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 282-1/4.[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 171-1/2. _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.)