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2.4.3 Immediate and surgical management

Management

  • If a cord is seen extending past the introitus with pulsations, keep the cord warm with a saline soaked cloth and avoid manipulation.
  • Attempt to place the mother in Trendelenburg or bring knees to chest to help keep the presenting part off of the cord.
    • If the cord is palpated on vaginal exam during labour, do not remove your hand, rather attempt to lift the presenting part off of the cord as above.
  • This position should be maintained until delivery via cesarean section or assisted vaginal delivery.
  • If the surgeon is the person who has identified the cord prolapse, another person should replace the surgeon’s hand while they scrub or get ready for delivery. If required, the patient should be prepped and draped for cesarean section while a hand is still in the vagina holding up the presenting part.

Assisted vaginal vs cesarean delivery

Depending on how dilated the cervix is and how low the presenting part is, an assisted vaginal delivery may be possible. If not fully dilated or otherwise unsafe to do a vaginal delivery, proceed with an immediate cesarean section. If cesarean section is not immediately possible or requires transfer to another hospital site, then insert a foley catheter into the bladder and fill with 500-700 cc of fluid. This may help lift the presenting part and suppress uterine contractions.

Other considerations

  • You can consider using tocolytics.
  • If this patient has had an epidural, a top up is likely feasible for the cesarean section. If not, the patient will likely need a general anesthetic for expedited delivery via cesarean section; this should be discussed with the anesthetist.
  • Ensure that there is someone capable of neonatal resuscitation is available at the delivery for a possibly depressed infant.
    • Note: Management depends on fetal viability. If detected late and the fetus is no longer viable, is likely too immature to survive, or has a lethal fetal anomaly, then allow labour to continue vaginally. If there are contraindications to vaginal delivery, then cesarean delivery may be required.
Updated on June 28, 2021

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