AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements that support safe umbilical cord prolapse management. The key safety elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP).
Who should use this tool: Nurses, physicians, midwives, anesthesiology providers, neonatal providers, and other labor and delivery (L&D) staff responsible for intrapartum care and managing deliveries that may be complicated by cord prolapse.
How to use this tool: Review the key perinatal safety elements with L&D leadership and relevant unit staff to determine how the elements will be implemented at your hospital. Consider any existing hospital procedures, policies, or processes related to cord prolapse management.
Key Perinatal Safety Elements
| Standardize When Possible (CUSP Science of Safety) | |
|---|---|
| Key Perinatal Safety Elements | Examples |
| Use a predetermined approach to management of a cord prolapse approved by unit leadership. | Unit-established approach to managing and documenting cord prolapse episodes. This approach can include—
|
| Standardize communication of information during episode. |
|
| Create Independent Checks (CUSP Element) | |
| Assess appropriateness of procedures that increase risk for cord prolapse. | Cognitive aids and checklists that list indications, contraindications, and maternal and fetal criteria for procedures that increase risk for prolapse such as2—
|
| Use cognitive aids such as checklists, algorithms, or protocols to guide a systematic approach to management and documentation of cord prolapse. | Cognitive aids such as checklists, algorithms, or protocols may improve team response and management of cord prolapse. Such aids can provide clinical teams with an independent check on steps for facilitating a safe delivery by offering logic and a clear focus during what can often be a chaotic event.
A sample checklist that operationalizes key safety elements is provided in the Appendix of this document; units can modify it based on unit preferences. Other samples are available from health care and government organizations or reviews3-5: http://kemh.health.wa.gov.au/development/manuals/O&G_guidelines/ http://contemporaryobgyn.modernmedicine.com/ http://www.perinatalservicesbc.ca/health-professionals/guidelines-standards/standards/core-competencies-for-management-of-labour |
| Learn From Defects (CUSP Element) | |
| Debrief and analyze near misses and adverse events related to cord prolapse. |
|
| Have a process in place to review severe maternal or neonatal morbidity and mortality events. |
|
| Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning. | Sites can decide how often, how much, and with whom this information will be shared and whether this is specified in a unit policy or is handled more informally. |
| Simulation (SPPC Program Pillar) | |
Sample scenario:
|
|
| Teamwork Training (TeamSTEPPS®) | |
| Have situational awareness. | Situational awareness refers to all staff caring for the patient—
In the context of cord prolapse, this includes risk awareness, timely recognition of a cord prolapse diagnosis, awareness and monitoring of time since diagnosis, and discussing next steps in the event of fetal deterioration. |
| Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop communication techniques. | Use SBAR, callouts, huddles, and closed-loop communication among team members. In the context of a cord prolapse, these techniques are particularly useful—
|
| Communicate during transitions of care. | Use of transition communication techniques assures a shared mental model of plan of care and perceived risks between shifts, between units. This includes communication between primary team and rapid responders, or between rapid responders and the operating room or OR team. |
Have high-reliability teams:
|
Team members protect each other from work overload and place requests or offers for assistance in the context of patient safety. It is expected that assistance will be actively sought and offered.
|
| Patient and Family Engagement (CUSP Module) | |
| Communicate with patient and family during episode. |
|
| Disclose any unintended outcomes. | Unit-established process for disclosing unintended outcomes. This may include the following:
|
References
- Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal Nurs 2008 Sep-Oct;37(5):510-5. PMID: 18761565.
- Holbrook BD, Phelan ST. Umbilical cord prolapse. Obstet Gynecol Clin North Am 2013 Mar;40(1):1-14. PMID: 23466132.
- Phelan ST, Holbrook BD. Umbilical cord prolapse: a plan for an OB emergency. Contemp OB/GYN. 2013 Sept 1. http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/umbilical-cord-prolapse?page=full. Accessed May 2, 2016.
- Government of Western Australia, Department of Health. Obstetric and Gynaecology Clinical Guidelines Section B. Obstetrics and Midwifery Care, Section b11.3.2 Umbilical Cord Prolapse. January 2015 http://kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/index.htm#11. Accessed July 4, 2016.
- Perinatal Services BC. Core Competencies--Management of Labor, Decision Support Tool 8A—Obstetrical Emergencies Cord Prolapse. 2014 April 14. http://www.perinatalservicesbc.ca/health-professionals/guidelines-standards/standards/core-competencies-for-management-of-labour. Accessed May 2, 2016.
- Siassakos D, Hasafa Z, Sibanda T, et al. Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG 2009 Jul;116(8):1089-96. PMID: 19438496.
Appendix
Every effort was made to ensure the accuracy and completeness of this resource. However, the U.S. Department of Health and Human Services makes no warranties regarding errors or omissions and assumes no responsibility or liability for loss or damage resulting from the use of information contained within.
Sample Cord Prolapse Management Checklist
___ Communicate the diagnosis to key staff.
| ___ Identify prolapse/cord pulsations [Call Time] (hh:mm:ss) ___ : ___ : ___ |
Communicate diagnosis to—
___ Patient/family members
___ Maternity care provider (physician or midwife)
___ Charge nurse
___ Nursing staff
___ Pediatric provider
___ Anesthesiology provider
___ Designate one team member as recorder.
___ Designate one team member as communicator.
___ Protect the cord.
- Minimize manipulation of the cord.
- If cord is protruding from vagina, cover with sterile towel saturated with warm saline.
If fetal heart rate abnormality is detected, consider taking the following actions:
- Minimize exposure to cold environment (i.e., room temperature). Retaining as much of the cord intravaginally as possible is recommended. [Call Time] [hh:mm:ss] ___:____:___
- Funic decompression—examiner’s hand is placed vaginally and gently elevates the fetal head or presenting part. [Call Time] [hh:mm:ss] ___:____:___
- Consider Trendelenburg positioning, knee-chest position, or gentle suprapubic elevation. [Call Time] [hh:mm:ss] ___:____:___
- Funic reduction (manual replacement of the cord)—This is a controversial practice. Earlier studies, prior to the advent of continuous fetal monitoring, showed association with increased risks of fetal hypoxia and death. Later but smaller series have shown success, particularly if cesarean section must be delayed, or if only a short segment of cord is prolapsed and vaginal delivery is imminent. [Call Time] [hh:mm:ss] ___:____:___
___ Stop oxytocin infusion (if receiving)
___ Assess indications for expectant management:
- Lethal fetal anomalies.
- Previable gestational age.
- Fetal demise.
___ Assess likelihood of safe vaginal birth within 15 minutes of elapsed time from diagnosis.
- Cervix is fully dilated, presenting part engaged, and station is low enough for an assisted or spontaneous vaginal delivery within 15 minutes → proceed with vaginal delivery.
[Call time of decision to proceed with vaginal delivery] [hh:mm:ss] ____:____:____
- Safe vaginal birth NOT likely within 15 minutes → proceed with cesarean section.
[Call time of decision to proceed with cesarean section] [hh:mm:ss] ____:____:____
- Obtain verbal consent from patient for cesarean section.
[Call Time] [hh:mm:ss] ____:____:_____
___ If appropriate, administer oxygen by face mask at 8–10 liter/min.
[Call Time] [hh:mm:ss] ___:____:___
___ If delay with proceeding to cesarean section:
- Consider retrofilling the bladder with 500–700 mL of normal saline. This MUST be drained prior to cesarean delivery.
[Call Time] [hh:mm:ss] ___:____:___
- Consider tocolytics.
___ Prepare for neonatal resuscitation.
___ Deliver baby.
[Call time of delivery of presenting part] [hh:mm:ss] ___:____:___
- Obtain umbilical cord blood for blood gas analysis.
___ Debrief with all team members.
___ Document key times, decisions, and interventions.
- Exam findings (e.g., cord pulsations) indicating prolapse and time of exam.
- Time of provider and team notification and arrival.
- Time of decision to proceed with vaginal delivery and rationale –OR– time of decision to proceed with cesarean section and rationale.
- Maneuvers used (positioning, bladder fill, oxygen, funic decompression and/or reduction), including sequencing, timing, and fetal response.
- Delivery description (vaginal, assisted vaginal, cesarean).
- Time of delivery and length between identification of prolapse and delivery.
- Staff present
Maternity care provider(s) ______________________________________________
Nursing staff_________________________________________________________
Anesthesia provider___________________________________________________
Pediatric provider_____________________________________________________
Other______________________________________________________________ - Neonatal status:
Birth weight (grams) _______
Outcome: deceased or live birth
Apgars: 1 min/5 min/10 min, if applicable
Blood gases: sent or not sent
Arterial: pH and base deficit: Venous: pH and base deficit:
Infant location after birth: remained in room with mother, transferred to NICU, transferred to newborn nursery - Maternal status after delivery
