|Year : 2015 | Volume
| Issue : 1 | Page : 20-24
Outcome of umbilical cord prolapse at Aminu Kano Teaching Hospital, Kano, North-Western Nigeria
Usman Aliyu Umar, Sulaiman Abdullahi Gaya
Department of Obstetrics and Gynaecology, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||8-May-2015|
Usman Aliyu Umar
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
Background: Prolapse of the umbilical cord is an obstetric emergency with life-threatening effect on the foetus. The outcome of umbilical cord prolapse (UCP) depends on immediate and proper interventions. Objectives: To determine the incidence of cord prolapse, predisposing factors, foetal outcome and decision-delivery interval in emergency caesarean section (c/s) due to cord prolapse in our Teaching Hospital. Materials and Methods: A retrospective review of 42 consecutive cases of UCP over a 5-year period was conducted at Aminu Kano Teaching Hospital, Kano, in North-Western Nigeria. Results: There were 42 cases of cord prolapse out of 13,292 deliveries during the study period giving an incidence of 0.32% or 1 in 316 deliveries. The highest incidence occurred in women aged 25-34 years. Multiparous women constituted 76.2% of the patients. Prematurity was the highest contributing factor (47.6%). Twenty-five (59.2%) of the 42 patients had emergency c/s (1.41% of the 1,771 emergency c/s and 0.99% of a total of 2,053 c/s). The mean decision to delivery interval in patients who had c/s was 92.8 minutes (range 10-180 minutes). The mean birth-weight was 2,864 g. The mean Apgar score at 5 minutes was 5.2. There were 19 fresh stillbirths with perinatal mortality of 45.2%. Conclusion: Cord prolapse is relatively uncommon in our environment. There is the need to identify and educate those women at increased risk of their babies having UCP. Delay in presentation may have contributed to the high perinatal mortality. Smooth organisation of an emergency c/s is essential for rapid and safe management of patients with UCP.
Keywords: Cord prolapse, foetal outcome, incidence, umbilical cord
|How to cite this article:|
Umar UA, Gaya SA. Outcome of umbilical cord prolapse at Aminu Kano Teaching Hospital, Kano, North-Western Nigeria
. Niger J Basic Clin Sci 2015;12:20-4
|How to cite this URL:|
Umar UA, Gaya SA. Outcome of umbilical cord prolapse at Aminu Kano Teaching Hospital, Kano, North-Western Nigeria
. Niger J Basic Clin Sci [serial online] 2015 [cited 2020 May 31];12:20-4. Available from: http://www.njbcs.net/text.asp?2015/12/1/20/156673
| Introduction|| |
Prolapse of the umbilical cord is an obstetric emergency demanding immediate attention. It is the presence of a loop of umbilical cord below the presenting part with ruptured membranes.  Prolapse of the umbilical cord to a level at or below the presenting part exposes the cord to intermittent compression between the presenting part and the pelvic inlet, cervix or vaginal canal. This compromises foetal circulation and depending on the duration and intensity of compression, may lead to foetal hypoxia, brain damage and death. 
The overall incidence of cord prolapse ranges from 0.1% to 0.6%.  The incidence in cephalic presentation is 0.5%; frank breech, 0.5%; complete breech, 15% and transverse lie, 20%.  Predisposing factors may include one of the following conditions: Unengaged presenting part, malpresentation, prematurity, multiple pregnancy and polyhydramnios. 
The perinatal mortality rate associated with umbilical cord prolapse (UCP) has fallen from 375 per 1,000 in 1924 to about 0.2% in the last few decades. , This reduction has been attributed to changes in obstetric practice like increased use of elective caesarean section (c/s) for non-cephalic or non-engaged presenting parts of the foetus,  and the more rapid and frequent recourse to c/s once cord prolapse is diagnosed. 
The main aims of management are an early and emergency delivery of the baby. Measures to alleviate compression on the prolapsed cord must be carried out until emergency delivery of the baby can be affected. With the identification of risk factors to UCP, some cases may be anticipated, diagnosed early or perhaps even prevented.  Alleviation of pressure on the prolapsed cord until delivery can be achieved through measures such as digital disengagement of the presenting part, raising the maternal pelvis or filling of the maternal bladder. ,, Most data suggest that if the cervix is not completely dilated, prompt delivery through c/s offers the best chance for a favourable foetal outcome. ,, The time taken to safely achieve such delivery is important in order to limit the duration of cord compression. The time between the decision to deliver by c/s and the actual delivery of the baby has been termed the "Decision to Delivery" (D-D) interval and guidelines have been drawn up by various international bodies as to what an acceptable interval is. The general consensus appears to favour a D-D interval of less than 20-30 minutes.  These recommendations have far reaching implications to the delivery suit layout and obstetric operating theatre services. ,
It is believed that this study, which has never been done in this hospital, will help create awareness among practitioners and generate better management practices. Furthermore, determination of D-D interval is very critical in the management of patients with this obstetric emergency.
| Materials and methods|| |
This is a retrospective study of patients presenting with UCP in labour at Aminu Kano Teaching Hospital (AKTH) from 1 st January 2009 to 31 st December 2013. Data on the booking status, maternal age and parity, cervical dilatation at presentation, route of delivery, D-D interval and foetal outcome were collected from the patients' folders, labour ward and theatre registry and analysed using EpiInfo TM 7 version. The D-D interval was estimated from the time decision was made for the surgery to the time baby was delivered. The study was approved by the hospital Research Ethic Committee. All patients that presented with live foetuses had either manual elevation of the presenting part, maternal head-down positioning or instillation of 500 mls of normal saline into the maternal bladder.
| Result|| |
During the study period, there were 42 cases of UCP among 13,292 deliveries. The incidence rate of UCP was 0.32% or 1 in 316 deliveries. Of the 42 cases, 25 (59.52%) had emergency c/s [see [Figure 1]. This accounted for 1.41% of the 1,771 emergency c/s and 0.99% of a total of 2,533 c/s during the study period.
Their ages varied between 19-40 years. The mean maternal age was 29.2 years (standard deviation, SD ± 5.8) and the highest prevalence was in the 23-34-year-old age-group. Multiparous women constituted up to 76.2% of cases in the study. Mean parity was 4.2 (SD ± 2.5). Twenty-two patients (52.3%) were booked in AKTH, 15 (35.7%) were booked elsewhere while 5 patients (12%) were unbooked. See [Table 1].
[Table 2] shows prematurity as the commonest associating risk factor: 20 (47.6%). Pre-labour rupture of membrane was a factor in six (14.4%), breech presentation in eight (19%), transverse lie in three (7.1%). There was no known associated factor in 4.8% of the cases. Seven (16.7%) had pre-labour rupture of membranes. In one case (2.4%), UCP occurred immediately following amniotomy.
[Table 3] shows that the gestational ages of the foetuses at the time of cord prolapse ranges from 27-41 weeks with a mean of 37.6 weeks (SD ± 3.9). Twenty-two patients (52.4%) were at term. The mean birth weight was 2864 g (SD ± 248) with a range of 1300-3900 g. Nineteen (45.2%) of the babies were of low birth-weight, out of which 16 died and only 3 survived. Twenty-three babies (54.8%) were of normal birth-weight and three died among them. Fresh stillbirths were recorded in 19 cases (45.2%), severe asphyxia in 4 (9.5%), moderate asphyxia in 13 (31%). The mean Apgar score at 5 minutes was 5.2. The perinatal mortality rate was 45.2%.
[Table 4] shows the mean D-D interval in patients who had emergency c/s which was 92.8 minutes (SD ± 12.5) with a range of 10-180 minutes. Only three surgeries (12%) were done in less than 30 minutes of the decision. All the emergency c/s were performed under general anaesthesia. There was no significant anaesthetic complication. Two fresh stillbirths were recorded in patients who had c/s. One patient had wound sepsis that required secondary closure. The mean post-operative hospital stay was 5.84 days (range 5-7).
|Table 4: Decision-Delivery intervals among patients who had caesarean section due to UCP |
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| Discussion|| |
UCP is an obstetric emergency as delay in management is associated with significantly increased neonatal morbidity and mortality.  Patients with UCP can expect good neonatal outcome if intervention is prompt. ,
The incidence of cord prolapse varies widely in many places, ,, with quoted rate of between 1 in 200 and 1 in 700. In this study, the incidence of 1 in 316 deliveries (0.32%) is similar to a study in Jos, Nigeria with an incidence of 1 in 358 deliveries or 0.28%  but higher than the study in Kaduna, Nigeria with 0.19% or 1 in 526 deliveries.  Other studies done in southern part of Nigeria showed higher incidences. , This may be due to differences in both health-seeking behaviour and use of antenatal services among women in northern and southern part of the country.
Multiparous women were responsible for 76.2% of all the cases of cord prolapse which agreed with other studies done in southern Nigeria. , This was however less than the 94.3% reported in Jos, Nigeria.  Other studies have found multiparous patients to be 60% more likely to experience UCP.  This may be because the multipara has a lax anterior abdominal wall that encouraged the occurrence of malpresentation, unstable lie or an unengaged head in labour.
Only five (12%) of the patients were unbooked in this study. This is contrary to findings in other studies where association between UCP and unbooked status were documented. , However, almost all the UCP (41 cases) occurred outside the hospital; therefore, delay in transfer to the hospital in improper position (sitting) may have contributed to this high prevalence among the booked patients. There is therefore the need to educate women during health talk at the antenatal clinic (ANC) on proper positioning should cord prolapse occur outside the hospital setting such as the lateral positioning with pelvic elevation or the knee-chest positioning. The later though may not be feasible especially during transportation to the hospital.
The perinatal mortality recorded in this study is 45.2%. This is similar to findings in other centres. , Other studies have shown declining trends in perinatal mortality from UCP due to early diagnosis and prompt management.  The perinatal mortality rates are lower where early diagnosis is made in labour and prompt delivery is effected and higher where facilities are not available for immediate delivery. Sixteen of the 19 stillbirths recorded had intrauterine foetal death before admission, mainly from unbooked patients. The two fresh stillbirths recorded in those that had c/s were referred cases of hand prolapse in a retained second twin and prolonged labour. Both foetuses were in distress on admission. Cord prolapse occurring outside a hospital setting has a higher perinatal mortality. 
Conditions that favour the occurrence of cord prolapse are those that interfere with the close application of the presenting part to the lower uterine segment. The major contributing factors in this study was prematurity (47.6%), followed by breech presentation (19%). This is similar to studies that showed positive association between prematurity and UCP. ,
In UCP, emergency delivery is recommended for normally formed and sufficiently matured foetuses. In the first stage of labour, a c/s is the only way to achieve early delivery; however with a completely dilated cervix the obstetrician has a choice between instrumental vaginal delivery and c/s. Several studies have quoted more favourable foetal outcome with c/s in the second stage of labour. ,,
Delay in the management of UCP is associated with significant perinatal morbidity and mortality. A crash c/s protocol established in some centres has been shown to reduce the mean D-D interval to 14.6 minutes (range 7-32).  The American College of Obstetricians and Gynaecologists believes a decision to delivery time of 30 minutes is appropriate while the German society for Gynaecology and Obstetrics recommends a D-D interval time of less than 20 minutes.  In this study, the mean D-D interval was 92.8 minutes (range 10-180). This was significantly higher than what was recommended. Only three patients (12%) were delivered in less than 30 minutes. These delays are mainly attributed to logistic problems, delay in obtaining consent and preparing the patient and insufficient manpower.
| Conclusion|| |
Cord prolapse is an uncommon obstetric emergency with poor foetal outcome. The incidence is low in our environment and prematurity is the commonest predisposing factor. The perinatal mortality is high as most of the cases occurred outside the hospital. The D-D interval in our centre is more than what is recommended by international bodies.
There is the need to identify those women at increased risk of their babies having UCP so that preventive measures can be instituted. These measures include: Proper and adequate antenatal care, use of ultrasound to rule out cord presentation, supervised hospital delivery for women at risk, close fatal heart monitoring after amniotomy and early resort to c/s where the foetus is still alive. Pregnant women should be educated on proper positioning should UCP occur outside the hospital.
Measures should be instituted to allow for rapid and safe conduct of emergency c/s in the event of UCP. This could be achieved by establishment of a "crash c/s" protocol in hospitals which will outline the procedures to be perform in the event of activation. The labour ward and theatre staff, anaesthesiologist and neonatologist should all be involved. Timely delivery could make a difference between life and death for the baby.
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[Table 1], [Table 2], [Table 3], [Table 4]