Cord prolapse: what do midwives do?

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.

7 thoughts on “Cord prolapse: what do midwives do?

  1. midwifemuse

    I am a community midwife who carries equipment for bladder filling in case of a cord prolapse at a homebirth. As women can not maintain knee chest position in an ambulance and transfer to the ‘local’ obstetric unit would take, on average, 30 minutes this is probably the best option.

    Reply
    1. midwifeshawn

      Cool! So just to be clear (because in the only transfer for cord prolapse I’ve been involved with, the woman did maintain knee chest position in the ambulance…) … you would have the woman on all fours, the when the ambulance arrived ask her to be .. reclined? on her left side? At what point would you fill her bladder, with how much water, and are you satisfied with the evidence base? Thanks for sharing your practice!

      Reply
  2. peachy

    RCOG Green-top guidelines No.50 Umbilical Cord Prolapse: “If the decision-to-delivery interval is likely to be prolonged, particularly if it involves ambulance transfer, elevation through bladder filling may be more practical. Bladder filling can be achieved quickly by inserting the end of a blood giving set into a Foley’s catheter. The catheter should be clamped once 500-750ml has been instilled. It is essential to empty the bladder again just before any delivery attempt, be it vaginal or caesarean section.”

    Supported by case reports from 1970, 1983 and 1980…

    Reply
    1. midwifeshawn

      Hello! I’m familiar with the RCOG guideline, which suggests elevation through bladder filling may be more practical when there is a delay, although I would prefer midwives to be writing guidelines on what is practical in a home birth setting. Managing obstetric complications with two professionals, or one if you are caught out in a precipitous situation, is very different from ringing the bell and the calvary runs in.

      Regarding the case reports, the original (Vago 1978) reports a series of 28 in which there was one death. Chetty and Moodley (1980) report a series of 24 with no deaths. The Oxford series in which simple digital elevation of the presenting part was used (internally, then externally using suprapubic pressure) reported one death in 132 cases, which involved a delay in transfer from home. None of these is an RCT, so for all we know Vago could have gone on to save hundreds of babies and been unlucky in that his one death occurred at number 28. But if I’m alone at a home birth, I’m not going to stop the simple manual displacement also recommended by RCOG to rummage through my birth bad for a blood giving set, catheter and other equipment to fill her bladder, which may or may not be successful, and may or may not contribute to future bladder dysfunction. (Outcomes for the mother do not appear to have been reported.)

      If I have a partner with me at this home birth, which I hope I do, and she is able to get this equipment ready, and transfer is delayed, and I’m losing the feeling in my arm .. by all means, let’s try it. Caspi et al (1983) seem to have more success with it. But I also note that Caspi’s cases all refer to a diagnosis in first stage (no deaths in 88 cases). For diagnosis in the second stage, they delivered. I’m all for improving the management of cord prolapse, but I don’t think preventing the delivery of multis or second twins at full dilatation is the way to do it.

      Thanks for contributing!

      Shawn

      Reply
    2. midwifeshawn

      I would also like to see case reports from midwifery-led settings, where this intervention is being advocated. Would love to hear from a midwife who has actually used bladder-filling outside a hospital setting!

      Reply
  3. Jen Hocking

    Thanks for posting Shawn – it’s always fantastic to rethink our practices, especially with well-being for the woman in mind….disappointing that the journal has such an outdated approach to feedback from its readership – let the blog prevail! I’ll keep reading with interest.

    Reply

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