Facetiously, a friend of ours is wont to say: “Mother Nature is beautiful, but we can improve on her.”
Similarly, the obstetrical complication of umbilical cord prolapse, an accident of nature, occurs once in 200 to 300 pregnancies – a frequency of 0.5 percent or less. Prolapse is defined as “a falling down of an organ or other part, especially its appearance at a natural orifice.”
In the last century, the incidence of umbilical cord prolapse has remained constant, while fetal mortality has decreased from 50 to 10 percent – at least in large urban hospitals – if prolapse occurs after hospital admission.
The numbers were 100 percent for a couple we knew back East. They were in their late 30s, and it was their first pregnancy – high hopes and high expectations. She was at term and had a gush of fluid – her “waters” broke – without labor “pains” or contractions. Active labor ensued. After a long ride to the hospital, she delivered a stillborn. The cause: lack of oxygen because of umbilical cord compression by the baby’s head. The couple’s devastation couldn’t be measured.
Immediate delivery, usually by Caesarian section, has increased survival from prolapse. While risk factors for prolapse have been recognized for decades, efforts to predict when, or in which women it will occur, have been mostly futile.
Consider the usual anatomy within the womb (uterus). The placenta, which provides oxygen and sustenance to the fetus through the umbilical cord, usually lies (is implanted) in the upper portion of the uterus. Within the uterus, the membranes wrap the whole package: fetus, cord and amniotic fluid. Until later in pregnancy, the fetus is usually “floating,” before settling head-down toward the pelvis and uterine cervix, “the birth canal.” When the head descends or settles into the pelvis and is no longer movable, it is said to be “engaged,” usually preventing the cord’s sliding by or out, i.e., prolapsing.
Certain conditions increase the risk of prolapse and cord compression. In addition to a floating head, breech presentations with the rump (or legs) headed south, are scenarios. The second baby of twin pregnancies (multiple gestations), low birth-weight, and lack of prenatal care are also known risk factors. For umbilical-cord prolapse, speculum or manual examination should be diagnostic, or the cord may actually be visible outside the vagina. Fetal distress, sustained heart rate below 120 or above 160 per minute, also constitutes an emergency.
A friend of mine, while a lowly medical student, was attending a delivery in a university hospital. After spontaneous rupture of membranes, a gush of fluid, and prolapse – he was ordered to apply pressure to the baby’s head. It was a life-preserving measure to limit cord compression en route to the operating room.
Now squatting at the operating table’s end, arm outstretched, gloved fingers you-know-where, he was under the sheets as the C-section began and rapidly progressed. Soon, he heard the unmistakable sound of breaking suction as the baby was pulled out. His dismissal came when the surgeon squeezed his fingers – from within.
There is no such thing as getting to a hospital too early. If transporting an obvious prolapse, gravity is your friend – pelvis above chest and shoulders – and/or apply pressure to the head.
www.alanfraserhouston.com. Dr. Fraser Houston is a retired emergency room physician who worked at area hospitals after moving to Southwest Colorado from New Hampshire in 1990.