PROLAPSUS OF THE UMBILICAL CORD.

Diagnosis.—Causes.—Treatment.—Reposition of the cord.

Although by no means a common occurrence, it every now and then happens that a portion of the umbilical cord falls down between the presenting part of the child and the mother’s pelvis either just before or during labour; so that, as the child advances through the passages, its life is placed in imminent danger from the pressure to which the cord is exposed, obstructing the circulation in it.

There is probably no disappointment, which the accoucheur has to meet with more annoying than a case of this kind; every thing has seemed to promise a favourable labour; the presentation is natural, the pains are regular, the os uteri is dilating readily, the mother, and, as far as we can ascertain, her child, are in perfect health, and yet because a minute loop of the cord has fallen down by the side of its head, the labour, unless interfered with by art, will almost necessarily prove fatal to it.

Diagnosis. If the membranes be not yet ruptured, we shall probably be able to feel a small projecting mass like a finger, close to the presenting part, and possessing a distinct pulsation, which, from not being synchronous with the mother’s pulse, instantly declares its real nature. When the membranes give way, more of the cord comes within reach, and probably forms a large coil, which passes through the os uteri into the vagina, or even appears at the os externum.

Causes. The earliest writer that we know of who has given a detailed account of cord presention was Mauriceau; few, even in hospital practice, and certainly none in private practice, have exceeded him in the number of cases described, and very few have surpassed him in the success of his treatment. He mentions chiefly three conditions as being liable to produce prolapsus of the cord, viz. a large quantity of liquor amnii, an unusually long cord, and malposition of the child: later authors have enumerated several other causes, many of which are imaginary; of these, by far the most correct list has been given by Boer, of Vienna, who has justly ridiculed the theoretical views which were maintained by his cotemporaries.“If there be a large quantity of liquor amnii present, and especially, as is not unfrequently the case, the child is at the same time under the usual size; if the head be not firmly pressed against the brim, and does not enter it sufficiently, or when the child’s position is faulty, especially if, at the same time, the cord is unusually long; if, under such circumstances, a large bag of membranes has formed, and the brim of the pelvis itself is very spacious; if perchance, the rupture of the membranes takes place at a moment when the patient is moving briskly on in some unfavourable posture, the cord will be very liable to prolapse. Nevertheless, cases are occasionally seen which arise without these predisposing circumstances.” (Boer, von Geburten unter welchen die Nabelschnur vorfÄllt.)

The uterus is the chief means by which the cord is prevented from falling down between the presenting part of the child and the passages, from the closeness with which its inferior portion encircles it: without this, from the erect posture of the human female, there would be a liability to prolapsus of the arm or cord in every labour.

“The contraction of the uterus, which comes on with the rupture of the membranes, and sometimes, where they protrude very much, even before, is of great importance. This contraction takes place in the inferior segment of the uterus; it surrounds the head, and when fully developed extends over the whole head of the child. Thus, for instance, if we attempt to operate at an early stage, it feels more like a hard ring round the head, of about a finger’s breadth, and it may be felt to extend itself higher up, in proportion as the stimulus of the hand excites the activity of the uterus.” (Michaelis, Neue Zeiteschrift fÜr Geburtskunde, band iii. heft. 1.)

Hence, therefore, whatever prevents the uterus from contracting with its inferior segment upon the presenting part of the child, deprives the cord of its natural support, and, therefore, renders it liable to prolapse. Many of the causes enumerated by Boer act in this way; thus, where the uterus is distended by an unusual accumulation of liquor amnii; where the contractions at the beginning of labour have been exceedingly irregular; where the arm, or shoulder, or feet present; or where a large bladder of membranes is formed, the lower part of the uterus will either not contract at all upon the head, or so imperfectly as to endanger the descent of the cord.

Malposition of the child has been mentioned by many authors as a cause of prolapsus of the cord, and in some cases it may possibly act thus from the inferior segment of the uterus being unable to surround sufficiently close so irregular a mass as the shoulder. In the majority of cases, however, the coincidence of these two circumstances depends upon their being produced by the same causes; thus an unusually large quantity of liquor amnii, or irregular contractions of the uterus, will just as much dispose to the one as the other.

The form or size of the pelvis can have, we think, but little effect upon the cord, so long as the uterine action is of the right character and the child alive. Most authors enumerate a large pelvis or small foetal head as a cause, why should we not, therefore, have prolapsus of the cord in every case of precipitate labour which arises from such circumstances? Nor are we at all disposed to consider deformed pelvis as capable of producing it, so long as the uterus is not immoderately distended and acting naturally: we do not deny that the cord is occasionally found prolapsed in cases of dystocia pelvica, but this is chiefly where the child has died from the severity of the labour, and where the flaccid pulseless cord has gradually slipped down during the intervals of the pains.

So long as the uterus exerts but a moderate degree of pressure round the head, it is impossible for the cord of a living child to descend, particularly as, according to Dr. Michaelis, the circular contraction of the portio vaginalis commences from below upwards, and would rather push back the cord if a portion of it had descended during the moments of uterine relaxation. The pulsating turgor of the cord when the child is alive will also assist much in preventing its descent, even where the uterus does not surround the presenting part so closely as usual.

The unusual length of the cord is also a very doubtful cause of its prolapsus, and will evidently, in great measure, depend upon the causes we have already alluded to.

We may also allude to another cause of prolapsus of the cord, which, although noticed nearly a century ago by Levret, and also by two or three authors after him, had nearly fallen into oblivion until lately, when it excited the attention of Professor NaegelÉ, junior. Levret, from the result of numerous observations on the insertion of the cord into the placenta, was led to suppose that the lower the situation of the placenta in the uterus, the lower also was the insertion of the cord into the placenta, so that if the edge of the placenta touched upon the os uteri, the cord was usually inserted into that part of its edge which corresponded with the os uteri.

Although it is certain that the situation of the placenta close to the os uteri, is by no means necessarily attended by insertion of the cord into its edge, and, therefore, by prolapsus of it when the membranes give way, inasmuch, as under such circumstances we ought to have every case of partial placenta prÆvia accompanied with the cord presenting: still, however, there is no doubt that cases of the above-mentioned complication do every now and then occur, and must necessarily incur no inconsiderable danger of prolapsus.

“There is no doubt that the situation of the placenta in the vicinity of the os uteri, may be looked upon as one of the predisposing causes of the cord presenting during labour; an accident which is the more to be feared, the nearer the cord is inserted into the inferior edge of the placenta. If its edge extends quite down to the os uteri, and the cord is inserted into it, or the umbilical vessels divide, as in the cases we have described, at some little distance from it, viz. in the membranes, the cord will present as a necessary result, and prolapse as soon as the membranes give way.” (Die GeburtshÜlfliche Auscultation, von Dr. H. F. NaegelÉ, p. 114.) The two cases referred to by Professor NaegelÉ, jun., of prolapsus of the cord from this cause, occurred so near after each other, as to render the circumstance the more remarkable. The fact was noticed by Giffard as early as in 1728, in a case of flooding from partial placenta prÆvia; but he does not appear then to have drawn any inferences from the position of the placenta, which he did not consider was attached, but was “in part, if not wholly, separated from the uterus.”[137]

Prolapsus of the cord is fortunately not a circumstance of frequent occurrence. Dr. Churchill, of Dublin, in a valuable paper, (Edin. Med. and Surg. Journal, Oct., 1838,) has collected the results of no less than 90,983 deliveries, amongst which the cord presented in 322 cases, being in the proportion of one in 282¼.[138] That prolapsus of the cord occurs most frequently in foot presentations, as supposed by Professor NaegelÉ, senior, is disproved by the results of Mauriceau’s large experience, as well as of many others since; thus, out of 33 cases which occurred in labour at the full term, (or nearly so,) 17 presented with the head, 1 with the face, 1 with the feet, 9 with the hand or arm, 3 with the hand or foot, 1 with the hand and breech, and 1 with the hand and head. In the 16,652 births which have been recorded by Dr. Collins, at the Dublin Lying-in Hospital, the cord prolapsed in 97 instances. “Twelve of the 97 occurred in twin cases, and in seven of the 12 it was the cord of the second child. Nine occurred where the feet presented, (not including two met with in twin children,) which was in the proportion of one in every fourteen of such presentations. Two only where the breech presented, which was in the proportion of one in every 121 of such presentations: this approaches nearly the proportional average in all deliveries, which is one in 171½. Four occurred where the shoulder or arm presented: this is in the proportion of one in nine of such presentations. Seven occurred where the hand came down with the head. Seven of the children were born putrid; three of the 97 were premature, viz. two at the seventh and one at the eighth month.” (Collins’s Practical Treatise on Midwifery, p. 346.) We may, therefore, conclude with safety, that presentations of the head are by far the most common.

Treatment. Left to itself prolapsus of the cord is almost certain destruction to the child, for unless the labour comes on very briskly, and the head passes rapidly through the pelvis, the cord is pressed upon so long as to render it impossible for the child to be born alive. Still, however, where the passages are yielding, and the pains active; where the head is of a moderate size, the pelvis spacious, and the cord in a favourable part of it, viz. towards one of the sacro-iliac synchondroses; where also the membranes remain unruptured until the last moment, there will be a very fair chance of the child being born alive. Under no circumstances is it of such paramount importance to avoid rupturing the membranes as in these cases, for the bag of fluid which they form dilates the soft passages and protects the cord from pressure.

“Many methods of relief have been recommended, such as turning, delivering with the forceps, pushing up the funis through the os uteri with the hand, and endeavouring to suspend it on some limb of the child, collecting the prolapsed cord into a bag, and then pushing it up beyond the head, pushing up, the funis with instruments of various kinds, endeavouring to keep it secured above the head by means of a piece of sponge introduced; these and many other similar expedients have been resorted to.” (Collins, op. cit. p. 344.)

The first two of these means have been chiefly used in cases of prolapsed funis, the others having, for the most part, been found entirely inefficient. Thus Mauriceau, in the 33 cases which he has recorded, turned 19 times: the children were all born alive, except one, which was dead, but required turning as it presented with the arm. In later times, turning or the forceps have been preferred, according to the period of labour at which the prolapsus was discovered or occurred. Thus Madame Boivin has recorded 38 cases, 25 of which occurred at the commencement of, and 13 during labour, the former were all turned; in the latter the forceps was used; 29 children were saved, seven were lost, and the two others were putrid.

Our practice must be in great measure guided by the circumstances of the case: where the os uteri is not fully dilated, where the head is still high and not much engaged in the pelvis, the liquor drained away, and the cord beginning to suffer pressure during the pains, we dare not wait until the case be sufficiently advanced to admit the application of the forceps, but must proceed as soon as possible to turn the child. The operation should be performed with the greatest possible caution; the cord should be guided to one of the sacro-iliac symphyses; the expulsion of the trunk must be very gradual; a dose of secale should be given to ensure the requisite activity of the uterus when the head enters the pelvis, and the forceps kept in readiness to apply the instant that its advance is not sufficiently rapid. On the other hand, where the labour has made considerable progress before the membranes give way, and the head has fairly engaged in the cavity of the pelvis, if the os uteri is fully dilated, it will be no longer advisable to attempt turning; the head is within reach of the forceps, which should be immediately applied, taking care that the cord does not get squeezed between the blades and the head. Where the arm or shoulder presents, this will of itself require that the child should be turned.

Reposition of the cord. Although the reposition of the cord has been recommended from the time of Mauriceau, and by the majority of authors since, it has nevertheless met with so little success as to have fallen into complete disuse until the last few years; one of its strongest opposers was the celebrated La Motte. “The delivery ought to be attempted as soon as we find that the string presents before the head, it being to no purpose to try to reduce it behind the head, which at that time fills up the whole passage, and can only admit you to push it back into the vagina, and it will fall down again at every pain; and if you have done so much as to reduce it into the uterus, what hinders you from finishing the delivery at once, by seeking for the feet? the chief difficulty is then over.” (La Motte, English translation, p. 304.) This mode of delivery (turning) has been more adopted by practitioners in such cases than any other, especially in former times, when the forceps was either not at all or imperfectly known; by none has it been so with more success than by Mauriceau himself, having saved every living child in which he attempted the operation. Still, however, he recommended that the attempt should be made to return the cord wherever it was possible, and has recorded four cases of this mode of treatment, all of which proved successful, although one of the children was born so feeble as to die shortly afterwards. Giffard seems to have attempted the reposition of the cord only once, and failed, apparently from the unusual size of the child. In later years Sir R. Croft, “has related two cases in which he succeeded, by carrying the prolapsed funis through the os uteri, and suspending it over one of the legs of the child. In both these cases the children were born alive.” (Merriman’s Synopsis, p. 99.) It is to Dr. Michaelis of Kiel that we are indebted for much recent and valuable information on the subject of replacing the prolapsed cord. Having pointed out the fact that it is the uterus alone which prevents the cord from prolapsing, he shows that, in order to replace the cord, we must carry it “above that circular portion of the uterus which is contracted over the presenting part.” The reposition of the cord may be effected by the hand, or by means of an elastic catheter and ligature. In replacing the cord by means of the hand alone, Dr. Michaelis remarks that we shall effect this more readily by merely insinuating the hand between the head and the uterus, and gradually passing it farther round the head, pushing the cord before it. In this manner we do not require to rupture the membranes when we have felt the cord before the liquor amnii has escaped; a point of considerable importance.

The reposition, by means of the catheter, is effected by passing a silk ligature, doubled, along a stout thick elastic catheter, from twelve to sixteen inches in length, so that the loop comes out at the upper extremity; the catheter is introduced into the vagina, and the ligature is passed through the coil of the umbilical cord, and again brought down to the os externum. A stilet with a wooden handle is introduced into the catheter, the point passed out at its upper orifice, and the loop of the ligature hung upon it; it is then drawn back into the catheter and pushed up to the end. The operator has now only to pull the ends of the ligature, so as to tighten it slightly, passing the catheter up to the cord, which now becomes securely fixed to its extremity. When the reposition has been effected, he has merely to withdraw the stilet; the cord is instantly disengaged.[139] To prevent any injury, the ligature should be brought away first, and then the catheter.

“Dr. Michaelis has recorded eleven cases of prolapsus of the cord, where it has been returned by the above means, in nine of which the child was born alive. In three cases the arm presented also, which was replaced, and the head brought down; in two of these the child was born alive.” (British and Foreign Med. Review, vol. i. p. 588.) A similar plan of replacing the cord by means of an elastic catheter has been tried by Dr. Collins, but he had not tried it sufficiently often at the time of publishing his Practical Treatise to be able to give a decided opinion about it.

The plan of introducing a piece of sponge after replacing the cord, in order to prevent its coming down again, is of no use whatever. Dr. Collins tried it in several instances, and considers that “it is quite impossible, however, in the great majority of cases, to succeed in this way in protecting the funis from pressure, as it is no sooner returned, than we find it forced down in another direction.” The plan has been recommended by several modern authors, but it is by no means a new invention, having been proposed by Mauriceau; it does not appear, however, that he ever put it in practice.

Where no pulsation can be felt in the prolapsed funis, which is flabby and evidently empty, no interference will be required; the child is dead, and therefore the labour may be permitted to take its course. We should, however, be cautious in examining the cord where it is without pulsation, and yet feels tolerably full and turgid, for a slight degree of circulation may go on nevertheless, sufficient to keep life enough in the foetus, even for it to recover if the labour be hastened. We should especially examine the cord during the intervals of the pains, and after we have guided it into a more favourable part of the pelvis, where it will not be exposed to so much pressure, for then the pulsation will become more sensible to our touch, and prove that the child is still alive.

The following case by Dr. Evory Kennedy is an excellent illustration of what we have now stated:—“The midwife informed me that there was no pulsation in the funis, which had been protruding for an hour; on examination made during a pain, a fold of the funis was found protruding from the vagina, at its lateral part, and devoid of pulsation. As the pain subsided, I drew the funis backwards towards the sacro-iliac symphysis, and thought I could observe a very indistinct and irregular pulsation; I now applied the stethoscope, and distinguished a slight foetal pulsation over the pubes. Fortunately on learning the nature of the case, I had brought the forceps, which were now instantly applied, and the patient delivered of a still-born child, which, with perseverance, was brought to breathe, and is now a living and healthy boy, four years of age. Had I not in this case ascertained by the means mentioned, that the child still lived, I should not have felt justified in interfering; but, supposing the child dead, would have left the case to nature, and five minutes, in all likelihood, would have decided the child’s fate.” (Dr. Evory Kennedy, on Pregnancy and Auscultation, p. 241.)