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Umbilical Cord

Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

The umbilical cord extends from the fetus to the placenta and transmits the umbilical blood vessels, two arteries and one vein. The cord is cover with a layer of amnion continuous with that covering the placenta. The average length of the cord is 50 cm.

Cord blood sampling

This may be required when:

  • The mother's blood group is Rhesus negative or her Rhesus type is unknown
  • Atypical maternal antibodies have been found during an antenatal screening test
  • A haemoglobinopathy is suspected (e.g. sickle cell disease)

The sample should be taken from the fetal surface of the placenta where blood vessels are easily visible.

Cord clamping

After the birth of the baby (or during the birth if the cord is tightly round the baby's neck) the cord is clamped.

Early clamping is carried out in the first 1 - 3 minutes immediately after birth, regardless of whether cord pulsation has ceased.

Proponents of late clamping suggest that no action be taken until cord pulsation has ceased or the placenta has been delivered.

The optimal time for umbilical cord clamping remains unknown. Delaying cord clamping for at least 2 minutes in a term neonate can be beneficial. A term baby at birth can be drawn up onto the mother's abdomen but raised no higher. A preterm baby should be kept at the level of the placenta to avoid blood draining from the baby to the placenta, resulting in anaemia; if held below the level of the placenta, the baby in effect receives a transfusion.

The Practising Midwife featured article

Management of umbilical cord clamping

2013; 16(2): 23 - 26

Author: Lucy Webbon

Further reading

American Congress of Obstetricians and Gynecologists (ACOG) (2012). Timing of umbilical cord clamping after birth. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Timing-of-Umbilical-Cord-Clamping-After-Birth

Controlled cord traction

See Labour, third stage

Umbilical haemorrhage

Usually occurs as a result of a poorly applied cord ligature. A purse-string suture should always be inserted if umbilical bleeding does not stop after 15 to 20 minutes.

Umbilical infection

Signs can include localised inflammation and an offensive discharge. Untreated infection can spread to the liver via the umbilical vein and cause hepatitis and septicaemia. Treatment may include:

  • Regular cleansing
  • Administration of an antibiotic powder
  • Appropriate antibiotic therapy.

Cord presentation and prolapse

Cord presentation

The umbilical cord lies in front of the presenting part, with the fetal membranes still intact

Cord prolapse

The cord lies in front of the presenting part and the fetal membranes are ruptured

Occult cord prolapse

The cord lies alongside, but not in front of, the presenting part

Predisposing factors

Any situation where the presenting part is neither well applied to the lower uterine segment nor well down in the pelvis may make it possible for a loop of cord to slip down in front of the presenting part. Such situations include:

  • High or ill-fitting presenting part
  • High parity
  • Prematurity
  • Malpresentation
  • Multiple pregnancy
  • Polyhydramnios.

Cord presentation

This is diagnosed on vaginal examination when the cord is felt behind intact membranes. It is, however, rarely detected but may be associated with aberrations in fetal heart monitoring such as decelerations, which occur if the cord becomes compressed.

Management

  • Under no circumstances should the membranes be ruptured
  • Summon medical aid
  • Assess fetal wellbeing, using continuous electronic fetal monitoring if available
  • Help the mother into a position that will reduce the likelihood of cord compression
  • Caesarean section is the most likely outcome

Cord prolapse

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Diagnosis

Diagnosis is made when the cord is felt below or beside the presenting part on vaginal examination. A loop of cord may be visible at the vulva.

Whenever there are factors present that predispose to cord prolapse, a vaginal examination should be performed immediately on spontaneous rupture of membranes. Variable decelerations and prolonged decelerations of the fetal heart are associated with cord compression, which may be caused by cord prolapse.

Immediate action and management

Immediate action

  • Call for urgent assistance
  • If an oxytocin infusion is in progress, this should be stopped
  • A vaginal examination is performed to assess the degree of cervical dilatation and identify the presenting part and station. If the cord can be felt pulsating, it should be handled as little as possible
  • If the cord lies outside the vagina, replace it gently to try to maintain temperature
  • Auscultate the fetal heart rate
  • Relieve pressure on the cord
  • Keep your fingers in the woman's vagina and, especially during a contraction, hold the presenting part off the umbilical cord
  • Help the mother to change position so that her pelvis and buttocks are raised. The knee-chest position causes the fetus to gravitate towards the diaphragm, relieving the compression on the cord
  • Alternatively, help the mother to lie on her left side, with a wedge or pillow elevating her hips (exaggerated Sims' position)
  • The foot of the bed may be raised
  • These measures need to be maintained until the delivery of the baby, either vaginally or by caesarean section
  • Consider inserting 500 ml of warm saline into the bladder to relieve the pressure if transfer to an obstetric unit is required

Treatment

  • Delivery must be expedited with the greatest possible speed
  • Caesarean section is the treatment of choice if the fetus is still alive and delivery is not imminent, or vaginal birth cannot be indicated
  • In the second stage of labour the mother may be able to push and you may perform an episiotomy to expedite the birth
  • Where the presentation is cephalic, assisted birth may be achieved through ventouse or forceps
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