Which of the following measures has the highest priority when an intrapartum woman has a prolapsed umbilical cord?

AHRQ Safety Program for Perinatal Care

Purpose of the tool: This tool describes the key perinatal safety elements that support safe umbilical cord prolapse management. The key safety elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP).

Who should use this tool: Nurses, physicians, midwives, anesthesiology providers, neonatal providers, and other labor and delivery (L&D) staff responsible for intrapartum care and managing deliveries that may be complicated by cord prolapse.

How to use this tool: Review the key perinatal safety elements with L&D leadership and relevant unit staff to determine how the elements will be implemented at your hospital. Consider any existing hospital procedures, policies, or processes related to cord prolapse management.

Key Perinatal Safety Elements

References

1. Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal Nurs 2008 Sep-Oct;37(5):510-5. PMID: 18761565.
2. Holbrook BD, Phelan ST. Umbilical cord prolapse. Obstet Gynecol Clin North Am 2013 Mar;40(1):1-14. PMID: 23466132.
3. Phelan ST, Holbrook BD. Umbilical cord prolapse: a plan for an OB emergency. Contemp OB/GYN. 2013 Sept 1. http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/umbilical-cord-prolapse?page=full. Accessed May 2, 2016.
4. Government of Western Australia, Department of Health. Obstetric and Gynaecology Clinical Guidelines Section B. Obstetrics and Midwifery Care, Section b11.3.2  Umbilical Cord Prolapse. January 2015 http://kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/index.htm#11. Accessed July 4, 2016.
5. Perinatal Services BC. Core Competencies--Management of Labor, Decision Support Tool 8A—Obstetrical Emergencies Cord Prolapse. 2014 April 14. http://www.perinatalservicesbc.ca/health-professionals/guidelines-standards/standards/core-competencies-for-management-of-labour. Accessed May 2, 2016.
6. Siassakos D, Hasafa Z, Sibanda T, et al. Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG 2009 Jul;116(8):1089-96. PMID: 19438496.

Appendix

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Sample Cord Prolapse Management Checklist

___ Communicate the diagnosis to key staff.

___ Identify prolapse/cord pulsations [Call Time] (hh:mm:ss)  ___ : ___ : ___

    Communicate diagnosis to—
       ___ Patient/family members
       ___ Maternity care provider (physician or midwife)
       ___ Charge nurse
       ___ Nursing staff
       ___ Pediatric provider
       ___ Anesthesiology provider

___ Designate one team member as recorder.

___ Designate one team member as communicator.

___ Protect the cord.

• Minimize manipulation of the cord.
• If cord is protruding from vagina, cover with sterile towel saturated with warm saline.

    If fetal heart rate abnormality is detected, consider taking the following actions:

• Minimize exposure to cold environment (i.e., room temperature). Retaining as much of the cord intravaginally as possible is recommended. [Call Time] [hh:mm:ss] ___:____:___
• Funic decompression—examiner’s hand is placed vaginally and gently elevates the fetal head or presenting part. [Call Time] [hh:mm:ss] ___:____:___
• Consider Trendelenburg positioning, knee-chest position, or gentle suprapubic elevation. [Call Time] [hh:mm:ss] ___:____:___
• Funic reduction (manual replacement of the cord)—This is a controversial practice. Earlier studies, prior to the advent of continuous fetal monitoring, showed association with increased risks of fetal hypoxia and death. Later but smaller series have shown success, particularly if cesarean section must be delayed, or if only a short segment of cord is prolapsed and vaginal delivery is imminent. [Call Time] [hh:mm:ss] ___:____:___

___ Stop oxytocin infusion (if receiving)

___ Assess indications for expectant management:

• Lethal fetal anomalies.
• Previable gestational age.
• Fetal demise.

___ Assess likelihood of safe vaginal birth within 15 minutes of elapsed time from diagnosis.

• Cervix is fully dilated, presenting part engaged, and station is low enough for an assisted or spontaneous vaginal delivery within 15 minutes → proceed with vaginal delivery.

  [Call time of decision to proceed with vaginal delivery] [hh:mm:ss] ____:____:____

• Safe vaginal birth NOT likely within 15 minutes → proceed with cesarean section.

  [Call time of decision to proceed with cesarean section] [hh:mm:ss] ____:____:____

• Obtain verbal consent from patient for cesarean section.

  [Call Time] [hh:mm:ss] ____:____:_____

___ If appropriate, administer oxygen by face mask at 8–10 liter/min.
         [Call Time] [hh:mm:ss] ___:____:___

___ If delay with proceeding to cesarean section:

• Consider retrofilling the bladder with 500–700 mL of normal saline. This MUST be drained prior to cesarean delivery.

  [Call Time] [hh:mm:ss] ___:____:___

• Consider tocolytics.

___ Prepare for neonatal resuscitation.

___ Deliver baby.

     [Call time of delivery of presenting part] [hh:mm:ss] ___:____:___

• Obtain umbilical cord blood for blood gas analysis.

___ Debrief with all team members.

___ Document key times, decisions, and interventions.

• Exam findings (e.g., cord pulsations) indicating prolapse and time of exam.
• Time of provider and team notification and arrival.
• Time of decision to proceed with vaginal delivery and rationale –OR– time of decision to proceed with cesarean section and rationale.
• Maneuvers used (positioning, bladder fill, oxygen, funic decompression and/or reduction), including sequencing, timing, and fetal response.
• Delivery description (vaginal, assisted vaginal, cesarean).
• Time of delivery and length between identification of prolapse and delivery.
• Staff present
  Maternity care provider(s) ______________________________________________
  Nursing staff_________________________________________________________
  Anesthesia provider___________________________________________________
  Pediatric provider_____________________________________________________
  Other______________________________________________________________
• Neonatal status:
  Birth weight (grams) _______
  Outcome: deceased or live birth
  Apgars: 1 min/5 min/10 min, if applicable
  Blood gases: sent or not sent
  Arterial: pH and base deficit:           Venous: pH and base deficit:
  Infant location after birth: remained in room with mother, transferred to NICU, transferred to newborn nursery
• Maternal status after delivery