The Difficult Delivery: Umbilical Cord Prolapse

A simplified approach to the initial assessment and management of emergency department patients with umbilical cord prolapse

Case

Once again, a 34 year old G5P4 woman at 39 weeks gestation is wheeled into your resus room in what appears to be precipitous delivery. You perform a quick exam, but instead of encountering the presenting part, you feel a pulsatile cord. Oh no, you remember hearing about umbilical cord prolapse back in medical school…

 

My approach

This is the simplest of our “difficult delivery” series:

As soon as the examining hand reveals an umbilical cord, the hand is used to elevate the presenting part and reduce compression of the cord. This hand remains in the vagina until baby is delivered by emergency c-section.

Call for help: Inform obstetrics and rapidly transport the patient to the OR for an emergency c-section.

Position the mother to reduce cord compression: either knee to chest position or left lateral with head down and pillow under mom’s hip.

If there is a delay to the OR, or if there is persistent fetal heart rate abnormalities, consider the use of a tocolytic:

  • Terbutaline 0.25mg subQ or 2.5-10mcg/min IV
  • Nitroglycerine 50-200mcg IV
  • Magnesium sulfate 4 grams IV over 15 minutes, then 1-4 grams/hr IV

Other FOAMed Resources

Again, I didn’t come across any while preparing this post, but I am happy to add links if you know of good resources.

 

References

VanRooyen MJ, Scott JA. Chapter 105. Emergency Delivery. In: Tintinalli JE et al eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381574

Royal College of Obstetricians and Gynaecologists. Green top guideline No. 50: Umbilical Cord Prolapse. November 2014. At: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-50-umbilicalcordprolapse-2014.pdf

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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