CORD PROLAPSE

There are three clinical types of abnormal descent of the umbilical cord by the side of the presenting part. All these are placed under the heading cord prolapse.

Occult prolapse - The cord is placed by the side of the presenting part and is not felt by the fingers on internal examination. It could be seen on

ultrasonography or during cesarean section.

Cord presentation - The cord is slipped down below the presenting part and is felt lying in the intact bag of membranes.

Cord prolapse: The cord is lying inside the vagina or outside the vulva following rupture of the membranes.

INCIDENCE: The incidence of cord prolapse is about 1 in 300 deliveries. It is mostly confined to parous women. Incidence is reduced with the increased use of elective CS in noncephali presentations.

ETIOLOGY: Anything which interferes with perfect adaptation of the presenting part to the lower uterine segment, disturbing the ball valve action may favor cord prolapse. Too often, more than one factor operates. The following are the associated factors:

(1) Malpresentations—the most common

being transverse (5–10%) and breech (3%) especially with flexed legs or footling and compound (10%)

presentation,

(2) Contracted pelvis,

(3) Prematurity

(4) Twins,

(5) Hydramnios

(6) Placental factor — minor degree placenta previa with marginal insertion of the cord or long cord,

(7) Iatrogenic—low rupture of the membranes, manual rotation of the head, ECV, IPV,

(8) Stabilizing induction.

DIAGNOSIS: Occult prolapse : is difficult to diagnose. The possibility should be suspected if there is persistence of variable deceleration of fetal heart rate pattern detected on continuous electronic fetal monitoring.

Cord presentation: The diagnosis is made by feeling the pulsation of the cord through the intact membranes.

Cord prolapse: The cord is palpated directly by the fingers and its pulsation can be felt if the fetus is alive. Cord pulsation may cease during uterine contraction which, however, returns after the contraction passes off. Temptation to pull down the loop for visualization or unnecessary handling is to be avoided to prevent vasospasm. Fetus may be alive even in the absence of cord pulsation. Hence, prompt USG for cardiac movements or auscultation for FHS to be done before fetal death is declared.

PROGNOSIS: Fetal—The fetus is at risk of anoxia from the moment cord is prolapsed. The blood flow is occluded either due to mechanical compression by the presenting part or due to vasospasm of the umbilical vessels due to exposure to cold or irritation when exposed outside the vulva or as a result of handling. The hazards to the fetus is more in vertex presentation especially when the cord is prolapsed through the anterior segment of the pelvis or when the cervix is partially dilated. The prognosis is, however, related with the interval between its detection and delivery of the baby and if the delivery is completed, within 10–30 minutes the fetal mortality can be reduced to 5–10%. The overall perinatal mortality is about 15–50%.

Maternal : The maternal risks are incidental due to emergency operative delivery, especially through the vaginal route. Operative delivery involves the risk of anesthesia, blood loss and infection.

ANTICIPATION AND EARLY DETECTION:

(1) Internal examination should be done whenever the membranes rupture prematurely or during labor in all cases of malpresentation, twins, hydramnios or vertex presentation where the head is not engaged.

(2) Surgical induction should preferably be conducted in the operation theater keeping everything ready for cesarean section. The uterine contraction may be initiated by oxytocin, if the head is not engaged prior to low rupture of the membranes. Internal examination both before and after amniotomy should be carried out with cord accident in mind.

(3) One should exclude cord presentation or occult prolapse, in unexplained fetal distress during labor.

HOMOEOPATHIC MEDICINES FOR MANAGING CORD PROLAPSE: -

1) Cal phos:- this remedy can help to strengthen a woman who tends toward easy tiredness,poor digestion, cold hands and feet, and poor absorption of nutrients. A person who needs cal phos is often irritable because of tiredness, and may long for a travel or a change of circumstances.

2) Caulophyllum:- this remedy may be helpful in women with weak muscle tone in the uterus. A history of irregular periods, slow and difficult labour with previous deliveries, or weakness of the cervix may bring this remedy to mind. She typically feels nervous, shaky, and trembling.

3) Carbo Veg:- this remedy can be helpful to a woman who feels weak and faints during pregnancy, with poor circulation, a general feeling of coldness, and a craving for fresh or moving air. She may also have frequent digestive upsets with burning pain and a tendency to belch.

4) Actaea racemosa:- this remedy can be helpful to women who are nervous and talkative,with a tendency to feel fearful and gloomy during pregnancy. They may become overagitated and a dear of miscarriage prevails.

5) Ferrum phos:- this remedy can be helpful for nervous sensitive women who feel weak or tired with easy flushing of face and a tendency towards anaemia. A woman who needs this remedy often has a slender build and may develop frequent neck and shoulder stiffness