Cord prolapse at full dilatation33-year-old woman, 70 kg, para 2, at 39 weeks

The patient

The examiner asks

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1. Consider

   What are the issues?

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   • A 33-year-old para 2 at term, fully dilated, with cord prolapse and fetal bradycardia. Patient
   • At term, general anaesthesia brings aspiration risk, a difficult airway and caval compression.
   • The cord is being compressed, and handling or cold makes its vessels spasm. Disease
   • Fully dilated, an instrumental birth in theatre may be fastest, with caesarean as backup. Surgery

2. Plan

   What is your plan?

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   • The midwife keeps the presenting part up by hand, or the bladder is filled with 500–750 mL. Surgery
   • For the move: knee–chest, or on her left side tipped head-down, pillow beneath the left hip. Patient
   • Abnormal heart rate makes this category 1: birth within 30 minutes. Stem trigger
   • In theatre I extend her epidural: 3% chloroprocaine or alkalinised 2% lidocaine reaches T4 in about 5 minutes. Disease
   • Terbutaline 0.25 mg subcutaneously can settle contractions while we get ready.
   • General anaesthesia prepared in parallel: sodium citrate, drugs drawn, videolaryngoscope checked. Airway
   • Neonatal team in theatre before the birth. After surgery

3. Crisis

   The ventouse fails after two pulls; the obstetrician wants an immediate caesarean. The block is at T10. What do you do?

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   • Category 1: 15–20 mL of 3% chloroprocaine in divided doses now, aiming for T4. (Crisis)
   • I test the block every minute; if it won't reach T4 in time, we go to general.
   • No new spinal: setting it up costs minutes this fetus doesn't have.
   • General: rapid sequence, propofol 2 mg/kg and rocuronium 1.0 mg/kg, airway plan stated aloud.
   • The presenting part stays elevated until the uterus is open; bladder emptied before delivery.

4. Crisis

   After the top-up, BP falls to 78/40, HR 110, and the fetal heart drops to 60/min. What do you do?

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   • Her hypotension is now starving the fetus: more left displacement and a fast fluid bolus. Crisis
   • Phenylephrine 100–150 mcg IV, repeated until she is back near her baseline.
   • Presenting part still elevated; surgery starts as soon as the block reaches T4.
   • If the block is short, rapid sequence general so delivery isn't delayed.
   • Afterwards a debrief and documented decision-to-delivery times. After surgery