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Prolapse of the umbilical cord
PROLAPSE A WILLIAM (From
OF THE
UBIRILICAL
Study of Sixty-three Cases
G. SLATE, CH.B., AND JOHN H. RANDALL, the
Department
CORD
of Obstetrics
and
Gynecology,
M.D., IOWA CITY, Iowa State
l’niuersity
of Iowa)
P
ROLAPSE of the umbilical cord is a complication of parturition which frequently leads to fetal death. For purposes of this study, presentation of the cord is considered to be that condition in which the umbilical cord lies below the presenting fetal part with intact membranes, and prolapse as that condition in which the cord is discovered alongside of or below the presenting part with ruptured membranes. Sixty-three cases of prolapse of the cord occurred among 15,578 deliveries at the State University of Iowa Hospitals between Jan, 1, 1940, and Dec. 31, 1953. This represents an incidence of 0.4 per cent or a ratio of 1 to 250 deliveries. A collection of statistics from 24 different authors showed 4,296 prolapsed umbilical cords in 669,547 deliveries, which is a ratio of 1 to 156. In this review of the literature, the maximum incidence was 1 to 74 in 20,000 dcliveries by Craginl and the minimum, 1 to 1,018 by Doer? in 25,461 deliveries. Etiology Maladaptation.-The size and/or shape of the presenting part in relation to the size and shape of the pelvis or the presence of a pelvic tumor can produce maladaptation and predispose to prolapse of the cord. Obstetric manipulations are sometimes responsible for maladaptation in a presentation which was previously satisfactory. Many authors have emphasized a relationship between the incidence of was present in 3.9 prolapse of the cord and contracted pelves. Disproportion per cent of Joubert’s3 series of 203 prolapsed cords and in 11.1 per cent of 216 cases reported by Fenton and D’Esop~.~ In 155 patients with prolapsed cords, however, Bourgeois5 had an incidence of 18.1 per cent of abnormal bony pelves. In this series there was an incidence of 4.8 per cent of associated contracted pelves with prolapse of the umbilical cord. Some authors feel63 7 that prolapse of the cord itself suggests the presence of a contracted pelvis. Certainly, when one is aware that a patient’s pelvis is contracted, prolapse of the cord should be anticipated, and a careful pelvic examination should be made following rupture of the membranes. Presentation.-The liability to prolapse of the umbilical cord is greatest in transverse or shoulder presentation, next in breech, and least likely in vertex. Statistics in support of this statement are shown in Table I. It will also be noted (Table II) that the most frequent presentation is that of vertex when a prolapsed cord is present. This is naturally due to the fact that most deliveries are vertex, resulting in a greater opportunity for prolapse of the umbilical cord to occur m association with this presentation. Next in order of frequency of association with prolapsed cord are breech and transverse presentations, respee,tively. 991
992
SLATE TABLE
I.
I
Kurzrockg Mengert and Longwelllz Brandeberry and Kistners Slate and Randall II.
HANl)AI,T,
PERCENTAGE INCIDENCE OF PROLAPSE OF UMBILICAL BREECH, AND TRANSVERSE PRESENTATIONS
AUTHOR
TABLE
AND
PERCENTAGE
INCIDENCE
AUTHOR
Kurzrockg Morgan14 Mengert and Longwelll:! Cope13 Kushlo Doer@ Jouberts Fenton4 Slate and Randall *Presentation was not
BREE(!H
0.5 0.37 0.25 0.24
6.0 4.54 4.58 2.3
OF PRESENTATION
NO. OF CASES
VERTEX
100 ii 350 105 25 203 216 59” recorded
VERTEX
in
59.0 62.0 58.5 60.0 52.0 60.0 46.3 63.5 58.0 4 cases.
IN
CASES
CORD IN VERTEX,
/
TRANSVERSp:-_
10.0 11.27 12.0 14.6
OF PROL~PSED
BREECH
TRANSVERSE
23.0 12.0 33.0 21.0 29.0 32.0 25.6 26.0 22.0
18.0 21.5 8.5 15.0 19.0 8.0 20.7 6.0 12.0
UMBILICAL
CORD
COMPOUND
4.5 4.0 7.4 4.5 8.0
Prematurity.-There were 18 premature babies according to birth weight (less than 2,500 grams). This represents an incidence of 28.6 per cent of prematurity, associated with prolapsed cord, which is more than four times the incidence of premature babies in all deliveries (6.9 per cent). Malposition and malpresentation are more common in premature than in full-term deliveries. The increased incidence of prolapse of the cord also results from the small size of the presenting part, which is insufficient to fill the pelvis, thus permitting the cord to escape more easily. Pa&Y.--In this series the danger of prolapse was nearly twice as great in multiparas (0.41 per cent) as in primiparas (0.25 per cent). This is probably due to the fact that the presenting part is usually higher in the multipara at the time of rupture of the membranes. Brandeberry and Kistner,8 and Kurzrock,g also observed an increased incidence of prolapse of the umbilical cord in multiparas. Cervical Dilatation.-Prolapse of the cord occurred with nearly equal frequency at all degrees of dilatation of the cervix in this series except for a peak incidence of 35 per cent at complete dilatation (Fig. 1). The cervix was dilated 8 cm. or more in 57 per cent of the patients when prolapse of the cord occurred. Fenton and D’Esopo4 observed the greatest incidence of prolapsed cords when the cervix was fully dilated. Joubert? and KushlO found in almost half of their cases, and Kurzrockg in three-fourths of his, that the cervix was fully or almost fully dilated when prolapse was diagnosed. Rupture of the Membranes.-The membranes were ruptured artificially in 17 cases for induction of labor. In 13 of these the rupture was performed following the usual medical induction, and in 4 the Voorhees bag was used in addition. Artificial rupture was done in 12 other cases during the course of labor to improve the character of uterine contractions. During artificial rupture of the membranes, the displacement of the presenting part upward along with the escape of amniotic fluid predisposes to prolapse of the cord. Keettel and his associatesll found that prolapse of the cord and arm was twice as frequent when the membranes were prematurely artificially ruptured as when they spontaneously ruptured.
Volume 72
Numlw
PROLAPSE
i
OF
UMBILICAL
CORD
!I!,3
Twin Pregnancies.-Eight twin pregnancies occurred in the series. This is an incidence of 1 to 7.9 in the prolapsed-cord series as compared to 1 to 86.9 in the entire group of patients. In twin labors several factors, such as the increased incidence of prematurity and hydramnios, and the high presenting part of the second twin when its amniotic sac ruptures, predispose to prolapse of the cord. Prolapse of the umbilical cord should be anticipated more often in twin labors, thus justifying more frequent vaginal examinat,ions, especially during the second stage. Length of the Umbilical Cord.-The average length of the umbilical cord was 61.7 cm. for all cases in the series. The cord was less than 40 cm. in 2 cases (30 and 38 cm.), and 75 cm. or more in 8. In a study of 545 long cords (75 cm. or more in length) by Mengert and Longwell,12 it was found that prolapse occurred in 20 cases? a frequency 6 times as great as that in the entire obstetric service. In the present study there were 248 long cords among all t,he deliveries with 8 prolapses, which is a frequency 8 times as great as wnul~l be cspecttd. M m--m
iOO%-
GROSS FETAL MORTALITY STILLBIRTH PROLAPSED CORD
80%-
60%-m
40 %-
20%
-*
018..
0
I
2
3
Cervical Fig.
I.-Fetal
mortality
in relation
dilatation
*. 4
. . . 5 6 7 8 (cm.) when prolapse diagnosed
to cervical dilatation diagnosed.
Perinatal
at
the
time
.8 9
IO
prolapse
of
the
co14
was
Mortality
When it occurs, prolapsed cord is responsible for a very high fetal loss and means death to the fetus before birth in almost 50 per cent of the cases, with additional neonatal fatalities from anosia and traumatic delivery. Some reduction in the fetal mortality rate in more recent years is indicated by the study of 2 ten-year periods by Cope,13 and by a comparison of the thirtecnyear period of Mengert and Longwell,lz with the present series (Table III). Various Factors in Relation to Perinatal Mortality.Parity: There were 15 primiparas with a gross fetal mortality rate of 40 per cent, and 48 multiparas with a rate of 43.7 per cent. These results do not confirm the findings of Mengert and Longwell’” that fetal mortality from prolapsed cord is twice as high in primiparas as in multiparas, but they support the observations of Fenton and D’Esopo4 and Hrandeberry and Kistner8 that the fetal risk is actually slightly lower in primiparous individuals. At least equal significance should, therefore, be attached to prolapse of the umbilical cord in multiparas, as the fetal dangers may be even slightly greater than in primiparas.
994
SLATE
TABLE
YEAR 1915-1927 1927-1947 1928-1937 1938-1947 1941 1940-1949 1948-1949 1924-1948 1926-1939 1947-1951 1948-1953 1940-1953
III.
PERINATAL
AKD
MORTALITY
Kurzroekg Cope13 Cope13 Cope13 Bourgeois5 Brandeberry
and
WITH
PROLAPSED NO. OF CASES
AUTHOR
I
Am. J. Obst. & Gynec. November, 1956
RANDALL
Kistners
cox15
Fenton4 Mengert and Longwell Kushlo Jouberts Nate and Randall
100 350 153 179 155 116 35 216 1E 203 63
CORD
I
GROSS ‘j$ 63.0 50.6 58.1 47.5 49.7 35.3 11.4 37.5 46.6 49.0 60.6 42.8
Presentation: In the presented series, the fetal mortality was higher in vertex presentation (35.3 per cent) than in breech (23.1 per cent), but less than in transverse (57.2 per cent). These findings are in agreement with the reports of Cope,13 Kurzrock,g and Mengert and Longwell.12 Fenton and D’Esopo4 found a higher mortality in breech than in vertex presentations, and concluded that in the.latter the favorable conditions more than compensated for the greater compression of the cord. The low fetal salvage in transverse or shoulder presentations reported by almost all authors is no doubt related to the greater difficulties encountered in delivering the baby. Xtation at time of diagnosis of prolapse of the cord: Of 56 cases on which information was available, 29 had a presenting part which was either floating or above the spines. Fourteen of these infants were stillborn (48.2 per cent), and 2 others died in the neonatal period. The presenting part was at or below the spines in 27, and of these, 6 were stillborn (22.2 per cent) and 3 died neonatally. Thus, the mortality risk was more than twice as great when the presenting part was not engaged. Other authors47 l2 have found a lower fetal salvage when the presenting part was high. Cervical dilatation at the time of diagnosis of prolapse of the cord: The greater the degree of cervical dilatation when the diagnosis of prolapsed cord is made, the lower the fetal mortality rate. This is due to the fact that conditions are then more favorable for delivery. Fig. 1 indicates the frequency with which prolapse of the cord occurred at the various degrees of cervical dilatation, and the associated fetal mortality rates. Time interval between rupture of membranes and diagnosis of prolapsed cord: The diagnosis of prolapsed cord was made immediately after the membranes ruptured in 19 patients and among these there were 4 stillbirths (21.0 per cent). Five cases of prolapsed cord were diagnosed within one-half hour of rupture of the membranes with 3 stillbirths. Of 35 prolapses occurring 2 or more hours before a diagnosis was made, there were 12 stillbirths (34.2 per In general, the sooner the diagnosis was made after the rupture of cent). the membranes, the better the outlook for the baby. Time of vaginal examination in relation to rupture of the membranes: The earlier the diagnosis was established after rupture of the membranes, the lower was the fetal mortality rate. Either a prolapse of the cord occurring late after the rupture of the membranes, or a delay of the diagnosis of an earlier prolapse from procrastination in performing a vaginal examination after rupture of the membranes may be responsible for a progressive increase in the stillbirth rate. This suggests that vaginal examination should be made in every labor at the time of rupture of the membranes to avoid any delay in diagnosing a prolapsed cord. Any alteration of the fetal heartbeat should
PROLAPSE
Volume 72
Nnmber 5
OF
UMBILICAT,
CORD
095
indicate a more thorough examination than would be normally carried out and would result in the detection of many cases of occult prolapsed cord. Additional information obtained from vaginal examination, such as the dilat,ation of the cervix and the presentation of the fetus, would be of great value to the obstetrician in accomplishing and making plans for delivery. Cart should be taken, however, not to push the presenting part out of the pelvis. and thus predispose to prolapse of the cord when making the examination. Time interuaZ between diagnosis and delivery: As would be expected, there was a progressive increase in the mortality rate with increase in time between the diagnosis of prolapsed cord and delivery. Our results are similar t,o those of Fenton and D’Esopo4 except that the mortality rate in their series rose con more dramatically when the time interval was increased from one-half to one hour, and reached ‘70 per cent if the delivery was not achieved until three hours after diagnosis (Fig. 2). A high incidence of operative delivery will be noted in Table IV. This was necessary in order to lessen the time interval between the diagnosis of prolapse of the cord and the birth of the baby. Operativr delivery was associated with a greater fetal mortality rate due to the fact that conditions were usually unfavorable for intervention.
100% 1
.--. -
FENTON et ol RANDALL 8 SLATE I’
9
60% -’ z-. L z ‘, 60%.. E 5 f 40%” 2 P ” 20%.0
I
I
I
Time interval
Fig.
2.-Fetal
mortality TABLE
IV.
TYPE OF DELIVERY
Spontaneous Forceps Breech Version and extraction Cesarean section Total
in TYPE
3
,
IO
5
0
relation
to
the
OF DELIVERY
(hrs.) between diagnosis
time
interval
AND ASSOCIATED
NO. OF CASES
NO. OF STILLBORNS
ii 15 6 5 63
: 7 I 1 21
20
30
and delivery
between FETAL
diagnosis
and
delivery.
MORTALITY
NO. OF NEONATAL DEAmS
0 1 3 1 1 6
PER CENT OF FETAI> MORTALITY
40.0 31.8 66.7 33.3 40.0
42.8
Petal mortality in relation to weight of the baby: The perinatal mortality for premature infants was 55.5 per cent, for mature babies 37.7 per cent, and for the entire group 42.8 per cent. Stillbirths occurred with equal frequencv (33 per cent) in premature and full-term babies. This is approximately $5
times as great as the stillbirth rate for all deliveries (2.1 per cent). The birth rate for all premature infants born during the period under review 15.1 per cent, which is about half of what it was when prematurity was ciated with prolapsed cord. There were in all 6 neonatal deaths, and these were of premature babies.
Maternal
stillwas a,sso4 of
Risks
Nine patients (14.3 per cent) suffered a blood loss of over 600 C.C. This is four times greater than the general incidence of postpartum hemorrhage (3.1 per cent) for the entire group and was probably due to the increased number of associated operative procedures. Twelve patients (19 per cent) had a morbid puerperium. This incidence might have been even higher had not prophylactic antibiotics been administered in 22 cases. The increased morbidity was related to the necessity for manipulative and operative procedures to accomplish rapid delivery. Maternal morbidity for the entire group of obstetric patients was 5.4 per cent. There was one maternal death, that of a 21-year-old multipara, who died on the tenth postpartum day after a severe sepsis (peritonitis and bilateral bronchopneumonia) . Diagnosis Because of the great risk to the fetus in the event of prolapse of the umbilical cord, the diagnosis should be made at the earliest possible moment so that treatment may be started at once and the fetal risk be substantially reduced. The condition should be kept in mind particularly when one or more etiological factors are present. A diagnosis of cord presentation can be made with certainty only by vaginal examination. However, the diagnosis of prolapsed cord was made by the appearance of the cord at the vulva in 24 instances. In 27 cases it was discovered primarily by vaginal examination. Six cases were detected by changes in the fetal heartbeat leading to further examination. In some patients the cord made its appearance at the vaginal introitus during a rectal examination. Early vaginal examination should be advocated in all suspected cases.
Treatment Cord Presentation.-Rupture of the membranes must be prevented if possible as the fetus is usually safe when they are intact. A close check of the fetal heartbeat will indicate any threat to the baby. An attempt to displace the cord to a higher level in the uterus can be attempted by postural means such as the knee-chest, elevated Sims, or Trendelenburg position, which are tolerated only for short periods without discomfort to the mother. Those patients in whom presentation of the cord is corrected should be delivered vaginally; otherwise cesarean section should be undertaken. Cord Prolapse.-Whenever a condition which predisposes to prolapse of the cord is present, every endeavor should be made to prevent the rupture of the membranes. If this occurs, an immediate vaginal examination should be made. When the cord is prolapsed, the patient should immediately be placed in a posture (knee-chest, deep Trendelenburg, elevated Sims position) so as to reduce compression of the cord. Attempts to replace the cord are usually futile and waste valuable time. The presenting part can be held up by an assistant with a finger in the vagina until delivery is accomplished by cesarean section or otherwise. Additional oxygen should be supplied to the mother and immediate delivery carried out. Vaginal delivery is preferred if conditions are suitable, The use of Diihrssen ‘S incisions when the cervix is not dilated
\‘olume iz liLin,l>er <
PROLAPSE
OF
UMBILICAL
C’ORT)
?!G
and the employment
of forceps or internal version will depend upon the contlitions present and the experience of the operator. If vaginal delivery is not feasible, cesarean section should be considered if one is reasonably certain tht* baby can be delivered alive. If there is any question as to whether the baby is alive or not, the benefit of the doubt should be given to the baby, who may still be alive although the fetal heartbeat is inaudible and no pulsation in the cord detectable, especially during or soon after a contraction, as both may return between contractions. Only in cases of extreme prematurity (nonviability) and cases of severe distress, associated with conditions not satisfactory for vaginal delivery ami showing no improvement by supportive efforts, should the presence of a prolapsed cord be accepted as an unfortunate circumstance about which nothing can be done. Summary and Conclusions
1. Sixty-three cases of prolapse of the umbilical cord which occurred at the State University of Iowa Hospitals between Jan. 1, 1940, and Dec. ::I. 1953, have been reviewed. 2. In a survey of 24 different publications, there were reported 4,296 prolapsed cords in 669,547 deliveries, an incidence of one case in 156 deliveries. 3. The liability of the umbilical cord to prolapse is greatest in transverse. less likely in breech, and least liable in vertex presentation. 4. The gross fetal mortality was 42.8 per cent and is mainly caused by (a) delay in the diagnosis of prolapse of the umbilical cord, (1~) high operative delivery rate, and (c) increased incidence of prematurity. 5. Prolapse of the umbilical cord could be diagnosed more quickly by frequent and repeated checks of the fetal heartbeat and by vaginal examinations performed soon after the rupture of the membranes. 6. Treatment of prolapse of the cord, when the fetus is still viable, is immediate delivery, by the vaginal route if conditions are suitable, otherwise I~!ccsarcan se&ion.
References 1. 2. 3. 4. 5. Ii. 7. 8. CI 1;): 11. Id. 13. 14. 1.5.
Cragin, E. B.: The Practice of Obstetrics, Philadelphia, 1916, Lea & Febiger. Doerr. Louis F.. Jr.: J. Michigan M. Sot. 46: 1277. 1947. J. 28: 570 1954.’ Joubert P. J.: ’ South African-M. AM. J. OBST. & GYNEC. 62: .52, l!J51. Fentom’Arnold N.. and D’ESORO, D. Anthony: Bourgeois, George A. : AM, J. ~B&T. & GYNEC. 41: 837, 1941. on Pathology of Labor, the Puerperium, and the McCormick, Charles 0. : A Textbook Newborn, ed. 2, St. Louis, 1947, The C. V. Mosby C0mpan.v. Titus, Paul: The Management of Obstetric Difficulties, ed. 3, St. Louis, 1945. The C. V. Mosby Company. Brandeberry. Keith R.. and Kistner, Robert a’.: Asr. J. OBST. & GYXEC. 61: 356. 1951. AM: J. OBST. & GYNEC. 23: 403, 1932. Kurzrock, Julius: Kush, Arthur W.: AM. J. OBST. & GYNEC. 66: ISS, 1953. Keettel, W. C., Diddle, A. W., and Plass, E. D.: AX J. OBST. & GYNEC. 40: 225, 1940. Mengert, William F., and Longwell, Freeman H.: AM. J. O&ST. & GYNEC. 40: 79, 1941). Cope, Edward: J. Obst. & Gynaec. Brit. Emp. 58: 259, 1951. Brit. M. J. 2: 820, 1948. Morgan, Joyce: Cox, J.. Woodrow: Lancet 1: 561, 1951.
OF THE
UBIRILICAL
Study of Sixty-three Cases
G. SLATE, CH.B., AND JOHN H. RANDALL, the
Department
CORD
of Obstetrics
and
Gynecology,
M.D., IOWA CITY, Iowa State
l’niuersity
of Iowa)
P
ROLAPSE of the umbilical cord is a complication of parturition which frequently leads to fetal death. For purposes of this study, presentation of the cord is considered to be that condition in which the umbilical cord lies below the presenting fetal part with intact membranes, and prolapse as that condition in which the cord is discovered alongside of or below the presenting part with ruptured membranes. Sixty-three cases of prolapse of the cord occurred among 15,578 deliveries at the State University of Iowa Hospitals between Jan, 1, 1940, and Dec. 31, 1953. This represents an incidence of 0.4 per cent or a ratio of 1 to 250 deliveries. A collection of statistics from 24 different authors showed 4,296 prolapsed umbilical cords in 669,547 deliveries, which is a ratio of 1 to 156. In this review of the literature, the maximum incidence was 1 to 74 in 20,000 dcliveries by Craginl and the minimum, 1 to 1,018 by Doer? in 25,461 deliveries. Etiology Maladaptation.-The size and/or shape of the presenting part in relation to the size and shape of the pelvis or the presence of a pelvic tumor can produce maladaptation and predispose to prolapse of the cord. Obstetric manipulations are sometimes responsible for maladaptation in a presentation which was previously satisfactory. Many authors have emphasized a relationship between the incidence of was present in 3.9 prolapse of the cord and contracted pelves. Disproportion per cent of Joubert’s3 series of 203 prolapsed cords and in 11.1 per cent of 216 cases reported by Fenton and D’Esop~.~ In 155 patients with prolapsed cords, however, Bourgeois5 had an incidence of 18.1 per cent of abnormal bony pelves. In this series there was an incidence of 4.8 per cent of associated contracted pelves with prolapse of the umbilical cord. Some authors feel63 7 that prolapse of the cord itself suggests the presence of a contracted pelvis. Certainly, when one is aware that a patient’s pelvis is contracted, prolapse of the cord should be anticipated, and a careful pelvic examination should be made following rupture of the membranes. Presentation.-The liability to prolapse of the umbilical cord is greatest in transverse or shoulder presentation, next in breech, and least likely in vertex. Statistics in support of this statement are shown in Table I. It will also be noted (Table II) that the most frequent presentation is that of vertex when a prolapsed cord is present. This is naturally due to the fact that most deliveries are vertex, resulting in a greater opportunity for prolapse of the umbilical cord to occur m association with this presentation. Next in order of frequency of association with prolapsed cord are breech and transverse presentations, respee,tively. 991
992
SLATE TABLE
I.
I
Kurzrockg Mengert and Longwelllz Brandeberry and Kistners Slate and Randall II.
HANl)AI,T,
PERCENTAGE INCIDENCE OF PROLAPSE OF UMBILICAL BREECH, AND TRANSVERSE PRESENTATIONS
AUTHOR
TABLE
AND
PERCENTAGE
INCIDENCE
AUTHOR
Kurzrockg Morgan14 Mengert and Longwelll:! Cope13 Kushlo Doer@ Jouberts Fenton4 Slate and Randall *Presentation was not
BREE(!H
0.5 0.37 0.25 0.24
6.0 4.54 4.58 2.3
OF PRESENTATION
NO. OF CASES
VERTEX
100 ii 350 105 25 203 216 59” recorded
VERTEX
in
59.0 62.0 58.5 60.0 52.0 60.0 46.3 63.5 58.0 4 cases.
IN
CASES
CORD IN VERTEX,
/
TRANSVERSp:-_
10.0 11.27 12.0 14.6
OF PROL~PSED
BREECH
TRANSVERSE
23.0 12.0 33.0 21.0 29.0 32.0 25.6 26.0 22.0
18.0 21.5 8.5 15.0 19.0 8.0 20.7 6.0 12.0
UMBILICAL
CORD
COMPOUND
4.5 4.0 7.4 4.5 8.0
Prematurity.-There were 18 premature babies according to birth weight (less than 2,500 grams). This represents an incidence of 28.6 per cent of prematurity, associated with prolapsed cord, which is more than four times the incidence of premature babies in all deliveries (6.9 per cent). Malposition and malpresentation are more common in premature than in full-term deliveries. The increased incidence of prolapse of the cord also results from the small size of the presenting part, which is insufficient to fill the pelvis, thus permitting the cord to escape more easily. Pa&Y.--In this series the danger of prolapse was nearly twice as great in multiparas (0.41 per cent) as in primiparas (0.25 per cent). This is probably due to the fact that the presenting part is usually higher in the multipara at the time of rupture of the membranes. Brandeberry and Kistner,8 and Kurzrock,g also observed an increased incidence of prolapse of the umbilical cord in multiparas. Cervical Dilatation.-Prolapse of the cord occurred with nearly equal frequency at all degrees of dilatation of the cervix in this series except for a peak incidence of 35 per cent at complete dilatation (Fig. 1). The cervix was dilated 8 cm. or more in 57 per cent of the patients when prolapse of the cord occurred. Fenton and D’Esopo4 observed the greatest incidence of prolapsed cords when the cervix was fully dilated. Joubert? and KushlO found in almost half of their cases, and Kurzrockg in three-fourths of his, that the cervix was fully or almost fully dilated when prolapse was diagnosed. Rupture of the Membranes.-The membranes were ruptured artificially in 17 cases for induction of labor. In 13 of these the rupture was performed following the usual medical induction, and in 4 the Voorhees bag was used in addition. Artificial rupture was done in 12 other cases during the course of labor to improve the character of uterine contractions. During artificial rupture of the membranes, the displacement of the presenting part upward along with the escape of amniotic fluid predisposes to prolapse of the cord. Keettel and his associatesll found that prolapse of the cord and arm was twice as frequent when the membranes were prematurely artificially ruptured as when they spontaneously ruptured.
Volume 72
Numlw
PROLAPSE
i
OF
UMBILICAL
CORD
!I!,3
Twin Pregnancies.-Eight twin pregnancies occurred in the series. This is an incidence of 1 to 7.9 in the prolapsed-cord series as compared to 1 to 86.9 in the entire group of patients. In twin labors several factors, such as the increased incidence of prematurity and hydramnios, and the high presenting part of the second twin when its amniotic sac ruptures, predispose to prolapse of the cord. Prolapse of the umbilical cord should be anticipated more often in twin labors, thus justifying more frequent vaginal examinat,ions, especially during the second stage. Length of the Umbilical Cord.-The average length of the umbilical cord was 61.7 cm. for all cases in the series. The cord was less than 40 cm. in 2 cases (30 and 38 cm.), and 75 cm. or more in 8. In a study of 545 long cords (75 cm. or more in length) by Mengert and Longwell,12 it was found that prolapse occurred in 20 cases? a frequency 6 times as great as that in the entire obstetric service. In the present study there were 248 long cords among all t,he deliveries with 8 prolapses, which is a frequency 8 times as great as wnul~l be cspecttd. M m--m
iOO%-
GROSS FETAL MORTALITY STILLBIRTH PROLAPSED CORD
80%-
60%-m
40 %-
20%
-*
018..
0
I
2
3
Cervical Fig.
I.-Fetal
mortality
in relation
dilatation
*. 4
. . . 5 6 7 8 (cm.) when prolapse diagnosed
to cervical dilatation diagnosed.
Perinatal
at
the
time
.8 9
IO
prolapse
of
the
co14
was
Mortality
When it occurs, prolapsed cord is responsible for a very high fetal loss and means death to the fetus before birth in almost 50 per cent of the cases, with additional neonatal fatalities from anosia and traumatic delivery. Some reduction in the fetal mortality rate in more recent years is indicated by the study of 2 ten-year periods by Cope,13 and by a comparison of the thirtecnyear period of Mengert and Longwell,lz with the present series (Table III). Various Factors in Relation to Perinatal Mortality.Parity: There were 15 primiparas with a gross fetal mortality rate of 40 per cent, and 48 multiparas with a rate of 43.7 per cent. These results do not confirm the findings of Mengert and Longwell’” that fetal mortality from prolapsed cord is twice as high in primiparas as in multiparas, but they support the observations of Fenton and D’Esopo4 and Hrandeberry and Kistner8 that the fetal risk is actually slightly lower in primiparous individuals. At least equal significance should, therefore, be attached to prolapse of the umbilical cord in multiparas, as the fetal dangers may be even slightly greater than in primiparas.
994
SLATE
TABLE
YEAR 1915-1927 1927-1947 1928-1937 1938-1947 1941 1940-1949 1948-1949 1924-1948 1926-1939 1947-1951 1948-1953 1940-1953
III.
PERINATAL
AKD
MORTALITY
Kurzroekg Cope13 Cope13 Cope13 Bourgeois5 Brandeberry
and
WITH
PROLAPSED NO. OF CASES
AUTHOR
I
Am. J. Obst. & Gynec. November, 1956
RANDALL
Kistners
cox15
Fenton4 Mengert and Longwell Kushlo Jouberts Nate and Randall
100 350 153 179 155 116 35 216 1E 203 63
CORD
I
GROSS ‘j$ 63.0 50.6 58.1 47.5 49.7 35.3 11.4 37.5 46.6 49.0 60.6 42.8
Presentation: In the presented series, the fetal mortality was higher in vertex presentation (35.3 per cent) than in breech (23.1 per cent), but less than in transverse (57.2 per cent). These findings are in agreement with the reports of Cope,13 Kurzrock,g and Mengert and Longwell.12 Fenton and D’Esopo4 found a higher mortality in breech than in vertex presentations, and concluded that in the.latter the favorable conditions more than compensated for the greater compression of the cord. The low fetal salvage in transverse or shoulder presentations reported by almost all authors is no doubt related to the greater difficulties encountered in delivering the baby. Xtation at time of diagnosis of prolapse of the cord: Of 56 cases on which information was available, 29 had a presenting part which was either floating or above the spines. Fourteen of these infants were stillborn (48.2 per cent), and 2 others died in the neonatal period. The presenting part was at or below the spines in 27, and of these, 6 were stillborn (22.2 per cent) and 3 died neonatally. Thus, the mortality risk was more than twice as great when the presenting part was not engaged. Other authors47 l2 have found a lower fetal salvage when the presenting part was high. Cervical dilatation at the time of diagnosis of prolapse of the cord: The greater the degree of cervical dilatation when the diagnosis of prolapsed cord is made, the lower the fetal mortality rate. This is due to the fact that conditions are then more favorable for delivery. Fig. 1 indicates the frequency with which prolapse of the cord occurred at the various degrees of cervical dilatation, and the associated fetal mortality rates. Time interval between rupture of membranes and diagnosis of prolapsed cord: The diagnosis of prolapsed cord was made immediately after the membranes ruptured in 19 patients and among these there were 4 stillbirths (21.0 per cent). Five cases of prolapsed cord were diagnosed within one-half hour of rupture of the membranes with 3 stillbirths. Of 35 prolapses occurring 2 or more hours before a diagnosis was made, there were 12 stillbirths (34.2 per In general, the sooner the diagnosis was made after the rupture of cent). the membranes, the better the outlook for the baby. Time of vaginal examination in relation to rupture of the membranes: The earlier the diagnosis was established after rupture of the membranes, the lower was the fetal mortality rate. Either a prolapse of the cord occurring late after the rupture of the membranes, or a delay of the diagnosis of an earlier prolapse from procrastination in performing a vaginal examination after rupture of the membranes may be responsible for a progressive increase in the stillbirth rate. This suggests that vaginal examination should be made in every labor at the time of rupture of the membranes to avoid any delay in diagnosing a prolapsed cord. Any alteration of the fetal heartbeat should
PROLAPSE
Volume 72
Nnmber 5
OF
UMBILICAT,
CORD
095
indicate a more thorough examination than would be normally carried out and would result in the detection of many cases of occult prolapsed cord. Additional information obtained from vaginal examination, such as the dilat,ation of the cervix and the presentation of the fetus, would be of great value to the obstetrician in accomplishing and making plans for delivery. Cart should be taken, however, not to push the presenting part out of the pelvis. and thus predispose to prolapse of the cord when making the examination. Time interuaZ between diagnosis and delivery: As would be expected, there was a progressive increase in the mortality rate with increase in time between the diagnosis of prolapsed cord and delivery. Our results are similar t,o those of Fenton and D’Esopo4 except that the mortality rate in their series rose con more dramatically when the time interval was increased from one-half to one hour, and reached ‘70 per cent if the delivery was not achieved until three hours after diagnosis (Fig. 2). A high incidence of operative delivery will be noted in Table IV. This was necessary in order to lessen the time interval between the diagnosis of prolapse of the cord and the birth of the baby. Operativr delivery was associated with a greater fetal mortality rate due to the fact that conditions were usually unfavorable for intervention.
100% 1
.--. -
FENTON et ol RANDALL 8 SLATE I’
9
60% -’ z-. L z ‘, 60%.. E 5 f 40%” 2 P ” 20%.0
I
I
I
Time interval
Fig.
2.-Fetal
mortality TABLE
IV.
TYPE OF DELIVERY
Spontaneous Forceps Breech Version and extraction Cesarean section Total
in TYPE
3
,
IO
5
0
relation
to
the
OF DELIVERY
(hrs.) between diagnosis
time
interval
AND ASSOCIATED
NO. OF CASES
NO. OF STILLBORNS
ii 15 6 5 63
: 7 I 1 21
20
30
and delivery
between FETAL
diagnosis
and
delivery.
MORTALITY
NO. OF NEONATAL DEAmS
0 1 3 1 1 6
PER CENT OF FETAI> MORTALITY
40.0 31.8 66.7 33.3 40.0
42.8
Petal mortality in relation to weight of the baby: The perinatal mortality for premature infants was 55.5 per cent, for mature babies 37.7 per cent, and for the entire group 42.8 per cent. Stillbirths occurred with equal frequencv (33 per cent) in premature and full-term babies. This is approximately $5
times as great as the stillbirth rate for all deliveries (2.1 per cent). The birth rate for all premature infants born during the period under review 15.1 per cent, which is about half of what it was when prematurity was ciated with prolapsed cord. There were in all 6 neonatal deaths, and these were of premature babies.
Maternal
stillwas a,sso4 of
Risks
Nine patients (14.3 per cent) suffered a blood loss of over 600 C.C. This is four times greater than the general incidence of postpartum hemorrhage (3.1 per cent) for the entire group and was probably due to the increased number of associated operative procedures. Twelve patients (19 per cent) had a morbid puerperium. This incidence might have been even higher had not prophylactic antibiotics been administered in 22 cases. The increased morbidity was related to the necessity for manipulative and operative procedures to accomplish rapid delivery. Maternal morbidity for the entire group of obstetric patients was 5.4 per cent. There was one maternal death, that of a 21-year-old multipara, who died on the tenth postpartum day after a severe sepsis (peritonitis and bilateral bronchopneumonia) . Diagnosis Because of the great risk to the fetus in the event of prolapse of the umbilical cord, the diagnosis should be made at the earliest possible moment so that treatment may be started at once and the fetal risk be substantially reduced. The condition should be kept in mind particularly when one or more etiological factors are present. A diagnosis of cord presentation can be made with certainty only by vaginal examination. However, the diagnosis of prolapsed cord was made by the appearance of the cord at the vulva in 24 instances. In 27 cases it was discovered primarily by vaginal examination. Six cases were detected by changes in the fetal heartbeat leading to further examination. In some patients the cord made its appearance at the vaginal introitus during a rectal examination. Early vaginal examination should be advocated in all suspected cases.
Treatment Cord Presentation.-Rupture of the membranes must be prevented if possible as the fetus is usually safe when they are intact. A close check of the fetal heartbeat will indicate any threat to the baby. An attempt to displace the cord to a higher level in the uterus can be attempted by postural means such as the knee-chest, elevated Sims, or Trendelenburg position, which are tolerated only for short periods without discomfort to the mother. Those patients in whom presentation of the cord is corrected should be delivered vaginally; otherwise cesarean section should be undertaken. Cord Prolapse.-Whenever a condition which predisposes to prolapse of the cord is present, every endeavor should be made to prevent the rupture of the membranes. If this occurs, an immediate vaginal examination should be made. When the cord is prolapsed, the patient should immediately be placed in a posture (knee-chest, deep Trendelenburg, elevated Sims position) so as to reduce compression of the cord. Attempts to replace the cord are usually futile and waste valuable time. The presenting part can be held up by an assistant with a finger in the vagina until delivery is accomplished by cesarean section or otherwise. Additional oxygen should be supplied to the mother and immediate delivery carried out. Vaginal delivery is preferred if conditions are suitable, The use of Diihrssen ‘S incisions when the cervix is not dilated
\‘olume iz liLin,l>er <
PROLAPSE
OF
UMBILICAL
C’ORT)
?!G
and the employment
of forceps or internal version will depend upon the contlitions present and the experience of the operator. If vaginal delivery is not feasible, cesarean section should be considered if one is reasonably certain tht* baby can be delivered alive. If there is any question as to whether the baby is alive or not, the benefit of the doubt should be given to the baby, who may still be alive although the fetal heartbeat is inaudible and no pulsation in the cord detectable, especially during or soon after a contraction, as both may return between contractions. Only in cases of extreme prematurity (nonviability) and cases of severe distress, associated with conditions not satisfactory for vaginal delivery ami showing no improvement by supportive efforts, should the presence of a prolapsed cord be accepted as an unfortunate circumstance about which nothing can be done. Summary and Conclusions
1. Sixty-three cases of prolapse of the umbilical cord which occurred at the State University of Iowa Hospitals between Jan. 1, 1940, and Dec. ::I. 1953, have been reviewed. 2. In a survey of 24 different publications, there were reported 4,296 prolapsed cords in 669,547 deliveries, an incidence of one case in 156 deliveries. 3. The liability of the umbilical cord to prolapse is greatest in transverse. less likely in breech, and least liable in vertex presentation. 4. The gross fetal mortality was 42.8 per cent and is mainly caused by (a) delay in the diagnosis of prolapse of the umbilical cord, (1~) high operative delivery rate, and (c) increased incidence of prematurity. 5. Prolapse of the umbilical cord could be diagnosed more quickly by frequent and repeated checks of the fetal heartbeat and by vaginal examinations performed soon after the rupture of the membranes. 6. Treatment of prolapse of the cord, when the fetus is still viable, is immediate delivery, by the vaginal route if conditions are suitable, otherwise I~!ccsarcan se&ion.
References 1. 2. 3. 4. 5. Ii. 7. 8. CI 1;): 11. Id. 13. 14. 1.5.
Cragin, E. B.: The Practice of Obstetrics, Philadelphia, 1916, Lea & Febiger. Doerr. Louis F.. Jr.: J. Michigan M. Sot. 46: 1277. 1947. J. 28: 570 1954.’ Joubert P. J.: ’ South African-M. AM. J. OBST. & GYNEC. 62: .52, l!J51. Fentom’Arnold N.. and D’ESORO, D. Anthony: Bourgeois, George A. : AM, J. ~B&T. & GYNEC. 41: 837, 1941. on Pathology of Labor, the Puerperium, and the McCormick, Charles 0. : A Textbook Newborn, ed. 2, St. Louis, 1947, The C. V. Mosby C0mpan.v. Titus, Paul: The Management of Obstetric Difficulties, ed. 3, St. Louis, 1945. The C. V. Mosby Company. Brandeberry. Keith R.. and Kistner, Robert a’.: Asr. J. OBST. & GYXEC. 61: 356. 1951. AM: J. OBST. & GYNEC. 23: 403, 1932. Kurzrock, Julius: Kush, Arthur W.: AM. J. OBST. & GYNEC. 66: ISS, 1953. Keettel, W. C., Diddle, A. W., and Plass, E. D.: AX J. OBST. & GYNEC. 40: 225, 1940. Mengert, William F., and Longwell, Freeman H.: AM. J. O&ST. & GYNEC. 40: 79, 1941). Cope, Edward: J. Obst. & Gynaec. Brit. Emp. 58: 259, 1951. Brit. M. J. 2: 820, 1948. Morgan, Joyce: Cox, J.. Woodrow: Lancet 1: 561, 1951.