Management of Umbilical Cord Avulsion to Prevent Stillbirth
Umbilical cord avulsion (separation from the placenta) is a rare obstetrical emergency requiring immediate intervention to prevent fetal death through rapid delivery and neonatal resuscitation.
Understanding Umbilical Cord Avulsion
- Umbilical cord avulsion is a rare but life-threatening complication where the umbilical cord separates from the placenta, leading to acute fetal hypoxia and rapid development of acidosis 1, 2
- This condition is significantly underreported in medical literature but represents a critical emergency requiring immediate intervention 3
- The umbilical cord serves as the mechanical conduit between fetus and placenta; when compromised, it can lead to rapid fetal deterioration 3
Risk Factors and Predisposing Conditions
- Furcate cord insertion (branching of umbilical vessels without protective Wharton's jelly before placental insertion) significantly increases risk of avulsion 2
- Other risk factors may include fetal anomalies such as two-vessel cord 4
- Abnormal placental attachment or placental abnormalities may predispose to cord avulsion 5
Detection and Diagnosis
- Diagnosis is often made after acute onset of fetal distress with variable fetal heart rate decelerations or bradycardia 6, 7
- Decreased fetal movement may be an early warning sign 4
- Ultrasound may identify predisposing conditions like furcate insertion, but most cases are diagnosed during delivery 2
Immediate Management Protocol
For Suspected Cord Avulsion During Labor:
Immediate cesarean delivery is the primary intervention when cord avulsion is suspected 6, 8
- Do not delay if fetal bradycardia or recurrent severe variable decelerations are present
- Cord arterial pH declines at a rate of 0.009 per minute during bradycardia 8
Position the mother to relieve cord compression 8
- Knee-chest position provides greatest elevation effect
- Trendelenburg position (15°) may be used if knee-chest position is not feasible
- Filling maternal bladder with 500 mL of fluid can help elevate the presenting part
Prepare for neonatal resuscitation 1, 4
- Ensure neonatal resuscitation team is present at delivery
- Anticipate need for volume resuscitation and possible blood transfusion
For Preterm Infants:
- For preterm infants not requiring immediate resuscitation, delayed cord clamping for at least 60 seconds is recommended 5
- For preterm infants 28-36 weeks gestation who cannot receive delayed cord clamping, umbilical cord milking is a reasonable alternative 5
- However, in cases of suspected cord avulsion, immediate delivery takes precedence over delayed cord clamping 8, 4
Post-Delivery Management
- Immediate neonatal assessment with Apgar scoring at 1,5, and 10 minutes 5
- Maintain neonatal temperature between 36.5°C and 37.5°C 5
- Anticipate need for blood transfusion in cases of significant fetal hemorrhage 2, 4
- Monitor for hyperbilirubinemia, which may be more common after significant blood loss 5
Prevention Strategies
- Increased documentation and awareness of conditions like furcate insertion can help identify high-risk cases 2
- Weekly antenatal testing for high-risk pregnancies with identified cord or placental abnormalities 4
- Prompt response to decreased fetal movement, especially in pregnancies with identified risk factors 4
Prognosis
- Historically, umbilical cord vascular rupture has led to rapid neonatal demise 4
- However, with prompt diagnosis and immediate intervention, intact newborn survival is possible 4
- The window of opportunity for successful intervention is extremely small, emphasizing the need for rapid response 3, 4
Key Pitfalls to Avoid
- Delaying cesarean delivery when fetal bradycardia is present in suspected cord avulsion 8
- Failing to prepare for neonatal blood transfusion in cases of confirmed cord avulsion 2, 4
- Overlooking prenatal ultrasound findings that might indicate increased risk (abnormal cord insertion, two-vessel cord) 2, 4
- Attempting delayed cord clamping in cases of suspected cord avulsion, which could worsen fetal outcomes 8