This post was originally written as a Letter to the Editor, but when I went to submit it, I discovered the on-line journal does not accept any unsolicited writing. All of the articles are ‘commissioned by the Editors from specialists in their field,’ so I guess we should read them as more of a pronouncement than the opening of a dialogue?

I have some concerns about an intervention for cord prolapse described in a recent article on Abnormal Labour (Obstetrics, Gynaecology and Reproductive Medicine, Volume 23, Issue 4, Pages 121-125, April 2013): “Filling the urinary bladder (with 500-750 ml normal saline) helps to elevate the presenting part off the cord – this technique is particularly more suitable to the homebirth or standalone midwifery unit setting where prolonged manual elevation during transfer to an obstetric unit is difficult to maintain. In the hospital setting, filling the urinary bladder offers no increase in survival or improvement in fetal umbilical cord gases over manual elevation alone, although may be a useful adjunct if there is no theatre immediately available.”

As I said, I have some concerns. The authors suggest filling the urinary bladder as a method of preventing cord compression following cord prolapse. They say this technique has not been shown to improve outcomes in a hospital setting, but is ‘particularly more suitable to the homebirth or standalone midwifery unit.’ There are no references provided for the evidence related to use of this technique in either setting. As a midwife who has worked in two countries and the complete range of midwifery-led settings, I have never encountered this technique, nor anyone carrying appropriate equipment to enact it. I am concerned that an unproven, potentially harmful intervention not in widespread use is being presented as best practice, for use by midwives.

I am also concerned that, although the case scenario ended in a vaginal birth, the discussion presents caesarean section as the preferred method of delivery when a cord prolapse is seen, without discussing the importance of determining whether or not delivery is imminent before intervening. Cord prolapse is a common occurrence preceding the birth of a second twin, and during the births of babies with complete (knees flexed) and footling breech presentations. A prolapsed cord at full dilatation may precede a healthy vaginal birth with a delivery interval significantly less than a caesarean section (Gannard-Pechin et al 2012, Huang et al 2012), and when accompanying non-frank breech and twin births is associated with fetal compromise less often than for cephalic singletons (Kouam & Miller 1980, Broche et al 2005). Therefore, giving the impression that the best course of action upon seeing a cord in every situation is to elevate the presenting part manually, effectively preventing descent and spontaneous delivery in preference of a crash section, in many instances will cause more harm than good. This may seem like a matter of course to experienced practitioners, but it won’t be for the inexperienced.

Judging which instances require such emergency measures, and which would benefit from cautious expectant management, is a matter of skill and experience (in theory and practice), to which articles like the one linked above could usefully contribute. Factors to consider include cervical dilatation, type of presentation, signs of fetal distress, and descent with expulsive effort. Additionally, management of breech deliveries with the woman in an all fours position may reduce cord compression (as the cord is above the fetal body rather than below), and can easily be converted to a knees-chest position for more active intervention if delivery does not progress as quickly as expected. This is a strategy midwives are actually using in the community.

Update (December 2014): Those of you who are interested in this topic should read this report from the Netherlands:

M Smit et al, Umbilical cord prolapse in primary care settings in the Netherlands; a case series, Part 2, The Practising Midwife 17 (7); 34-38.

When considering what is recommended and best practice for midwives working in primary care settings, evidence needs to come from those settings. In this study, 2/8 UCP’s were managed with retrograde bladder filling, and these two instances were associated with the poorest Apgars, and the only death reported. While the numbers are small, they suggest that bladder filling in primary care settings may not offer benefits over manual elevation of the presenting part. Additionally, because it is time consuming, especially for a single midwife on her own at home, it may lead to unnecessary delays, compared to outcomes which were conducted in settings where assistance from other staff was immediately available.

What do you think? Are you carrying equipment to inflate women’s bladders if you detect a cord prolapse at home?

Broche, D. E., Riethmuller, D., Vidal, C., Sautiere, J. L., Schaal, J. P., & Maillet, R. (2005). [Obstetric and perinatal outcomes of a disreputable presentation: the nonfrank breech]. J Gynecol Obstet Biol Reprod (Paris), 34(8), 781-788.

Gannard-Pechin, E., Ramanah, R., Cossa, S., Mulin, B., Maillet, R., & Riethmuller, D. (2012). [Umbilical cord prolapse: a case study over 23 years]. J Gynecol Obstet Biol Reprod (Paris), 41(6), 574-583. doi: 10.1016/j.jgyn.2012.06.001

Huang, J. P., Chen, C. P., Chen, C. P., Wang, K. G., & Wang, K. L. (2012). Term pregnancy with umbilical cord prolapse. Taiwan J Obstet Gynecol, 51(3), 375-380. doi: 10.1016/j.tjog.2012.07.010

Kouam, L., & Miller, E. C. (1980). [Prolapse of umbilical cord – new aspects]. Zentralbl Gynakol, 102(13), 724-733.