Considerations

This patient has two prior deliveries. She currently is in labor. Her cervix is 5 cm dilated, and fetal vertex is at -3 station, indicating that the fetal head is unengaged. With artificial rupture of membranes, fetal bradycardia is noted. This situation is very typical for a cord prolapse, where the umbilical cord protrudes through the cervical os. Usually, the fetal head fills the pelvis and prevents the cord from prolapsing. However, with an unengaged fetal presentation, as in this case, umbilical cord accidents are more likely. Thus, as a general rule, artificial rupture of membranes should be avoided with an unengaged fetal part. Situations such as a transverse fetal lie or a footling breech presentation are other predisposing conditions. It is not uncommon for a multiparous patient to have an unengaged fetal head during early labor. The lesson in this case is not to rupture membranes with an unengaged fetal presentation. With fetal bradycardia, the next step would be digital examination of the vagina to assess for the umbilical cord, which would feel like a ropelike structure through the cervical os. If the umbilical cord is palpated and the diagnosis of cord prolapse confirmed, the patient should be taken for immediate cesarean delivery. The physician should place the patient in Trendelenburg position (head down) and keep his or her hand in the vagina to elevate the presenting part, thus keeping pressure off the cord.

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