Cord Prolapse Questions

[veganjoy]

Wonderful MDC midwives, I hope you can help answer some of questions on cord prolapse.

How common is cord prolapse?
Is it evident right away that this is the problem?
What can be done when it occurs?
Is there any way to prevent this in pregnancy? (I doubt it, but... )

I've been working through my fears about birth, and this is the only really lingering issue. I know it's supposed to be extremely rare, but my undrstanding is that it's also extremely dangerous. My hope is that getting a more thorough understanding will help me let it go; I'm planning a homebirth, and want to feel really comfortable with it.

[onlyboys]

Hi! I hope this finds you well! I'm not a midwife, but a midwifery student.

Cord prolapse is dangerous, as you know, but it's also rare. I do not know how rare, honestly, the literature I'm reading doesn't have incidence rates.

It's funny that you ask how you prevent cord prolapse, and there are some ways you can do that: don't let anyone break your bag of waters before baby is engaged (or at all), don't let anyone check your cervix before your water breaks (because of accidental ROM), don't let anyone insert a pressure catheter, or internal scalp electrode. Basically, some incidences of cord prolapse are precipitated by intervention. Avoid the intervention and you will avoid prolapse from those causes.

This doesn't mean that you eliminate your risk entirely, but as the midwives I work with love to quote, "Birth is as safe as life gets." There are inherent risks to everything, even going out to get the mail.

If you did have a cord prolapse, your midwife will relieve the pressure on the cord by pushing up on the presenting part--in essence hold your baby off the cord and then you will be transported to the hospital for a cesarean section. I have heard of some cord prolapses that happen when pushing is imminent, and the baby just comes out with the cord; there isn't enough pressure for long enough to cause hypoxia. I think this is rarer than the other response, because it has to happen at a certain particular time (during pushing).

Good luck! I had my one particular "issue" that I worried about, too. I worried for FOUR births, without it happening. For what it's worth, I didn't think about it at all in labor or immediate postpartum.

[veganjoy]

Thank you. I think I was under the impression that cord prolapse always results in death, and that's just that.

Very reassuring to know that something can be done.

[MsBlack]

Sorry, I can't give you a number off the top of my head...but I guess I should look it up so that it's at the tip of my tongue or fingers for people who might ask...

Anyway, true cord prolapse is not common by any stretch, as long as there has been no artificial rupture of membranes while baby is still high enough that the rush of waters carries the cord down past presenting part (head, butt or feet) to either have a loop of it emerging in front of that part, OR, getting down beside it ('occult'/hidden prolapse, where you can't actually feel or see it). Whether visible or not, such a prolapse means that cord will get squeezed shut as baby descends.

I've never dealt with one myself....but I did get a ph. call one night from some friends who'd moved far away and were attempting UC. Dad says, 'what do you do when the cord is presenting in front of the head?' says me: 'are you sure it's the cord?' "Well, her water broke, and so I reached up inside to check her cervix...and the first thing I feel is something round, and pulsing...couldn't really feel the baby's head.' So I told them to get to the hospital ASAP, w/mom in knee chest position. She got a caesarian, and all was well. In their case, baby simply stayed high enough throughout that there was never any compression on the cord.

Cord prolapse CAN be fatal, no matter what anyone tries to do to prevent excess compression. However, in many cases it is indeed possible to prevent harm--the trick is in finding whatever position keeps most of babies weight off the cord (which would be compressed between baby and mom's pelvis). Sometimes, a knee chest or sidelying position is enough by itself--if baby is not real low yet. Other times, someone does have to insert a hand and physically hold the baby up off of cord. Figuring out what is needed usually requires either a doppler to monitor baby's heart tones, or someone who is very good at using a fetascope--you'd want to know which position and/or manuever will help produce the most normal possible heart tones.

Prolapse occurs far more frequently with artificial rupture than with natural rupture of membranes--tho as you can see from my story above, it can happen even without interference. I also want to add that I myself once had spontaneous rupture of membranes with a big flood (in the grocery store! my 11 yr old was so mortified)--and this is one of the hallmark signs for possible prolapse. If you get a little gush, followed by smaller leaks periodically, this usually means that baby was low enough to prevent cord getting past presenting part. But with a big gush, esp. if followed by more hefty flow of waters, this means that baby is high (usually, at least with a head or butt presentation), and thus there is room for cord to descend to level of presenting part or lower. In my case, tho, even though I had a big gush followed by a lot more water flow over the next hr (gradually bringing baby down), there was no prolapse at all.

[Valerie]

I dealt with it once, many years ago. Right as I walked in the door of the home of the laboring mother, her water broke with a gush. Because we knew that the baby's head was high at the last prenatal exam, she agreed to let me check her. She was about 6-7 cm, with the cord prolapsed into her vagina and the baby's head pressed firmly against it. I put the rest of my hand into her vagina, and held the baby's head up off the cord.

"We really need to go to the hospital," I told the parents. "The cord has prolapsed, and the only way to get this baby out ok here would be if you could deliver the whole baby in one push."

"Welllllll...ok.......but can we pray about it first?"

"How about you pray about it while you call 911?"

The EMTs showed up in short order, arriving like a SWAT team, as they usually do for calls involving childbirth. My hand was still inside the mother's vagina, and by now she was in a knee-chest position. The pulse in the cord was still strong.

"We need to put her on the cot like this," I told the EMTs.

"Well, ok," they told me. "But you can't go with us -- our insurance won't allow it."

"Ok then. One of YOU is gonna have to put your hand inside this lady and hold the baby's head up off the cord."

After glancing at each other, they looked back at me.

"Uh..I guess it would be ok if you did it...."

So we went to the hospital in that position, mom in knee-chest, me next to the cot holding the baby's head up off the cord as mom's increasingly strong contractions tried to push out her baby.

After we got to the ER, one of the doctors jumped into the back of the ambulance, his hand replaced mine, and the mother was rushed off to the OR.
Because I was restricted to the waiting room, the rest of the story is from the mother...

"They put me on the operating table," she told me, "but I remembered what you told me about pushing out the baby in one push. As soon as the doctor took his hand out, I did it! The baby was born right on the operating table -- no one even caught her!"

The baby did wonderfully -- Apgars of 9/10. But I would love to have seen the faces on the medical staff in that OR! I, of course, was ripped up and down by the OB on call. She ranted and raved and told me "that baby could be a zombie!!". Well, "that baby" is now a lovely, healthy teenager.

The point, I guess, is that cord prolapse can be a really nasty thing. But if one remembers the right thing to do, it can have a good outcome. One of the things I remembered most at the time was something I read in Varney (I think?) regarding cord prolapse: "The next action you take will be what determines whether the baby lives or dies."

Valerie
Illinois

[michiganmidwife]

Also it might be comforting to know that cord prolapse is more common with pre-term birth, malpresentation such as transverse or breech, polyhydramnios (more than normal amount of amniotic fluid) and the risk also increases with moms who have had many babies because they tend to have more malpresentations and their babies tend to not engage until the onset of labor.
By the time you go into labor if you don't have any of these risk factors, and the baby's head is engaged well, there is almost no chance of a cord prolapse.

Iv'e had two in my practice. Both turned out well with proper transport. One was a 35 week breech. The other was a first time mom with head high and lots of fluid. I also had one during my training with a mom having her 6th baby.
Happy Birthing!

~Bridgett

[SublimeBirthGirl]

Originally Posted by veganjoy

Wonderful MDC midwives, I hope you can help answer some of questions on cord prolapse.

How common is cord prolapse?

Very rare. Two per thousand, maybe?

Originally Posted by veganjoy

Is it evident right away that this is the problem?

Not always. Sometimes you can see it, sometimes it shows up during labor as fetal heart decels when the cord is pinched.

Originally Posted by veganjoy

What can be done when it occurs?

Keep the baby up as high as possible and have a cesarean quickly, usually.

Originally Posted by veganjoy

Is there any way to prevent this in pregnancy? (I doubt it, but... )

Don't let them break your water.

[junamoss]

I have been involved with two cord prolapses. One was a doula client who had poly, we had gone over what a risk this could be for her. Her water broke and had to go to the hospital (because of another medical condition). The nurse checked her, she was doing wonderfully. maybe 2 hours later the RN checked again and did what I would never do, push a little on the babes head, she had to have, there was a huge splash of amniotic fluid, client was great, got up to void, called me into the bathroom and there was a 8-10 inch loop of cord hanging out. I firmly believe it was that SVE that moved babes head and helped the cord prolapse. (babe was fine, out in 8 minutes,section room and her doc were prep'd for another case)
Second prolapse was Dr caused, she broke her water at 2-3 cm's. We just noticed varibles with every contrx dipping to the 50's. Then a bit of cord was felt, immediate section, baby was great.

[MsBlack]

Sublime Birth Girl--

I think you may be close on that estimate. When I first saw this thread, "3" was in my head, but I knew it couldn't be 3%. I think it must be .3% (3 per 1000) of births...but a casual survey of some of my texts yesterday did not reveal this magic number.

[LemonPie]

I know this is a very old thread that I'm bumping, but I just wanted to say THANK-YOU for the questions and answers. This is my "one issue" that's causing me to fear a HB as well, and this thread has been QUITE reassuring.

Can I ask a further question on the subject? Would you all recommend a VE if the waters break spontaneously before/during early labor just to rule this out?

[jeninejessica]

Hey guys... I just wanted to clarify...

What we're saying if that if we have a cord prolapse identified... that unless we can be SURE that mom can push that baby out within basically one push, then a c-section is absolutely necessary?

Just want to make sure I have my facts straight as a new doula- I don't want to be telling some poor woman that maybe she should give it a try, when really we should be heading to the OR.

Thanks

[Hallielynn01]

Originally Posted by jeninejessica

Hey guys... I just wanted to clarify...

What we're saying if that if we have a cord prolapse identified... that unless we can be SURE that mom can push that baby out within basically one push, then a c-section is absolutely necessary?

Just want to make sure I have my facts straight as a new doula- I don't want to be telling some poor woman that maybe she should give it a try, when really we should be heading to the OR.

Thanks

I think that as a doulas, it would be far out of our scope of practice to give her ANY medical advice in a situation like this. (or any medical advice at all, but in particular, in a situation like a prolapse) Whether we know the answer or not. This would be a time for a Dr of MW to be giving any and all adivce of a medical nature, and for a doula to be offering support and comfort, as this would be, with out a doubt, very scary for even a seasoned mother.

[jeninejessica]

Oh Don't worry... I realize that this is well outside of my scope as a doula... but I do also know that often clients look to you for the information required to make their decisions. If the client is asking me "hey... do you think I could keep trying, I really don't want a c-section"... I want to be able to tell her "well it is greatly recommended that you have a c-section" as opposed to telling her that if she wants to try it, then that's what she should do...

In most cases, I want to be able to support my client in any decision she feels is best for her and her baby, even if I don't agree with it... but I also want to be able to let her know if this time, the Dr's really are right to push for a c-section, as our first instinct in almost every other case is that they are just surgery happy, kwim?

[holly6737]

From everything I've read, a cord prolapse is a case in which a cesarean is an absolute necessity.

[mrs.yd]

Originally Posted by veganjoy

Wonderful MDC midwives, I hope you can help answer some of questions on cord prolapse.

How common is cord prolapse?
Is it evident right away that this is the problem?
What can be done when it occurs?
Is there any way to prevent this in pregnancy? (I doubt it, but... )

I've been working through my fears about birth, and this is the only really lingering issue. I know it's supposed to be extremely rare, but my undrstanding is that it's also extremely dangerous. My hope is that getting a more thorough understanding will help me let it go; I'm planning a homebirth, and want to feel really comfortable with it.

First of all, I'm not a midwife, just a mom who wants to homebirth and is also wanting to find out about cord prolapse. My searching led me to this information which I thought I would share with you:

"Cord prolapse is a complication which could be fatal in home or hospital. The National Birthday Trust Fund study of planned home births in the UK reported on the incidence of cord prolapse. In the home and hospital groups totalling 10,695 women, only one cord prolapse occurred, in the home birth group - but no fetal death was reported*. The authors point out that cord prolapse occurs on average once in every 900 deliveries (cord presentation once in every 300), but is much more likely in certain high-risk categories: breech or transverse lie, small babies, polyhydramnios (excessive amniotic fluid). Very few women planning a home birth have pregnancies which fall into these categories."

I got that from this website:
http://www.homebirth.org.uk/

I find it interesting that in that survey 1 in 10,695 had cord prolapse, but in most other things I have read they say cord prolapse happens 1 in 300 births- I wonder if maybe they are not breaking it down into cord presentation vs. cord prolapse. Also, when figures for cord prolapse are given there is no way to determine how many of those situations had other circumstances, like artificial rupture of membranes.

I'm figuring that if my water breaks first, we'll check for a cord. My midwife will have to come ASAP anyway since my last 2 labors were so short. The time it takes her to get here is the same amount of time it would take us to get to a hospital. So, it would basically take the same amount of time for us to find out if there was a cord prolapse or whatever and then at least we would be able to monitor the heartbeat on the way to the hospital and have an extra pair of hands to hold the head in, etc. I know I might sound silly the way I have it all thought out, but that's just me. I feel comfortable with it now. I realized that with my last two labors (in the hospital) if the cord was prolapsed it would have gone on for the 2 hours after the water broke before we got to the hospital. In a very real way, homebirth is safer for me b/c the midwife will get here long before I would be getting to a hospital. We'll be able to check the heartbeat and position much sooner.

[Earthy Mama]

My second pregnancy ended with a prolapsed cord. The ob broke my water (which later realized probably caused it). There was meconium in the fluid and then with each contraction, her heart rate dropped. When it was time to deliver the cord was coming out with her head so my ob pushed her back in me and wheeled me to the or.