to occur in malpresentations or malpositions of the fetus. Umbilical cord prolapse is the descent of the umbilical cord into the vagina before the ovary which results in compression of the cord between the ovary and the mother's pelvis. This is a rare obstetric emergency that occurs when the umbilical cord descends beside or outside the presenting part of the fetus. This can be life-threatening to the fetus because the blood flow through the central vessels is unable to adapt to the compression of the umbilical cord between the fetus and the uterus, cervix, or pelvic neck. This situation causes the fetus to experience hypoxia which can result in asphyxia. Therefore, careful decisions and management are needed. Umbilical cord prolapse is divided into three, namely:

1. The umbilical cord prolapse is also called funiculi prolapse, if the umbilical cord is felt out or on the side and passes through the lowest part of the fetus in the birth canal, the umbilical cord can prolapse into the vagina or even outside the vagina after the amniotic fluid ruptures.

Figure 2.3. Occult Prolapse (hidden umbilical cord) The cord is more likely to prolapse if something prevents the presenting part of the fetus in the lower uterine segment or its descent into the mother's pelvis. 2 Umbilical cord presentation and hidden cord are rarely diagnosed, requiring careful examination. This examination should be performed in all cases of labour, such as in preterm labor or if there is a malpresentation or malposition of the fetus. Figure 2.4. Normal umbilical cord location 5 Figure 19.5. Umbilical cord prolapse

The umbilical cord prolapse (prolapsed funicular) does not directly affect the mother's condition, on the contrary it is very dangerous for the fetus because the umbilical cord can be compressed between the front of the fetus and the pelvic wall which eventually causes asphyxia in the fetus. The biggest danger is in cephalic presentation, because at any time the umbilical cord can be pinched between the lowest part of the fetus and the birth canal can result in impaired fetal oxygenation. In the leading umbilical cord or umbilical cord, before the forefront of the amniotic fluid rupture, the threat to the fetus is not that great, but after the amniotic rupture, the danger of fetal death is very great. 2.2 Epidemiology The mortality of umbilical cord prolapse in the fetus is around 11-17%. The incidence of the occurrence of the umbilical cord is 1: 3000 births, prolapse of the umbilical cord (funikuli prolapse) is approximately 1: 200 births, the incidence of occult prolapse (hidden umbilical cord) 50% is unknown.

• 0.5 % in head presentation.
• 5% breech location.
• 15% in foot presentation.
• 20% latitude. 6, Obstetric conditions where the pelvic inlet is not fully occupied with the lowest part of the fetus (presentation) will facilitate the occurrence of cord prolapse, especially in:
• Incomplete breech presentation (foot position) Abnormal position (latitude presentation)
• Hydramnios
• Premature
• PJT (Inhibited Fetal Growth) Several occult prolapse events (hidden umbilical cord) lead to one or more events with the diagnosis of cord compression. Cord prolapse is more common when the cord is long and when the placenta is low lying. Myles reported the results of his research in the world literature that the incidence of cord prolapse ranged from 0.3% to 0.6% of deliveries.

It consists of an umbilical vein that enters the general circulation via the Ductus Venosus Aranthii vein which eventually leads to the Inferior Vena Kava. Its function: to provide oxygen and nutrients from mother to fetus. Wrapped in Wharton's jelly so that it is protected from possible compression which will interfere with blood flow to and from the fetus through the retroplacental circulation. The umbilical cord is longer so it appears to be tortuous in Wharton's jelly. The existence of the umbilical cord has special interests including:  The umbilical cord is a distributor of nutrients and O2 so that the fetus gets enough calories to grow and develop in the womb.  The umbilical cord that is long enough will give the fetus the opportunity to move so that muscle and other activities are trained before labor takes place.  When labor occurs, it is possible that the retroplacental circulation will be disrupted, but the umbilical cord, which is protected by Wharton's jelly, will not be disturbed. 2.4 Pathophysiology The umbilical cord must be longer than 20-35 cm to allow delivery of the fetus, depending on whether the Placenta is located below or above. The long umbilical cord is mostly caused by a low lying placenta. 1,7 Abnormal cord length ranges from no visible cord (acordia) to a length exceeding 300 cm. This cord is more likely to prolapse through the cervix. An umbilical cord that is too long makes it easier for the umbilical cord to develop (funicular prolapse) so that the umbilical cord can be pressed against the birth canal which ultimately causes fetal death due to asphyxia. This is most likely in terms of spending. 1,10, The factors determining the length of the cord are still being debated. Cord length is positively affected by amniotic fluid volume and fetal mobility. Excessive umbilical cord length can also be caused by twisting of the umbilical cord and the fetus accompanied by stretching when the fetus moves 2.5 Etiology

In general, prolapse of the umbilical cord is found in conditions where the lowest part of the fetus is not fixed at the pelvic inlet, for example in:  Multipara  Latitude  Breech position  Multiple locations  Narrow pelvis  Hydrocephalus and anencephaly  Hydramnios  Placenta previa  Multiple pregnancy  Cephalopelvic disproportion  Premature rupture of membranes  Premature labor The conditions above can cause impaired adaptation of the lower part of the fetus to the pelvis, so that the pelvic inlet (pap) is not covered by the lower part of the fetus. This predisposes to descent of the umbilical cord and the occurrence of prolapse of the umbilical cord (funicular prolapse). The prolapsed umbilical cord (funicular prolapse) is often found in transverse and breech positions, especially breech and foot presentations.4,6,7, Any condition that causes the pelvic inlet (pap) to not be covered by the front can cause the umbilical cord to prolapse (funicular prolapse) such as cephalopelvic disproportion, latitudinal latency, ft position, multiple pregnancies, multiple pregnancies, and hydramnios. These conditions are more common in long umbilical cords and low lying placentas. In multiple locations, prolapse of the umbilical cord often occurs and this greatly affects the prognosis. This situation is not always diagnosed by internal examination, especially if the umbilical cord is located beside the head (occult prolapse / hidden umbilical cord), where there is compression of the umbilical cord (the umbilical cord is compressed between the fetal head and pelvis) which can result in fetal distress. This multiple position occurs when the pelvic inlet is not properly closed by the anterior portion of the fetus, as in multiparas. Umbilical cord prolapse (funicular prolapse) is more common in multiparas than

the normal range or indicates tachycardia or bradycardia. Normal heart sound is 120-140x per minute Figure 19.7. Umbilical cord prolapse on ultrasound examination 1, The diagnosis of umbilical cord prolapse is enforced if on internal examination a throbbing umbilical cord is palpable on vaginal examination or if the umbilical cord appears to be protruding from the vagina, but sometimes this is not palpable on internal examination which is called occult prolapse / hidden umbilical cord. In addition, cord prolapse should be suspected if the fetal heart sounds become irregular accompanied by periodic bradycardia or tachycardia of varying duration. A definite diagnosis can also be made through an obstetric ultrasound examination The existence of a prolapsed umbilical cord (funikuli prolapse) or a leading umbilical cord / leading umbilical cord in general can only be known by internal examination after the opening of the uterine ostium occurs. In the leading umbilical cord / leading umbilical cord, the pulsating part behind the amniotic membranes can be felt, whereas in the prolapsed umbilical cord (funikuli prolapse), the umbilical cord can be felt with two fingers, the pulsating umbilical cord indicates that the fetus is still alive. Because the diagnosis can generally only be made on the basis of internal examination, an internal examination is absolutely necessary at the time of rupture of the membranes if the lowest part of the fetus has not entered the pelvic cavity. An internal examination is also necessary if there is a delay in fetal heart sounds without any clear cause. The waters have broken and the head is still

rocking, on inspection you can feel the umbilical cord, also how to feel the pulsation of the umbilical cord. Cardiotocography always shows a picture of fetal distress in the form of very deep slow decelerations or single prolonged decelerations as shown in the following image: 2.8 Management The management of cord prolapse depends on the condition of the fetus at diagnosis and the gestational age and degree of cervical dilatation. If the fetus is dead, birth can be awaited. If the fetus is alive and cervical dilation is incomplete, cesarean section is the safest course of action for the baby. While preparing for the section it is useful to reduce pressure on the umbilical cord. The important treatment is so that the diagnosis can be made quickly and an internal examination should be carried out if the membranes have ruptured, while the head is still high. Also if the heart sound becomes bad in labor, it should be checked whether it is not caused by the prolapse of the umbilical cord (funikuli prolapse). If labor monitoring is carried out by cardiotocography (KTG), it will provide a picture of variable decelerations which can mean fetal distress The general management of cord prolapse is administration of 4-6 L oxygen per minute via a mask or nasal cannula. And the specific management is determining whether the umbilical cord is still throbbing or not. a. The umbilical cord pulsates

• If the umbilical cord is throbbing, it means the fetus is still alive.
• If the mother is in the first stage of labour, in all cases  Wearing sterile or high-level disinfected (DTT) gloves, insert one hand into the vagina and push the presenting part up to relieve pressure on the cord and expel the presenting part of the pelvis.  Place the other hand on the abdomen (suprapubic) to keep the presenting part outside the pelvis.  After the presenting part is held firmly above the pelvic inlet, remove the hand from the vagina. Keep hands over abdomen until cesarean section is performed.

reduce pressure on the umbilical cord, for example by placing the mother in the Trendelenburg position. Before carrying out a cesarean section, the fetal heart sound is checked again.  When the opening is complete:

• Do a cesarean section if the head is still high, shake the head and extract or cesarean section.
• Vacuum extraction or forceps if the largest head has passed through the pelvic inlet.
• In small children (child II gemeli) it can be attempted to express the fundus first and if the requirements for forceps are met, extraction is carried out with forceps.
• Don't waste time trying to reposition the cord.

2. In transverse position: Perform cesarean section.
3. In breech position: If the membranes rupture, immediately do an internal examination to ensure that there is no prolapse of the umbilical cord. If cord prolapse occurs and delivery does not occur, deliver the fetus by cesarean section.  If the opening is still small/incomplete, do a cesarean section.  If a complete opening is performed, a cesarean section or an extraction version is performed if the lowest part of the fetus descends deep into the pelvis and preparation for surgery takes a long time or if the child's heart sounds are bad.  The fetus is delivered by leg extraction if the fetus is small or not very large
4. In multiparas with normal pelvic size, at the time of complete dilation, the fetus should be delivered immediately.
5. In posterior head presentation, strong enough pressure is applied to the uterine fundus at the time of hys, so that the fetal head enters the pelvic cavity and can be delivered immediately, if necessary, this action can be assisted by performing a sharp extraction. 1,3,6, B. Leading or leading umbilical cord

Try not to rupture the membranes, the mother is in the Trendelenburg position lying on her side in the opposite direction to where the umbilical cord is. Reposition and push the head into the pelvic inlet. As long as the fetus is alive and able to survive, oxygen is given to the mother and the presenting part of the fetus is elevated by hand in the vagina to prevent compression of the umbilical cord. The patient is immediately placed in the Trendelenburg or knee- chest position. Not done, attempt to reposition the umbilical cord. Unless the cervix is fully dilated, the best results will be obtained by prompt cesarean section, as long as the fetal heart sounds are good. If the cervix is completely dilated and the fetal head or breech is deep in the pelvis, delivery may be accomplished by forceps or breech extraction if an experienced obstetrician is available. If the decision is made to perform a cesarean section, while waiting for the preparation it is necessary to keep the umbilical cord from experiencing pressure and being pinched by the lowest part of the fetus. For this reason, apart from placing the woman in the Trendelenburg position, one hand is inserted into the vagina to prevent the lowest part from descending into the pelvic cavity. You can also fill the bladder with 300 ml of NaCl and can be given a tocolytic in the form of terbutaline 0.25 mg subcutis. While preparations for the opera are being carried out, it is also possible to give ridothrin intravenously to prevent uterine contractions. Keep presentations on the rise until surgery begins. If the cervix is thinner and fully dilated, vaginal delivery may occur more quickly. If the fetus dies, no surgery is needed In the leading umbilical cord / leading umbilical cord, the patient is put to sleep in the Trendelenburg position with the hope that the amniotic fluid does not rupture too early and the umbilical cord reenters the uterine cavity. While waiting, the fetal heart sounds are closely watched while the progress of labor should always be assessed by internal examination to determine what actions need to be taken next. In circumstances where the fetus has died, there is no reason to complete labor immediately. Labor is supervised so that it takes place spontaneously, and action is only taken when necessary for the mother's sake 2.9 Complications