Immediate Management for Suspected Cord Avulsion versus Placenta Detachment
For suspected umbilical cord avulsion, immediate cesarean delivery is required to prevent fetal death, while placental detachment requires immediate cesarean delivery with preparation for maternal hemorrhage management and neonatal resuscitation. 1
Differential Diagnosis and Initial Assessment
- Umbilical cord avulsion is a rare but life-threatening emergency where the umbilical cord separates from the placenta, leading to acute fetal hypoxia 1
- Placental detachment (abruption) involves separation of the placenta from the uterine wall before delivery, causing maternal bleeding and fetal compromise 2
- Both conditions require immediate intervention to prevent fetal mortality 1, 2
Management of Suspected Cord Avulsion
Immediate Actions
- Perform immediate cesarean delivery when cord avulsion is suspected 1
- Prepare for neonatal resuscitation with anticipation of volume resuscitation and possible blood transfusion 1
- If resuscitation is required, place the child between the mother's legs, start positive pressure ventilation with the umbilical cord intact, and delay clamping for at least 60 seconds if possible 3
Post-Delivery Management
- Perform immediate neonatal assessment with Apgar scoring at 1,5, and 10 minutes 1
- Monitor for hyperbilirubinemia, which may be more common after significant blood loss 1
- Measure cord blood gases to assess for metabolic acidosis 4
Management of Suspected Placental Detachment (Abruption)
Immediate Actions
- Proceed with immediate cesarean delivery when placental abruption is diagnosed 2
- Do not delay management pending confirmation by ultrasonography, as ultrasound is not a sensitive tool for diagnosis 5
- Administer oxygen supplementation to maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation 5
- Establish two large bore (14-16 gauge) intravenous lines for fluid resuscitation 5
Maternal Stabilization
- After mid-pregnancy, move the gravid uterus off the inferior vena cava using manual displacement or left lateral tilt to increase venous return and cardiac output 5
- Administer oxytocin immediately after delivery of the infant to reduce maternal blood loss in the third stage of labor 3
- Transfuse O-negative blood when needed until cross-matched blood becomes available for Rh-negative mothers 5
Special Considerations for Both Conditions
- For viable pregnancies (≥23 weeks), perform cesarean section no later than 4 minutes following maternal cardiac arrest if it occurs 5
- In cases of abnormal fetal heart rate patterns suggesting cord or placental compromise, expedite delivery via operative vaginal delivery or cesarean section 4
- Administer anti-D immunoglobulin to all Rh-negative pregnant trauma patients to prevent alloimmunization 5
Cord Management During Emergency Delivery
- In preterm infants born at <37 weeks who do not require immediate resuscitation, defer cord clamping for at least 60 seconds 3
- In term infants, delay cord clamping for at least 1 minute to decrease anemia and improve neurodevelopmental outcomes 3
- If immediate neonatal resuscitation is required, the priority is stabilization of the infant, and immediate cord clamping may be necessary 3
- For preterm infants who cannot receive deferred cord clamping, consider umbilical cord milking for infants 28-36 weeks gestation 3
Common Pitfalls to Avoid
- Delaying definitive intervention when signs of fetal distress persist despite intrauterine resuscitation measures 4
- Failing to recognize the significance of absent variability with recurrent variable decelerations, which indicates potential fetal hypoxia or acidemia 4
- Delaying management of suspected placental abruption while waiting for ultrasound confirmation 5
- Underestimating the severity of fetal compromise in cord avulsion cases, which require immediate delivery and aggressive neonatal resuscitation 1, 6