Tehniyat Ishaq Khattak
Department of Gynaecology and Obstetrics
Khyber Teaching Hospital,
Peshawar
Pakistan

Bilquis Afridi
Department of Gynaecology and Obstetrics
Khyber Teaching Hospital,
Peshawar,
Pakistan

Jamila Javaid Shah
Department of Gynaecology and Obstetrics
Khyber Teaching Hospital,
Peshawar
Pakistan

This prospective descriptive study was conducted in Gynaecology and Obstetrics unit B of Khyber Teaching Hospital Peshawar from June 1995 to June 1997. All the patients (25) who were treated for umbilical cord prolapse during this period were enrolled in the study.

Diagnosis was made on the basis of clinical findings. The patients were treated according to the condition of the fetus and cervical dilatation and effacement. If the cord was found to be prolapsed and lying outside the introitus, it was checked for pulsations, was gently replaced into the vagina and dilatation of cervix was determined. If cervix was fully dilated and vaginal delivery was considered safe, it was done. If cervix was not fully dilated, immediate caesarian section was done, keeping the presenting part of the fetus off the cord until delivery of the fetus. Unnecessary handling of the cord was avoided to prevent spasm of the vessels and fetal distress.

If the fetus was dead, labour was allowed to continue unless contraindicated. If amniotomy was to be done, extreme care was taken to avoid dislodging the fetal head by applying a little fundal pressure. Fundal height was assessed and fetal heart sound recorded prior to and immediately after the procedure.

Patient was discharged with advice to have an early antenatal booking and regular antenatal check ups in the next pregnancy and to have hospital admission in early labour to have a short diagnosis delivery interval.

During the two year period, there were a total 5,322 obstetrics admissions. Total number of deliveries during this time period was 4,650 and out of these, 25 labours (0.4%) were complicated by umbilical cord prolapse. Frequency was 1.6 per 300 deliveries. (Table 1)

The majority of the patients in this series were non booked. Only 2 patients were booked out of 25 patients (8%). The non-booked patients were received via emergency or referred
by the peripheral hospitals .Most of these patients were in labour at the time of admission. Among those who came with cord prolapse, the highest percentage was of those with overt compared with occult prolapse; the highest percentage of cord prolapse was noted in multi and grand multi gravidas (80%) compared with primary gravidas (20%).

In this series the most common associated factor was abnormal lie (32%). Out of these 87.5% of the patients had transverse lie and 12.5% presented with oblique lie. The second highest incidence was in premature labour. Five out of twenty five patients presented with abnormal presentation (3 as breech and 2 as compound presentation); flex breech was more commonly seen as compared with extended breech. Three out of twenty five patients had major degree placenta previa. Two patients had twins. In one patient cord prolapse was followed by amniotomy for induction of labour. (Table 2)

INCIDENCE IN PRIMIGRAVIDA AS COMPARED WITH MULTI & GRAND MULTIGRAVIDA


BOOKING STATUS OF THE PATIENTS

As shown in Table 3, twelve out of twenty five (48%) fetuses came distressed. Although pulsation in the prolapsed cord was positive the fetal heart showed abnormal tachycardia or bradycardia. Seven out of twenty five showed normal heart rate and six were dead.

Twenty eight percent (7 out of 25) when they came in with cord prolapse were not in labour. Fifty two percent (13 patients) came in the first stage of labour and twenty percent (5 patients) were in the second stage of labour at the time of admission.

Sixteen patients were managed by caesarian section. Three out of 25 had normal vaginal delivery. Outlet forceps were applied on two patients and three were delivered as assisted breech and only one patient had vacuum extraction as shown in Table 4

Table 5 and 6 show the Apgar score of the delivered fetuses and perinatal deaths respectively. The majority of the fetuses that died, were stillborns. Five out of eleven died during the first week of life due to neonatal complications like neonatal sepsis and birth asphyxia. The majority of the stillborns were premature and prematurity itself is a major cause of perinatal morbidity and mortality.

Umbilical cord prolapse is an obstetrical emergency during pregnancy or labour that endangers the life of the fetus. This is associated with anything that prevents the presenting part from fitting closely into the lower uterine segment and thus shutting off the fore waters from the hind waters. Such cases include transverse lie, breech presentation especially with flexed legs, when the risk is trebled3. In one study in over 53% of cases a malpresentation was present7. Umbilical cord prolapse demands immediate attention. Delay in management is associated with significant perinatal morbidity and mortality8 due mainly to prematurity and birth asphyxia and occasionally congenital anomalies9. Four fifths of the cases occurred in multiparous patients especially in higher parities. Forewater amniotomy or manual rotation prior to forceps extraction has been responsible for up to 20% of umbilical cord prolapse in various series but in large series, risk of amniotomy appears small.10 It occurs when the baby's umbilical cord falls into the birth canal ahead of the baby's head or other parts of the baby's body. When the cord is compressed or squeezed e.g. between the baby and the wall of the uterus or vagina, the baby's supply of blood and oxygen is cut off which can lead to severe brain damage or death if the problem is not taken care of within minutes.

If the accident occurred outside the hospital, many babies would be dead or severely asphyxiated upon arrival in the hospital. Previous reports suggested that even if the neonates were delivered immediately after cord prolapse, the complication rate remained elevated. This is related to the fact that fetal prematurity and congenital anomalies are major contributory factors. In our series 6 babies were delivered before 37 completed weeks of pregnancy.

Some epidemiological studies have shown that the incidence of cord prolapse has remained stable through the years with the quoted rate of between 1 in 200 and 1 in 700. Our rate of 1.6 in 300 deliveries is in this quoted range. There is however conflicting evidence as to whether the fetal outcome is actually improved with better obstetric care 11,12,13 . We believe that the neonatal outcome is improved with the practice of immediate caesarian section. In our study there were 5 stillbirths and 6 babies died during the first week of life in the neonatal care unit; the majority of them due to prematurity and low level of neonatal care facilities. The majority of the stillbirths were due to referrals from remote areas either mishandled by unqualified birth attendants or reached late and the fetal demise already occurred in utero or the fetus was severely asphyxiated.

The immediate management of umbilical cord prolapse is determined by 3 factors: fetal viability, fetal maturity and presence of any lethal fetal anomalies. Emergency delivery is recommended for a normally formed and sufficiently mature fetus. In the first stage of labour, a caesarian section is the only way to achieve early delivery, however with a completely dilated cervix, the obstetrician has a choice between instrumental vaginal delivery and caesarian section. Several studies have quoted more favourable outcomes with caesarian section even in the second stage of labour. 14
Upon diagnosis of umbilical cord prolapse, various manoeuvers have been advocated to alleviate pressure on the prolapsed cord. We found that digitally elevating the presenting part was quicker and the most important component in addition to other methods described in the literature such as urinary bladder distension with saline, pelvic elevation or tocolysis.15

The German Society of Gynaecology and Obstetrics recommends a decision to delivery time of less than 20 minutes. The American College of Obstetricians and Gynaecologists believes a decision to incision time of 30 minutes is appropriate. We believe that this rapid decision to delivery interval contributes to reducing the morbidity of the cord prolapse. In our study of 25 cases, the main cause for delay was a logistic problem in preparing an operating theatre.

In our series, a predisposing factor was present in the vast majority of cases as seen in the table above. These are abnormal lie, malpresentation, prematurity, multiple pregnancy, polyhydramnios.16
There is a lack of consensus as to whether obstetric interventions are associated with higher risk of cord prolapse 17,18 In our series only 4% of the patients had cord prolapse following an amniotomy.
When a patient has spontaneous rupture of membranes or an ominous cardiotocographic tracing, immediate vaginal examination enables umbilical cord prolapse to be diagnosed.

In addition patients should be educated on the early signs of labour or pre-labour rupture of membranes so that they come to the hospital early for supervised delivery, as early delivery can make a difference between life and death for the baby.

Prolapse of umbilical cord is an obstetrical emergency with a well documented grave fetal prognosis in the literature. A high index of suspicion and recognition of predisposing factors may allow for early detection and timely delivery, thereby minimizing perinatal morbidity and mortality. More and more stress on regular antenatal checkups and supervised hospital delivery is also mandatory. A multidisciplinary approach to the organization of an emergency caesarian section is essential to allow the rapid and safe conduct of an emergency caesarian section to minimize maternal and fetal risks in such an emergency that threatens the life and well being of the fetus and indirectly of the mother.

Immediate delivery is the ideal if the fetus is alive and sufficiently mature.