cord presentation in labour

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Umbilical Cord Prolapse

Original Author(s): Leena Khan Last updated: 22nd December 2017 Revisions: 21

• 1 Pathophysiology
• 2 Risk Factors
• 3 Clinical Features and Differential Diagnosis
• 4 Management

Umbilical cord prolapse is where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus. It affects 0.1 – 0.6% of births.

Cord prolapse occurs in the presence of ruptured membranes, and is either occult or overt:

• Occult (incomplete) cord prolapse  – the umbilical cord descends alongside the presenting part, but not beyond it.
• Overt (complete) cord prolapse  – the umbilical cord descends past the presenting part and is lower than the presenting part in the pelvis.
• Cord presentation  – the presence of the umbilical cord between the presenting part and the cervix. This can occur with or without intact membranes.

Although the incidence is relatively low, the mortality rate for such babies is high (~91 per 1000). This is largely because cord prolapse occurs more frequently in preterm babies, who are often breech, and who may also have other  congenital defects .

In this article, we shall look at the risk factors, clinical features and management of cord prolapse.

Pathophysiology

Umbilical cord prolapse is where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus. Subsequently, f etal hypoxia  occurs via two main mechanisms:

• Occlusion – the presenting part of the fetus presses onto the umbilical cord, occluding blood flow to the fetus.
• Arterial vasospasm – the exposure of the umbilical cord to the cold atmosphere results in umbilical arterial vasospasm, reducing blood flow to the fetus.

Risk Factors

The main risk factors for cord prolapse include:

• Breech presentation – in a footling breech, the cord can easily slip between and past the fetal feet and into the pelvis.
• If >37 weeks gestation, consider inpatient admission until delivery due to risk of cord prolapse
• Artificial rupture of membranes  – particularly when the presenting part of the fetus is high in the pelvis.
• Polyhydramnios – excessive amniotic fluid around the fetus

Fig 1 – A footling breech and umbilical cord prolapse.

Clinical Features and Differential Diagnosis

Cord prolapse should always be considered in the presence of a non-reassuring fetal heart rate pattern and absent membranes. It can be confirmed by external inspection or on digital vaginal examination. This is one of the reasons that vaginal assessment, after abdominal examination, encompasses a full assessment in the presence of a non-reassuring fetal heart rate pattern.

The fetal heart rate patterns can vary from subtle changes, such as decelerations with some of the contractions, to more obvious signs of fetal distress, such as a fetal bradycardia . The latter is strongly associated with cord prolapse; relating to the mechanism of occlusion of the cord by the presenting part.

An alternative diagnosis may be considered in the presence of bleeding per vagina or heavily blood-stained liquor with ruptured membranes. This would suggest placental abruption (the placenta starts to separate from the uterine wall) or vasa praevia (fetal vessels running in the fetal membranes adjacent to the internal os of the cervix).

Firstly, call for help – umbilical cord prolapse is an obstetric emergency . It should be managed as follows:

• Avoid handling the cord  to reduce vasospasm.
• Manually elevate the presenting part by lifting the presenting part off the cord by vaginal digital examination. Alternatively, if in the community, fill the maternal bladder with 500ml of normal saline (warmed if possible) via a urinary catheter and arrange immediate hospital transfer.
• Encourage into left lateral position with head down and pillow placed under left hip OR knee-chest position. This will relieve pressure off the cord from the presenting part.
• Consider tocolysis (e.g. terbutaline)  – if delivery is not imminently available this will relax the uterus and stop contractions, relieving pressure off the cord. It may be sufficient to allow enough time for transfer to a location where delivery is feasible (e.g. an operating theatre for a Caesarean section). This is a particularly useful strategy if there are fetal heart rate abnormalities while preparing for a C-section.
• If fully dilated and vaginal delivery appears imminent, encourage pushing or consider instrumental delivery.
• If at threshold for viability (23 + 0 weeks – 24 + 6 weeks) and extreme prematurity, expectant management may be discussed due to significant maternal morbidity with caesarean at this gestation and poor fetal outcomes.

Fig 2 – The knee-chest position, used in the management of cord prolapse.

• Umbilical cord prolapse occurs when the cord descends through the cervix and is alongside or below the presenting part of the fetus.
• It is an obstetric emergency, with a fetal mortality rate of 91 per 1000.
• The diagnosis should be suspected in any patient with a non-reassuring fetal heart trace and absent membranes.
• The first step is to call for help when the diagnosis is made.
• Manage by manually elevating the presenting part, and deliver via the quickest mode (usually Caesarean section).

Umbilical cord prolapse is where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus. It affects 0.1 - 0.6% of births.

• Occult (incomplete) cord prolapse  - the umbilical cord descends alongside the presenting part, but not beyond it.
• Overt (complete) cord prolapse  - the umbilical cord descends past the presenting part and is lower than the presenting part in the pelvis.
• Cord presentation  - the presence of the umbilical cord between the presenting part and the cervix. This can occur with or without intact membranes.
• Occlusion - the presenting part of the fetus presses onto the umbilical cord, occluding blood flow to the fetus.
• Arterial vasospasm - the exposure of the umbilical cord to the cold atmosphere results in umbilical arterial vasospasm, reducing blood flow to the fetus.
• Breech presentation - in a footling breech, the cord can easily slip between and past the fetal feet and into the pelvis.
• Artificial rupture of membranes  - particularly when the presenting part of the fetus is high in the pelvis.
• Polyhydramnios - excessive amniotic fluid around the fetus

Firstly, call for help - umbilical cord prolapse is an obstetric emergency . It should be managed as follows:

• Consider tocolysis (e.g. terbutaline)  - if delivery is not imminently available this will relax the uterus and stop contractions, relieving pressure off the cord. It may be sufficient to allow enough time for transfer to a location where delivery is feasible (e.g. an operating theatre for a Caesarean section). This is a particularly useful strategy if there are fetal heart rate abnormalities while preparing for a C-section.
• If at threshold for viability (23 + 0 weeks - 24 + 6 weeks) and extreme prematurity, expectant management may be discussed due to significant maternal morbidity with caesarean at this gestation and poor fetal outcomes.

[start-clinical]

[end-clinical]

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Persistent Funic Presentation And Sonographic Assesment Of The Risk For Umbilical Cord Prolapse

Ioakeim sapantzoglou.

1 First Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece

Alexandros Psarris

Panagiota diamantopoulou, antonis koutras, thomas ntounis, savia pittokopitou, ioannis prokopakis, panagiotis antsaklis, marianna theodora, michail sindos, ekaterini domali, alexandros rodolakis, georgios daskalakis, introduction.

Funic presentation (also known as cord presentation) is a rare entity with an incidence that ranges from 0.006% to 0.16% in the third trimester scans (Ezra et al., Gynecol Obstet Invest 2003; 56 : 6–9. 2003) and is defined as the presence of the cord between the presenting part of the fetus and the internal cervical os, with or without intact membranes (“Umbilical Cord Prolapse (Green-top Guideline No. 50) | RCOG,” n.d.). It may be a transient phenomenon and is usually considered insignificant until ~32 weeks. However, its persistence beyond that gestational age raises the concern of cord prolapse during labor as cervical dilation progresses. Consequently, current bibliography recommends Caesarean delivery when funic presentation is detected during labor making antenatal ultrasound detection a valuable asset in the effort to prevent the complications that cord prolapse has been associated with (Jones et al., BJOG 2000; 107 : 1055–7 ). Cord prolapse is the most significant complication of funic presentation and as such, the antenatal detection of cord presentation cases and the determination of patients that carry an increased risk for UCP are of paramount importance.

It is a mostly unpredictable obstetric emergency, in which the umbilical cord comes through the cervical os in advance of ( overt prolapse – usually palpable or even visible within the vagina) or alongside ( occult prolapse) the fetal presenting part in the presence of ruptured membranes. The reported incidence of umbilical cord prolapse ranges from 1 to 6 per 1000 pregnancies (Faiz et al., Saudi Med J 2003; 24: 754–7).Though rare, it is associated with high perinatal mortality and morbidity as cord compression and umbilical artery vasospasm may occur preventing blood flow to and from the fetus leading to fetal asphyxia (Critchlow et al., Am J Obstet Gynecol 1994; 170: 613–8).

Case Presentation

A 30-year-old pregnant woman at 32+2 weeks of gestation, gravida 5, para 4, presented to the outpatient clinic of our institution during the third trimester of her pregnancy, due to painless vaginal bleeding. The antenatal course had been otherwise uncomplicated. The woman’s past medical history was uneventful.

During her pregnancy, she underwent no prenatal testing except for a first trimester scan at 9 weeks of gestation where the exact gestational age was determined.

She had previously had four uncomplicated pregnancies, having delivered vaginally the first two, while the third and the fourth pregnancies were delivered via caesarean section – the first one because of a footling breech presentation and the other one because of the previous caesarean section. The woman was hemodynamically stable, and the biophysical profile was normal.

The sonographic examination revealed a singleton pregnancy with positive cardiac function and an anterior low-lying placenta with its lower edge 24.8 mm from the internal os ( Fig. 1 ). The cord insertion was noted to be marginal towards the lower placental edge ( Fig. 1 ). Furthermore, multiple free loops of the umbilical cord were noted to be running over the internal cervical os ( Fig. 2 ). The cervix measured 24 mm in length with funneling at the time.

Transvaginal ultrasound revealed a marginal cord insertion in the placenta close to the lower placental edge.

Umbilical cord free loops were detected overlying the cervical internal os.

All fetal growth parameters, the amniotic fluid index and the Doppler assessment were within normal range for the gestational age (EFW: 2342gr (89th percentile)).

A single course of antenatal corticosteroids was given at 32+2 and 32+3 weeks of gestation, due to the fear of an impending umbilical cord prolapse.

The pregnancy was followed up with weekly ultrasound scans. The free loops remained in close proximity to the internal os, lying between the presenting part and the cervix. The pregnancy was monitored until 36+0 weeks of gestation, when the patient began complaining of regular contractions, a fact that was confirmed with the use of cardiotocography. A new ultrasound examination was performed with the umbilical cord loops still present between the fetal head and the cervix and an emergency caesarean section was performed.

A live, female newborn was delivered, weighing 3040 g with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The gross examination of the placenta confirmed the marginal cord insertion of the umbilical cord ( Fig. 3 ).

Τhe examination of the placenta postpartum confirmed the marginal cord insertion.

Identification and antenatal detection of umbilical cord presentation cases are of utmost importance due to their association with umbilical cord prolapse, which is linked to significant perinatal mortality and morbidity. The current paper presents a case of funic presentation at our department and the management that was carried out and also provides a summary of all of the available published evidence on the association between funic (cord) presentation and cord prolapse. The studies by Vintzileos et al.( J Clin Ultrasound. 1983 Nov-Dec; 11(9): 510–1) and Raga et al. (J Natl Med Assoc. 1996; 88(2): 94–6) describe cord presentation as the precursor to impending cord prolapse, thus highlighting the need for focused ultrasound imaging to diagnose and manage these pregnancies and then to plan the delivery of these fetuses by cesarean section.

In contrast, (Ezra et al., Gynecol Obstet Invest 2003; 56 : 6–9) demonstrated that cord prolapse was preceded by the identification of cord presentation via routine ultrasound in just 12.5% of cases. In addition, a considerable proportion of funic presentation cases diagnosed antenatally resolved spontaneously without resulting in cord prolapse (4 out of 7 turned to vertex presentation), underlining that the two conditions are not synonymous. The authors, however, stated that the sonographic finding of cord presentation carries a significant risk of cord prolapse given the fact that, in their dataset, 1 out of 13 women with cord presentation had a clinical prolapse. Contradictory to the above results, there is some case report evidence underlining the necessity of the assessment of the position of the placental cord insertion in funic presentations since it is the author’s belief that the anatomic relationship between the internal os and the marginal or velamentous cord insertions would preclude the possibility of such a resolution (Oyelese et al., Ultrasound Obstet Gynecol. 2004; 24(6): 692–3).

In terms of following up the pregnancies with cord presentation, there is only one cohort study with historical controls that assessed the efficacy of weekly internal ultrasound examinations in women with breech fetuses after 36 weeks of gestation (Kinugasa et al., J Obstet Gynaecol Res. 2007; 33(5): 612–8). There were no cases of cord prolapse when such a screening method was adopted, in a 10-year period (1995–2005), while in the historic control group there were 10 cases of cord prolapse noted along with one perinatal death in an 11-year period (1983–1994). The authors agreed with Ezra et al. that the two conditions are not synonymous and underlined the importance of serial transvaginal ultrasound assessments given the fact that there were cases in which there were no funic presentations initially, but they developed eventually.

It is well established that transvaginal ultrasound is the best available modality to diagnose a funic presentation and it is a great tool to differentiate it from vasa previa, a condition in which the fetal vessels traverse the membranes near the internal os in advance of the fetal presenting part. In funic presentation cases, the umbilical cord moves away from the cervix during ultrasound examination whereas in vasa previa the cord remains fixed in place. However, there is currently no definitive consensus regarding the optimal timing of delivery in cases of funic presentation. Some researchers advocate close monitoring in an effort to achieve vaginal delivery, while others recommend scheduled cesarean delivery prior to the onset of labor (Jones et al., BJOG 2000; 107 : 1055–7). Current evidence, based on the data provided by Ezra et al., is inclined towards a more personalized approach to the condition given the fact that funic presentation will not inevitably lead to prolapse (Jones et al., BJOG 2000; 107 : 1055–7). However, several cases of cord prolapse did not appear to have detectable cord presentations prenatally. Weekly ultrasound examination could be performed, and vaginal delivery could be considered in cases of resolution of the funic presentation.

The presence of funic presentation has been established as a documented risk factor for cord prolapse and its detection prenatally raises the risk of such an adverse event during labor. Ultrasound assessment is a well-established tool for the prenatal detection of cord presentation but the evidence regarding the proper management and the timing and mode of delivery is quite limited as it is the result of case reports and retrospective cohorts. The need for randomized controlled studies or case-control studies with a larger sample size should be emphasized in an effort to ameliorate the situation and optimize the management of the care of these pregnant women.

Conflict of Interest The authors declare that they have no conflict of interest.

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Cord presentation in labour: imminent risk of cord prolapse

Affiliations.

• 1 Gynaecology Department, Centro Hospitalar Universitário São João, Porto, Portugal [email protected].
• 2 Obstetrics Department, Centro Hospitalar Universitário São João, Porto, Portugal.
• 3 Gynaecology Department, Centro Hospitalar Universitário São João, Porto, Portugal.
• PMID: 33947682
• PMCID: PMC8098917
• DOI: 10.1136/bcr-2021-243320

Keywords: obstetrics and gynaecology; pregnancy; reproductive medicine.

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Conflict of interest statement

Competing interests: None declared.

Transvaginal ultrasound showing the umbilical…

Transvaginal ultrasound showing the umbilical cord between the fetal head and the cervix.

Transvaginal ultrasound showing loops of…

Transvaginal ultrasound showing loops of cord presenting above the internal cervical os. Flow…

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• Risk factors and perinatal outcome of umbilical cord prolapse in Ebonyi State University Teaching Hospital, Abakaliki, Nigeria. Kalu CA, Umeora OU. Kalu CA, et al. Niger J Clin Pract. 2011 Oct-Dec;14(4):413-7. doi: 10.4103/1119-3077.91746. Niger J Clin Pract. 2011. PMID: 22248940
• Umbilical cord prolapse: revisiting its definition and management. Wong L, Kwan AHW, Lau SL, Sin WTA, Leung TY. Wong L, et al. Am J Obstet Gynecol. 2021 Oct;225(4):357-366. doi: 10.1016/j.ajog.2021.06.077. Epub 2021 Jun 26. Am J Obstet Gynecol. 2021. PMID: 34181893 Review.
• Umbilical cord prolapse and perinatal outcomes. Kahana B, Sheiner E, Levy A, Lazer S, Mazor M. Kahana B, et al. Int J Gynaecol Obstet. 2004 Feb;84(2):127-32. doi: 10.1016/S0020-7292(03)00333-3. Int J Gynaecol Obstet. 2004. PMID: 14871514
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• Ezra Y, Strasberg SR, Farine D. Does cord presentation on ultrasound predict cord prolapse? Gynecol Obstet Invest 2003;56:6–9. 10.1159/000072323 - DOI - PubMed
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• Mimura K, Endo M, Matsuzaki S, et al. . Persistent funic presentation due to velamentous cord insertion adjacent to the internal os but not vasa previa. Taiwan J Obstet Gynecol 2020;59:167–8. 10.1016/j.tjog.2019.10.001 - DOI - PubMed
• Jones G, Grenier S, Gruslin A. Sonographic diagnosis of funic presentation: implications for delivery. BJOG 2000;107:1055–7. 10.1111/j.1471-0528.2000.tb10415.x - DOI - PubMed

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Cord presentation in labour: imminent risk of cord prolapse

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Umbilical Cord Prolapse (Green-top Guideline No. 50)

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Cord prolapse has been defined as the descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes. Cord presentation is the presence of the umbilical cord between the fetal presenting part and the cervix, with or without membrane rupture. The overall incidence of cord prolapse ranges from 0.1% to 0.6%. In the case of breech presentation, the incidence is slightly higher than 1%. It has been reported that male fetuses appear to be predisposed to cord prolapse. The incidence is influenced by population characteristics and is higher where there is a large percentage of multiple gestations.

Cases of cord prolapse appear consistently in perinatal mortality enquiries, and one large study found a perinatal mortality rate of 91/1000. Prematurity and congenital malformations account for the majority of adverse outcomes associated with cord prolapse in hospital settings but birth asphyxia is also associated with cord prolapse. Perinatal death has been described with normally formed term babies, particularly with planned home birth. Delay in transfer to hospital appears to be an important contributing factor.

Asphyxia may also result in hypoxic–ischaemic encephalopathy and cerebral palsy. The principal causes of asphyxia in this context are thought to be cord compression and umbilical arterial vasospasm preventing venous and arterial blood flow to and from the fetus. There is a paucity of long-term follow-up data of babies born alive after cord prolapse in both hospital and community settings.

The management of prolapsed cord is one of the labour ward guidelines mandated by the Clinical Negligence Scheme for Trusts (CNST), Welsh Pool Risk and Clinical Negligence and Other Risks Scheme (CNORIS) maternity standards in England, Wales and Scotland, respectively.

The purpose of this guideline is to describe modalities to prevent, diagnose and manage cord prolapse. It addresses those pregnant women at high risk of or with a diagnosis of cord prolapse in hospital and community settings. Pregnancies complicated by fetal malformation or with cord prolapse before 22 completed weeks of gestation ate not covered by this guideline. All later gestations are included.

COVID disclaimer

This guideline was developed as part of the regular programme of Green-top Guidelines, as outlined in our document  Developing a Green-top Guideline: Guidance for developers (PDF) , and prior to the emergence of COVID-19.

Version history

This is the second edition of this guideline.

Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request.

Developer declaration of interests

Available on request.

This page was last reviewed 05 November 2014.

• DOI: 10.1136/bcr-2021-243320
• Corpus ID: 233733385

Cord presentation in labour: imminent risk of cord prolapse

• T. Aguiar , João Cavaco Gomes , Teresa Rodrigues
• Published in BMJ Case Reports 1 May 2021

4 References

Does cord presentation on ultrasound predict cord prolapse, sonographic diagnosis of funic presentation: implications for delivery, persistent funic presentation due to velamentous cord insertion adjacent to the internal os but not vasa previa., royal college of obstetricians and gynaecologists (rcog), related papers.

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Management of Umbilical Cord Prolapse

• Medline and NHS databases • Women’s Hospitals Australasia – Clinical Practice Guidelines - Cord Prolapse – Last Reviewed June 2005 • RCOG - Green-top Guideline - No. 50 - April 2008   Levels of Evidence   Evidence Category and Source   Grading of Recommendations   Recommendation Grade  Definition Cord prolapse has been defined as descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes.   Definition Cord presentation is the presence of one or more loops of umbilical cord between the fetal presenting part and the cervix, without membrane rupture.   Background • The overall incidence of cord prolapse ranges from 0.1% 0.6% • With breech presentation, the incidence is just above 1% • Male fetuses seem to be predisposed. • The incidence is higher in multiple gestations.  Background Cases of cord prolapse appear consistently in perinatal mortality enquiries, and one large study found a perinatal mortality rate of 91 per 1000.  Background • Prematurity and congenital malformation account for the majority of adverse outcomes associated with cord prolapse in hospital settings, but cord prolapse is also associated with birth asphyxia and perinatal death with normally-formed term babies, particularly with home birth. • Delay in transfer to hospital appears to be an important factor with home birth.  Background • Asphyxia may also result in hypoxic-ischaemic encephalopathy and cerebral palsy. • The principal causes of asphyxia in this context are thought to be:

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Introduction, latent labor: labor management and timing of admission, term prelabor rupture of membranes, continuous support during labor, routine amniotomy, intermittent auscultation, techniques for coping with labor pain, hydration and oral intake in labor, maternal position during labor, second stage of labor: pushing technique, immediate versus delayed pushing for nulliparous women receiving epidural analgesia, family-centered cesarean birth, for more information.

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Number 766 (Replaces Committee Opinion No. 687, February 2017. Reaffirmed 2021)

Committee on Obstetric Practice

The American College of Nurse-Midwives endorses this document. This Committee Opinion was developed by the Committee on Obstetric Practice in collaboration with committee members Allison S. Bryant, MD, MPH and Ann E. Borders, MD, MSc, MPH.

ABSTRACT: Obstetrician–gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue. Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring. The widespread use of continuous electronic fetal monitoring has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. For most women, no one position needs to be mandated or proscribed. Obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor. Birthing units should carefully consider adding family-centric interventions that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode. This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth.

For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.

Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses’ status are reassuring. The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures.

When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.

Obstetrician–gynecologists and other obstetric care providers should recommend labor induction to pregnant women with term prelabor rupture of membranes (also referred to as premature rupture of membranes) (PROM) who are candidates for vaginal birth, although the choice of expectant management for a limited time may be considered after appropriate counseling. Obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term PROM who decline labor induction in favor of expectant care of the potential risks associated with expectant management and the limitations of available data. For appropriately counseled women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for 12–24 hours may be offered. For women who are group B streptococci (GBS) positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.

Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor.

For women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.

To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor.

Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions that best meet the needs of each individual woman.

Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.

When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each woman should be encouraged to use her preferred and most effective technique.

Collectively, and particularly in light of recent high-quality study findings, data support pushing at the start of the second stage of labor for nulliparous women receiving neuraxial analgesia. Delayed pushing has not been shown to significantly improve the likelihood of vaginal birth and risks of delayed pushing, including infection, hemorrhage, and neonatal acidemia, should be shared with nulliparous women receiving neuraxial analgesia who consider such an approach.

Birthing units should carefully consider adding family-centric interventions (such as lowered or clear drapes at cesarean delivery) that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode.

This Committee Opinion reviews the evidence for labor care practices that facilitate a physiologic labor process and minimize intervention for appropriate women who are in spontaneous labor at term. The desire to avoid unnecessary interventions during labor and birth is shared by health care providers and pregnant women. Obstetrician–gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction 1 . This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth.

As used in this document, “low risk” indicates a clinical scenario for which there is not clear demonstrable benefit for a medical intervention. What constitutes low risk will, therefore, vary depending on individual circumstances and the proposed intervention. For example, a woman who requires oxytocin augmentation will need continuous electronic fetal monitoring (EFM) and, therefore, would not be low risk with regard to eligibility for intermittent auscultation. Rather than categorize laboring women as low or high risk, the goal of this document is to ensure that the obstetrician–gynecologist or other obstetric care provider carefully selects and tailors labor interventions to meet clinical safety requirements and the individual woman’s preferences.

Observational studies have found that admission in the latent phase of labor is associated with more arrests of labor and cesarean births in the active phase and with a greater use of oxytocin, intrauterine pressure catheters, and antibiotics for intrapartum fever 2 3 4 . However, these studies were unable to determine whether these outcomes reflected interventions associated with earlier and longer exposure to the hospital environment or a propensity for dysfunctional labor among women who present for care during the latent phase. A randomized controlled trial (RCT) that compared admission at initial presentation to the labor unit (immediate admission) versus admission when in active labor (delayed admission) found that those allocated to the delayed admission group had lower rates of epidural use and augmentation of labor, had greater satisfaction, and spent less time in the labor and delivery unit. Although there were no significant differences between study groups in operative vaginal or cesarean births or newborn outcomes, the study was underpowered to assess these outcomes 5 .

Importantly, recent data from the Consortium for Safe Labor support updated definitions for latent and active labor. In contrast to the prior suggested threshold of 4 cm, the onset of active labor for many women may not occur until 5–6 cm 6 7 8 . These data suggest that expectant management is reasonable for women at 4–6 cm dilatation and considered to be in latent labor, as long as maternal and fetal status are reassuring. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. An agreed-upon time for reassessment should be determined at the time of each contact. Care of women in latent labor may be enhanced by having an alternate unit where such women can rest and be offered support techniques before admission to labor and delivery.

Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue 9 10 . When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial 11 12 .

When membranes rupture at term before the onset of labor, approximately 77–79% of women will go into labor spontaneously within 12 hours, and 95% will start labor spontaneously within 24–28 hours 13 14 . In the TERMPROM trial, a RCT of labor induction versus expectant management of rupture of membranes at term, the median time to delivery for women managed expectantly was 33 hours; 95% had delivered by 94–107 hours after rupture of membranes 15 . A 2017 Cochrane review that compared immediate induction with expectant management did not find a difference in cesarean delivery or definite early-onset neonatal sepsis, but did find a decreased risk of chorioamnionitis or endometritis, or both (relative risk [RR], 0.49; 95% CI, 0.33–0.72), a decreased risk of definite or probable early-onset neonatal sepsis (RR, 0.73; 95% CI, 0.58–0.92), and a decreased risk of neonatal admission to a special or intensive care unit (RR, 0.75; 95% CI, 0.66–0.85) in the induction group 16 . The Cochrane authors commented that the quality of evidence to support reduced risk of maternal and probable neonatal infection remains low and that “women should be appropriately counselled in order to make an informed choice between planned early birth and expectant management for PROM at 37 weeks’ gestation or later.” However, given the available evidence, obstetrician–gynecologists and other obstetric care providers should recommend labor induction to pregnant women with term PROM who are candidates for vaginal birth, although the choice of expectant management for a limited time may be considered after appropriate counseling.

The RCTs that addressed women who were experiencing term PROM included expectant care intervals that ranged from 10 hours to 4 days. The risk of infection increases with prolonged duration of ruptured membranes. However, the optimal duration of expectant management that maximizes the chance of spontaneous labor while minimizing the risk of infection has not been determined. In line with the knowledge that a large proportion of women will go into spontaneous labor within 12–24 hours after term PROM and recognizing questions that remain unanswered, obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term PROM who decline labor induction in favor of expectant care of the potential risks associated with expectant management and the limitations of available data. For appropriately counseled women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for 12–24 hours may be offered 15 16 . For women who are GBS positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.

Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Benefits described in randomized trials include shortened labor, decreased need for analgesia, fewer operative deliveries, and fewer reports of dissatisfaction with the experience of labor 1 17 . As summarized in a Cochrane evidence review, a woman who received continuous support was less likely to have a cesarean birth (RR, 0.75; 95% CI, 0.64–0.88) or a newborn with a low 5-minute Apgar score (RR, 0.62; 95% CI, 0.46–0.85) 1 . Continuous support for a laboring woman that is provided by a nonmedical person also has a modest positive effect on shortening the duration of labor (mean difference −0.69 hours; 95% CI, −1.04 to −0.34) and improving the rate of spontaneous vaginal birth (RR, 1.08; 95% CI, 1.04–1.12) 1 .

It also may be effective to teach labor-support techniques to a friend or family member. This approach was tested in a randomized trial of 600 nulliparous, low-income, low-risk women, and the treatment resulted in significantly shorter duration of labor and higher Apgar scores at 1 minute and 5 minutes 18 . Continuous labor support also may be cost effective given the associated lower cesarean rate. One analysis suggested that paying for such personnel might result in substantial cost savings annually 19 . Given these benefits and the absence of demonstrable risks, patients, obstetrician–gynecologists and other obstetric care providers, and health care organizations may want to develop programs and policies to integrate trained support personnel into the intrapartum care environment to provide continuous one-to-one emotional support to women undergoing labor.

Amniotomy is a common intervention in labor and may be used to facilitate fetal or intrauterine pressure monitoring. Amniotomy also may be used alone or in combination with oxytocin to treat slow labor progress. However, whether elective amniotomy is beneficial for women without a specific indication has been questioned. A Cochrane review of 15 studies found that among women in spontaneous labor, amniotomy alone did not shorten the duration of spontaneous labor (mean difference, –20.43 minutes; 95% CI, –95.93 to 55.06) or lower the incidence of cesarean births. Likewise, when compared with women who did not undergo amniotomy, those who did were similar in terms of patient satisfaction, frequencies of 5-minute Apgar scores less than 7, umbilical cord prolapse, and abnormal fetal heart rate patterns 20 . Another study evaluated the combination of early amniotomy with oxytocin augmentation as a joint intervention for women in spontaneous labor or for women with mild delays in labor progress 21 . This meta-analysis of 14 trials found that amniotomy together with oxytocin augmentation is associated with modest reduction in the duration of the first stage of labor (mean difference, –1.11 hours; 95% CI, −1.82 to −0.41) and a modest reduction in cesarean birth rates when compared with expectant management (RR, 0.87; 95% CI, 0.77–0.99). Overall, these data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.

Continuous EFM was introduced to reduce the incidence of perinatal death and cerebral palsy and as an alternative to the practice of intermittent auscultation. However, the widespread use of continuous EFM has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Low risk in this context has been variously defined but generally includes women who have no meconium staining, intrapartum bleeding, or abnormal or undetermined fetal test results before giving birth or at initial admission; no increased risk of developing fetal acidemia during labor (eg, congenital anomalies, intrauterine growth restriction); no maternal condition that may affect fetal well-being (eg, prior cesarean scar, diabetes, hypertensive disease); and no requirement for oxytocin induction or augmentation of labor. A Cochrane review of 13 RCTs included women with varying degrees of a priori risk of fetal acidemia at the onset of labor 22 . This meta-analysis found that continuous EFM was associated with an increase in cesarean deliveries (RR, 1.63; 95% CI, 1.29–2.07; n=18,861, 11 RCTs) and an increase in instrumental vaginal birth rate (RR, 1.15; 95% CI, 1.01–1.33; n=18,615, 10 RCTs) when compared with intermittent auscultation. However, continuous EFM was associated with a halving of the rate of early neonatal seizures (RR, 0.50; 95% CI, 0.31–0.80, n=32,386, nine trials, 0.15% for EFM versus 0.29% for intermittent auscultation group), but the authors found no significant difference in the rates of perinatal death or cerebral palsy when compared with intermittent auscultation 22 . In the largest RCT conducted, the group that had early onset seizures had a neonatal death similar to those allocated to EFM versus intermittent auscultation. Moreover, at 4 years of age, there was no difference in the rate of cerebral palsy (1.8 per 1,000 in the EFM group versus 1.5 per 1,000 in the intermittent auscultation group) 23 .

To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor 24 25 26 27 28 29 30 . In considering the relative merits of intermittent auscultation and continuous EFM, patients and obstetrician–gynecologists and other obstetric care providers also should evaluate how the technical requirements of each approach may affect a woman’s experience in labor; intermittent auscultation can allow freedom of movement, which some women appreciate. The effect on staffing is an additional important consideration. Guidelines, indications, and protocols for intermittent auscultation are available from the American College of Nurse–Midwives 30 , the National Institute for Health and Care Excellence 31 , and the Association of Women’s Health, Obstetric and Neonatal Nurses 29 .

Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. These techniques can be used sequentially or in combination. Some nonpharmacologic methods seem to help women cope with labor pain rather than directly mitigating the pain. Conversely, pharmacologic methods mitigate pain, but they may not relieve anxiety or suffering. Data about the relative effectiveness of nonpharmacologic techniques are limited because, until recently, evaluation of labor pain has relied on the use of the numeric pain scale of 1–10, which some have argued is insufficient to assess the complex and multifactorial experience of labor 32 . As an alternative, a coping scale has been developed and approved by the Joint Commission. The coping scale asks, “On a scale of 1 to 10, how well are you coping with labor right now?” 33 . Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions that best meet the needs of each individual woman.

Most women can be offered a variety of nonpharmacologic techniques. None of the nonpharmacologic techniques have been found to adversely affect the woman, the fetus, or the progress of labor, but few have been studied extensively enough to determine clear or relative effectiveness. During the first stage of labor, water immersion has been found to lower pain scores without evidence of harm 8 34 . Intradermal sterile water injections, relaxation techniques, acupuncture, and massage may result in reduction in pain in many studies, but methodologies for rating pain and applying these techniques have been varied; therefore, exact techniques that are most effective have not been determined 35 36 . Other techniques, such as childbirth education, transcutaneous electrical nerve stimulation, aromatherapy, or audioanalgesia, may help women cope with labor more than directly affect pain scores 11 36 . The importance of avoiding versus seeking pharmacologic analgesia or epidural anesthesia will vary with individual patient values and medical circumstances. In the hospital setting, pharmacologic analgesia should be available for all women in labor who desire medication 37 .

Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. Although safe, intravenous hydration limits freedom of movement and may not be necessary. Oral hydration can be encouraged to meet hydration and caloric needs. Arguments for limiting oral intake during labor center on concerns for aspiration and its sequelae. Current guidance supports oral intake of moderate amounts of clear liquids by women in labor who do not have complications. However, particulate-containing fluids and solid food should be avoided 38 39 . These restrictions have recently been questioned, citing the low incidence of aspiration with current obstetric anesthesia techniques 40 . This information may inform ongoing review of recommendations regarding oral intake during labor. Assessment of urinary output and the presence or absence of ketonuria can be used to monitor hydration. If such monitoring indicates concern, intravenous fluids can be administered as needed. If intravenous fluids are required, the solution and the infusion rate should be determined by individual clinical need and anticipated duration of labor. Despite historic concerns regarding the use of dextrose-containing solutions and the possibility that these solutions may induce neonatal hypoglycemia, recent RCTs did not find lower umbilical cord pH values or increased rates of neonatal hypoglycemia after continuous administration of 5% dextrose in normal saline 41 42 .

Observational studies of maternal position during labor have found that women spontaneously assume many different positions during the course of labor 43 . There is little evidence that any one position is best. Moreover, the traditional supine position during labor has known adverse effects such as supine hypotension and more frequent fetal heart rate decelerations 44 45 . Therefore, for most women, no one position needs to be mandated or proscribed.

In research studies, it was difficult to isolate the independent effect of position on labor progress. Women are unlikely to stay in a single position during the course of a study and cannot be expected to do so. Nonetheless, a recent meta-analysis that compared upright positioning (including walking, sitting, standing, and kneeling), ambulation, or both, with recumbent, lateral, or supine positions during the first stage of labor found that upright positions shorten the duration of the first stage of labor by approximately 1 hour and 22 minutes (mean difference, −1.36; 95% CI, −2.22 to −0.51), a mean difference that exceeded the effect of amniotomy with oxytocin (mean difference, −1.11 hours). Women in upright positions also were less likely to have a cesarean delivery (RR, 0.71; 95% CI, 0.54–0.94) 43 . A second Cochrane meta-analysis of RCTs that examined the effect of position during the second stage of labor found that upright or lateral positions compared with supine positions are associated with fewer “abnormal” fetal heart rate patterns (RR, 0.46; 95% CI, 0.22–0.93), a reduction in episiotomies (RR, 0.75; 95% CI, 0.61–0.92), and a decrease in the incidence of operative vaginal births (RR, 0.75; 95% CI, 0.66–0.86) 46 . In this analysis, however, upright positions were associated with a possible increase in second-degree perineal tears (RR, 1.20; 95% CI, 1.00–1.41) and an increase in estimated blood loss greater than 500 mL (RR, 1.48; 95% CI, 1.10–1.98) 46 . A 2017 RCT of upright versus lying positioning during the second stage of labor among nulliparous women with low-dose epidurals demonstrated that fewer spontaneous vaginal births occurred among women assigned to upright positioning (adjusted risk ratio 0.86, 95% CI, 0.78–0.94) without evidence of other associated harms. 47 . Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.

Obstetrician–gynecologists and other obstetric care providers in the United States often encourage women in labor to push with a prolonged, closed glottis effort (ie, Valsalva maneuver) during each contraction. However, when not coached to breathe in a specific way, women push with an open glottis 48 . A Cochrane review of eight RCTs that compared spontaneous to Valsalva pushing in the second stage of labor found no clear differences in the duration of the second stage, spontaneous vaginal delivery episiotomy, perineal lacerations, 5-minute Apgar score less than 7, or neonatal intensive care admissions, or duration of pushing 49 .

A meta-analysis that included three RCTs of low-risk nulliparous women at 36 weeks of gestation or more without epidural analgesia found no differences in the rates of operative vaginal delivery, cesarean delivery, episiotomy, or perineal lacerations. However, the study found a somewhat shorter second stage of labor with Valsalva, although confidence intervals were wide (mean difference −18.59 minutes; 95% CI, −0.46 to −36.75) 50 . One of these RCTs found an increased frequency of abnormal urodynamics 3 months after giving birth in association with Valsalva pushing 51 . The long-term clinical significance of this finding is uncertain. However, in consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each woman should be encouraged to use her preferred and most effective technique 49 50 .

Offering nulliparous women receiving epidural analgesia a rest period at 10 cm dilatation before pushing is based on the theory that a rest period allows the fetus to passively rotate and descend while conserving the woman’s energy for pushing efforts 52 . This practice is called delayed pushing, laboring down, or passive descent. The second stage of labor has two phases: 1) the passive descent of the fetus through the maternal pelvis and 2) the active phase of maternal pushing. Studies that suggest an increased risk of adverse maternal and neonatal outcomes with increasing second-stage duration generally do not account for the duration of these passive and active phases 53 54 .

Two meta-analyses of RCTs compared maternal and neonatal outcomes in women assigned to immediate versus delayed pushing have been published 49 55 . Both studies found that delaying pushing for 1–2 hours extended the duration of the second stage by a mean of approximately 1 hour and was associated with approximately 20 minutes less active maternal pushing efforts. Although both reports noted a significantly increased spontaneous delivery rate, this difference was no longer significant when the analysis was restricted to high quality RCTs (RR, 1.07; 95% CI, 0.98–1.16) 55 . However, a recent large retrospective analysis found that delaying pushing by 60 minutes or more was associated with modest increases in cesarean delivery (adjusted odds ratio [AOR], 1.86; 95% CI, 1.63–2.12) and operative vaginal delivery (AOR, 1.26; 95% CI, 1.14–1.40), postpartum hemorrhage (AOR, 1.43; 95% CI, 1.05–1.95), and transfusion (AOR, 1.51; 95% CI, 1.04–2.17), but no increase in adverse neonatal outcomes 56 . The study design does not determine causation and was not able to account for important confounders such as the indications for delayed pushing or fetal station at the onset of the second stage of labor that were addressed by the more recent randomized trial 56 .

A recent 2018 multicenter RCT of more than 2,400 nulliparous women receiving epidural analgesia, assigned participants to begin pushing at the start of the second stage of labor or to delay pushing for 60 minutes unless the urge or health care provider recommendation to push occurred sooner. The trial was stopped before the intended recruitment was complete because of concern for excess morbidity in the delayed pushing group 57 . No differences in rates of spontaneous vaginal births were noted even after consideration of fetal station and head position. Women assigned to push at the start of the second stage had lower rates of chorioamnionitis (RR, 0.7; 95% CI, 0.6–0.9) and postpartum hemorrhage (RR, 0.6; 95% CI, 0.3–0.9), and had neonates with lower risk of acidemia (overall risk 0.8% versus 1.2%, RR, 0.7; 95% CI, 0.6–0.9) 57 . Collectively, and particularly in light of recent high-quality study findings 57 , data support pushing at the start of the second stage of labor for nulliparous women receiving neuraxial analgesia. Delayed pushing has not been shown to significantly improve the likelihood of vaginal birth and risks of delayed pushing, including infection, hemorrhage, and neonatal acidemia, should be shared with nulliparous women receiving neuraxial analgesia who consider such an approach.

Although the delivery goal for many low-risk women is vaginal birth, delivery by cesarean is sometimes the result, whether for obstetric indications or by maternal request. Recent attention has focused on the description and implementation of techniques in the operating room to promote increased involvement of the family in the procedure itself. One 2008 study, described the “natural cesarean” 58 . Various institutional protocols have adopted some or all of the principles, which include preparation of the operating room itself with low lighting and minimal extraneous noise, positioning women to best allow access to the neonate after delivery (eg, not securing the upper extremities to arm boards, placing pulse oximetry probes on nondominant hands, or on toes rather than fingers), allowing women and their partners to view the birth (by lowering the drapes or using drapes with specially-designed viewing windows), slowed delivery of the neonate through the hysterotomy to allow autoresuscitation, delayed umbilical cord clamping, and early skin-to-skin contact 58 59 . A large body of evidence to support efficacy of these techniques, whether each on its own or in combination, is lacking, though the merits of delayed umbilical cord clamping and early skin-to-skin contact have been extensively reviewed elsewhere. One randomized trial of a number of family-centered cesarean birth interventions demonstrated greater parental satisfaction in the intervention group; skin-to-skin care was achieved in 72% of women assigned to the intervention, and the intervention was associated with higher breastfeeding rates than in the traditional cesarean group 60 .

In one U.S. academic medical center, the family-centered cesarean birth was introduced in 2013 and the efforts studied. Skin-to-skin care in the operating room increased from 13% to 39% of cases, with exclusive breastfeeding rates among neonates born by cesarean similarly increasing from 35% to 64%. An increase in neonatal hypothermia associated with skin-to-skin care, a theoretic concern given the ambient temperatures in operating rooms, was not noted 59 . In a cohort study that compared women who gave birth by cesarean delivery after the introduction of family-centered cesarean delivery with historical controls, unplanned nursery admission, but not respiratory morbidity or hypothermia, increased (unplanned admission in 21% in the period of study compared with 7% of historical controls).

Absent better-quality evidence of benefit or harms of these interventions, birthing units should carefully consider adding family-centric interventions (such as lowered or clear drapes at cesarean delivery) that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode.

Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. In addition, some women may seek to reduce medical interventions during labor and delivery. Satisfaction with one’s birth experience also is related to personal expectations, support from caregivers, quality of the patient–caregiver relationship, and the patient’s involvement in decision making 61 . Therefore, obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor.

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/LimitInterventionDuringLabor .

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

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Back to Journals » International Journal of Women's Health » Volume 10

Optimal management of umbilical cord prolapse

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Authors Sayed Ahmed WA   , Hamdy MA

Received 8 January 2018

Accepted for publication 24 April 2018

Published 21 August 2018 Volume 2018:10 Pages 459—465

DOI https://doi.org/10.2147/IJWH.S130879

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 4

Editor who approved publication: Professor Elie Al-Chaer

Waleed Ali Sayed Ahmed, Mostafa Ahmed Hamdy Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt Abstract: Umbilical cord prolapse (UCP) is an uncommon obstetric emergency that can have significant neonatal morbidity and/or mortality. It is diagnosed by seeing/palpating the prolapsed cord outside or within the vagina in addition to abnormal fetal heart rate patterns. Women at higher risk of UCP include multiparas with malpresentation. Other risk factors include polyhydramnios and multiple pregnancies. Iatrogenic UCP (up to 50% of cases) can occur in procedures such as amniotomy, fetal blood sampling, and insertion of a cervical ripening balloon. The perinatal outcome largely depends on the location where the prolapse occurred and the gestational age/birthweight of the fetus. When UCP is diagnosed, delivery should be expedited. Usually, cesarean section is the delivery mode of choice, but vaginal/instrumental delivery could be tried if deemed quicker, particularly in the second stage of labor. Diagnosis-to-delivery interval should ideally be less than 30 minutes; however, if it is expected to be lengthy, measures to relieve cord compression should be attempted. Manual elevation of the presenting part and Vago’s method (bladder filling) are the most commonly used maneuvers. Care should be given not to cause cord spasm with excessive manipulation. Simulation training has been shown to improve/maintain all aspects of management and documentation. Prompt diagnosis and interventions and the positive impact of neonatal management have significantly improved the neonatal outcome. Keywords: umbilical cord prolapse, neonatal outcome, obstetric emergency, simulation training

Introduction

Umbilical cord prolapse (UCP) is an uncommon but potentially fatal obstetric emergency. Its incidence has decreased over the years and significant advances in its management have led to improved perinatal outcome. This article reviews the risk factors, perinatal outcomes, prevention and the optimal management of UCP.

Definitions

Cord presentation (fore-lying cord) is the presence of the umbilical cord (UC) between the fetal presenting part and the cervix, regardless of the membrane status (intact or ruptured). Descent of the UC through the cervix is essential for diagnosing cord prolapse. It can be either overt (past the presenting part) or occult (alongside the presenting part).

UCP is an uncommon obstetric emergency but with potentially significant neonatal adverse outcomes. The overall incidence is reported at 0.1%–0.6% with higher incidences in non-cephalic presentations, multiple gestations, and earlier gestational ages. 1 However, a lower incidence (0.018%) has been reported recently 2 and there is a trend toward decreasing incidence throughout the years: 0.6% in 1932, 3 0.2% in 1990, 4 and 0.018% in 2016. 2 The decreasing incidence has also been documented by Gibbons et al in their retrospective review of 69 years. 5 Liberal use of cesarean section (CS) for some of the most important risk factors of UCP, eg, breech presentation, may explain such decreasing trends. In addition, the decreasing occurrence of grand multiparity, better diagnosis, and improved obstetric care is linked to the falling incidence.

UCP is diagnosed by seeing or palpating the prolapsed cord in addition to the presence of abnormal fetal heart (FH) tracings. In overt UCP, the diagnosis is straightforward as the UC is seen coming out of the vagina or palpated as a soft pulsating mass during vaginal examination. However, the diagnosis of occult UCP may be more difficult. Abnormal fetal heart rate (FHR) tracings in the form of recurrent, variable, sudden severe, and/or prolonged (lasting a minute or more) decelerations may be the first sign of UCP, especially the occult type. These FHR abnormalities may occur in up to 67% of cases. 6

Fore-lying umbilical cord can be diagnosed by ultrasound scan. 2 Lange 7 estimated an antenatal incidence of approximately 1:167 (0.6%) live births; however, with the increased use of antepartum obstetric ultrasound, especially with color flow Doppler, the incidence could be higher. Cord presentation is transient and usually insignificant prior to 32 weeks. Large studies showed that the presence of cord presentation does not necessarily lead to cord prolapse during delivery, 8 , 9 and that antenatal ultrasound diagnosis has a poor sensitivity and is a poor predictor of cord prolapse. 8 However, when diagnosed in the third trimester, cord presentation requires follow up scans in addition to intrapartum assessment to finalize the mode of delivery.

A significant percentage of UCP cases are diagnosed at the time of amniotomy (24%) or spontaneous rupture of membranes (SROM) (35%). 2 Attention should be paid to this complication at these times especially when abnormal FHR tracings follow membrane rupture.

Differential diagnosis of these presentations – soft mass in the vagina and sudden FHR decelerations – must be considered. The presence of fetal limb, caput succedaneum and face presentation should be excluded. In addition, numerous causes of sudden fetal bradycardia such as maternal hypotension, placental abruption, uterine rupture should be carefully evaluated.

Risk factors

Several risk factors for UCP have been identified ( Table 1 ). Clinicians should be aware of these risk factors as this would represent the first step in anticipating this obstetric emergency and decreasing the perinatal morbidity/mortality.

Almost half of the risk factors are iatrogenic. 10 Artificial rupture of fetal membranes (ARM) especially in a multiparous case with high non-engaged head, attempted rotation of the fetal head in cases of abnormal positions, placement of intrauterine pressure catheter or fetal scalp electrode and external cephalic version are the most common examples of iatrogenic risk factors. Interventions that may cause elevation of the fetal presenting part predispose to UCP.

Other obstetric risk factors that may lead to UCP include multiparity, especially grand multiparity (75% of cord prolapse events in the 1940s), 5 malpresentations, polyhydramnios, multiple gestations particularly in the second twin, preterm labor, and preterm premature rupture of membranes (PPROM).

The relationship between malpresentations including breech and transverse lie and UCP is well documented and is due to the poor engagement/non-engagement of the presenting part into the maternal pelvis allowing the space for the cord to prolapse. In one study, breech presentation accounted for 36.5% of UCP cases. 3 Multiple gestation is another risk factor and can lead to UCP due to the abnormal fetal presentation, and it may occur with both first or second twin.

The use of cervical ripening balloon may predispose to UCP especially when filled with a large amount of fluid, and it may occur after insertion, removal or spontaneous expulsion of the balloon. 2

Although prematurity is associated with increased risk of UCP as a result of poor application of the presenting part to the cervix, most UCP cases occur in term pregnancies. 11

Pathophysiology

Compression of the UC can lead to either profound or total acute asphyxia or subacute hypoxia with different neonatal outcomes. It has been suggested that the pathophysiology of cord prolapse is almost an “all or none event”, either causing overwhelming neurological injury and death or causing little or no cerebral injury, and this is supported by the very low incidence of stillbirth/neonatal death, neonatal encephalopathy, and cerebral palsy. 5

The mechanism of fetal demise is through near-total or total acute asphyxia, which occurs when the umbilical cord is compressed between the fetal head and bony pelvis. 12 This results in failure of the normal autoregulatory mechanisms of the brain resulting from hypotension and bradycardia 5 and leads to the failure of cerebral blood redistribution, with cell death of the brainstem – the most metabolically active area of the brain. This is unlike cases of subacute hypoxia where blood can be distributed to the more vital areas of the brain, sparing the brainstem and resulting in minimal or short-lasting neurological manifestation.

Umbilical cord prolapse is an acute obstetric emergency that mandates delivery of the baby as quickly as possible. The route of delivery is usually by CS but vaginal/instrumental delivery can be attempted if deemed quicker. The Royal College of Obstetricians and Gynecologists (RCOG) recommends the diagnosis-to-delivery interval (DDI) to be less than 30 minutes in order to optimize the perinatal outcome, particularly in the presence of evidence of fetal compromise. 1 However, further decreases of DDI below the 30-minute limit do not necessarily improve the neonatal outcome. 6 Prompt recognition and rapid action are the mainstays of managing this emergency.

When UCP is diagnosed, it is important to amass personnel for help. As emergency CS is typically the treatment of choice, so the anesthetist and operation room staff need to be informed promptly to get ready. Continuous FHR monitoring and recording are carried out until delivery. O 2 supplementation by face mask improves the O 2 delivery to the baby.

If the woman is in the first stage of labor or early in the second stage, prompt cesarean delivery is recommended. If vaginal delivery is imminent or instrumental delivery is possible, they can be contemplated.

There are several measures to relieve cord compression which should be carried out till CS is performed ( Box 1 ). These measures include manual elevation of the fetal presenting part using two fingers or the whole hand through the vagina, the positioning of the patient in steep Trendelenburg, exaggerated Sim’s position 13 or knee-chest position, filling the bladder with 500–700 cc or more of saline and the now out-of-favor method of cord replacement. Care should be exercised not to excessively manipulate the cord as this can result in umbilical artery vasospasm and do more harm than good.

Vago 14 described successfully using bladder filling as a means of relieving cord compression. This method is especially useful if the cord is prolapsed in a remote area where delivery is not imminent. Filling the bladder with 500 cc or more of normal saline or when the bladder is visibly seen above the pubic area would relieve cord compression by elevating the presenting part and may help in decreasing uterine contractions. 14 The addition of tocolytics in the form of intravenous ritodrine infusion (250–400 μg/min) was shown to improve the FHR tracing and the Apgar score ≥7 at 5 minutes. 15

Manual cord replacement (funic reduction) to above the presenting part is rarely carried out nowadays. This maneuver could be tried while preparations for an emergency CS are being made up. If cord prolapse occurred in a remote area, replacement could be tried till CS is done. However, Vago’s method would be the measure of choice to reduce the cord compression. Barrett 16 in his small series of cord replacements in the management of UCP recommended certain criteria before this procedure is contemplated: a short segment of the cord (<25 cm), cervical dilatation ≥4 cm, the presenting part could be easily elevated above −1 station and rapid completion of the procedure (within 2 minutes).

Tocolytics had been used with the aim of decreasing the uterine contractions, relieving the pressure on the prolapsed cord in addition to improving the placental perfusion and hence the blood supply to the baby, which might be helpful if DDI is expected to be prolonged. 17 However, tocolytics may cause uterine atony following delivery and in cases where UCP occurs in the hospital, expedient delivery should be undertaken without recourse to tocolytics.

There are several case reports of conservative management of cord prolapse and all are in pre-viable gestation fetuses with the aim of prolongation of pregnancy. 18 , 19 In these cases, the extreme prematurity and low birthweight may have resulted in less cord compression, minimizing asphyxia and improving fetal outcome. 18 Pre-viable gestation is one of the contraindications for immediate delivery in cases of UCP ( Box 2 ); the others being fetal demise and lethal fetal anomalies. Conservative treatment of UCP should be reserved in carefully selected cases after full counselling of the parents about the prognosis.

A special note on unstable lie is worth mentioning as it is particularly relevant to UCP. When unstable lie is diagnosed after 37 weeks of gestation, the risks, especially UCP, should be clearly explained to the pregnant woman and the management options offered. These include admission at 38–39 weeks gestation, elective CS, expectant management or active management in the form stabilizing induction, ie, external version then induction of labor. If vaginal delivery is contemplated, care should be exercised during ARM and vaginal examination should be carried out if SROM occurred to exclude cord prolapse and ascertain the presentation.

The urgent nature of the management of UCP that often ends by emergency CS can be traumatic to the woman and those accompanying her. Debriefing the patient and her partner regarding the course of events is important, explaining why this happened and if it has any implications related to future deliveries, eg, repeat CS or recurrence of UCP. If antenatal diagnosis of cord presentation was made, detailed discussion and advice about the management of the remaining antenatal period, mode of delivery and intrapartum care – if vaginal delivery is being contemplated – are of paramount importance.

Perinatal outcome

Perinatal mortality and morbidity

The perinatal mortality and morbidity largely depend on the location where the prolapse occurred (inside or outside the hospital facility) and the gestational age/birthweight of the fetus. Where the prolapse occurs outside the hospital; mortality rates as high as 44% have been reported, compared to 3% if this occurs inside the hospital. 3 The perinatal mortality rate was estimated at 6.8% and was likely to occur in nulliparous women. 20 Premature infants and those of low birth weight have less favorable outcomes and have twice the risk of perinatal mortality compared to those without UCP. 4

UCP can be associated with perinatal morbidity, including low 5-minute Apgar scores, assisted ventilation requirement, low cord pH, meconium aspiration, hyaline membrane disease, neonatal seizures, neonatal encephalopathy (2%), and cerebral palsy (0.43%). 5 However, a recent study estimated a neonatal encephalopathy incidence of only 0.32%. 20 Neonatal encephalopathy was defined as either neonatal seizures or two of the following lasting longer than 24 h: abnormal consciousness, difficulty maintaining respiration or feeding (both of central origin), or abnormal tone/reflexes. 20 An increased incidence of placental abruption and meconium-stained amniotic fluid has been reported which can result in increased neonatal morbidity. 11

There is a trend toward decreasing perinatal mortality and morbidity and overall survival over the years. In one study, stillbirth decreased from 48% (1940s) to 2.1% (2000s) and overall survival improved to 94% (2000s) from 46% (1940s). 5 Improved diagnosis and interventions and the positive impact neonatal management explain these improvements.

Predictors of the outcome

Several predictors of perinatal outcome have been identified including the DDI, the FHR changes, and the mode of delivery ( Table 2 ).

DDI less than 30 minutes is associated with lower mortality rates in infants >2,500 g 21 and higher Apgar scores. 6 , 22 However, hypoxemic encephalopathy had been reported with very short DDI (<15 minutes), which suggests that other factors may play part in the outcome. 23 Such factors include the occurrence of prolapse preceding diagnosis by a significant length of time, the degree of cord compression, and the presence of fetal compromise.

The location where UCP occurs can have an effect on the perinatal outcome. Occurrence in the hospital with rapid recourse to delivery is associated with improved perinatal outcome, compared to occurring at a remote location. Those fetuses who maintain normal heart rate tracings at the time of UCP have lower incidence of adverse neonatal outcome. 24

Cesarean delivery is significantly associated with decreased perinatal mortality and morbidity compared to vaginal delivery. Critchlow et al 25 found that delivery by emergency CS significantly reduced the risks of an Apgar score <3 at five minutes and neonatal mortality when compared to spontaneous normal delivery. However, spontaneous or operative vaginal deliveries may be contemplated in the second stage of labor if deemed feasible, quick, and highly likely to succeed. When operative vaginal delivery is contemplated, the same rules for applying forceps or ventose should be maintained, eg, full cervical dilatation, and engaged head.

Long-term disability

UCP has been shown to have an all-or-nothing effect on the neonatal outcome and the evidence for long term disability remains inconclusive. There is a very low incidence of neonatal encephalopathy; 20 however, long-term sequelae in the surviving infants in the form of cerebral palsy of the spastic quadriplegic and dyskinetic types have been reported in both preterm and term infants. 26

Knowledge of the risk factors of UCP does not significantly decrease its occurrence; 6 however, the anticipation of this problem can lead to improvement of fetal morbidity and mortality. Of note, cord prolapse can occur in pregnancies without obvious risk factors, 1 , 4 which renders this complication unpreventable ( Box 3 ).

Caution should be exercised during interventions that carry a high risk of UCP. Amniotomy in a patient where the head is not well applied is better postponed, unless it is necessary, where it should be carried out with caution. A controlled rupture by a more experienced obstetrician allows the drainage of liquor in a slow gush. Some would advise the use of hypodermic needle or pudendal block trumpet to get a slow and controlled drain of amniotic fluid. 27

Manipulation of the fetal head, especially if non-engaged, should also be kept to minimum and dealt with extra care. Interventions such as placement of fetal scalp electrode or intrauterine pressure catheter as well as the application of cervical ripening balloon may result in elevation of the fetal head and lead the cord to prolapse. It is difficult to abolish the risk of UCP with these interventions but the anticipation of this complication may lead to better diagnosis, earlier intervention, and better perinatal outcome.

Antenatal ultrasound diagnosis of cord presentation should be sought, especially in pregnancies at higher risk of cord prolapse such as those with abnormal presentations, preterm labor, and PPROM. This has the value of counselling women regarding the complications of cord prolapse and what to do if the membrane ruptures. However, intervention, ie, CS based on ultrasound diagnosis, has not been yet justified.

Continuous FHR monitoring in high-risk women would not prevent UCP as such but it will help in early diagnosis when FHR abnormalities are detected.

Perinatal mortality was shown to be higher with planned out-of-hospital birth compared to planned in-hospital birth; however, both settings carried a low risk of perinatal death. 28 In a study from the Netherlands, eight cases of UCP in primary midwifery care were diagnosed in one year resulting in one infant death from severe birth asphyxia, giving a perinatal mortality incidence of 12.5%. 29 Despite the low number of cases and the well-established birth in primary care in the Dutch obstetrical system, this incidence is considered high. Women should be informed about the risks of delivery in non-hospital settings and careful selection of low risk women may further decrease obstetric complications, including UCP.

Simulation training for umbilical cord prolapse

Despite a documented decrease in the incidence of UCP, this potentially fatal obstetric emergency will continue to occur. Simulation training in obstetric emergencies helps to improve teamwork, awareness, knowledge, and skills in life-threatening and/or uncommon obstetric complications. 30

The aim of simulation training in such an obstetric emergency is to improve the team work in order to optimize the neonatal outcome. In addition, training involves maneuvers to alleviate cord compression, effective communication between those involved in the management, the use of spinal anesthesia and event documentation regarding the presence or absence of fetal distress ( Box 4 ).

Studies examining the effect of simulation training on the outcome of UCP revealed different results. Siassakos et al found that annual training was associated with improved management of cord prolapse in the form of improvement of DDI (from 25 to 14.5 minutes) as well as in Apgar scores below 7 at 5 minutes. 31 However, Copson et al found non-significant improvements in all aspects of management apart from an increase in the number of babies with Apgar scores <7 at 5 minutes, and explained this by the high standard care prior to training. 32 In their case, Copson et al concluded that simulation training would maintain the high standard of care in their units.

Documentation is very important for medico-legal issues. An identified member of the managing team should be responsible for recording the sequence of events, interventions, and maternal and neonatal outcomes. Documentation items are shown in Box 5 .

Umbilical cord prolapse is an acute obstetric emergency that is associated with increased perinatal morbidity and mortality, thus requiring rapid identification and intervention. Once diagnosed, the most rapid method of delivery should be carried out. If delivery is not imminent, alleviation of cord compression should be contemplated by elevating the presenting part either manually or by bladder filling in addition to repositioning of the patient. Prior knowledge of risk factors as well as regular simulation training that helps develop team work, DDI and documentation will benefit those unfamiliar with the condition to improve their management and hence the neonatal outcome.

The authors report no conflicts of interest in this work.

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Umbilical cord constriction can be due to intrinsic or extrinsic mechanisms. Constriction may lead to different degrees of flow limitation in the cord"s vessels, which can be demonstrated by pulsed Doppler flow studies. Intrinsic constriction is characterized by localized absence of Wharton"s jelly, leading to narrowing of the cord, thickening of the vascular walls and narrowing of the vascular lumens. In this setting, fetal death might occur due to acute vasospasm, acute oligohydramnios and uterine contraction, or an obliterating thrombus (10). Extrinsic constriction can be caused by:

Occasionally loops of cord may lie between the lower uterine segment and the presenting part (cord or funic presentation). This is important to recognize as it predisposes to cord prolapse and possible fetal death when the membranes rupture. Funic presentation is more common with malpresentations (especially breech and transverse lie).

• Transient and usually insignificant prior to 32 weeks. If this is persistent one must look for a cause.
• Marginal cord insertion from the caudal end of a low-lying placenta.
• Uterine fibroids / Uterine adhesions.
• Congenital uterine anomalies that may prevent the fetus from engaging well into the lower uterine segment.
• Cephalopelvic disproportion.
• Polyhydramnios.
• Multiple gestations.
• Increased umbilical cord length.

• Prolapse of the cord occurs in 0.5% of cases.
• High perinatal mortality rate due to cord compression (1).
• Selbing A. Umbilical cord compression diagnosed by means of ultrasound. Acta Obstet Gynecol Scand 1988;67:565-567.
• Hales ED, Westney LS. Sonography of occult cord prolapse. JCU 1984;12:283-285.
• Dudiak CM, Salomon CG, Posniak HV et.al. Sonography of the umbilical cord. Radiographics 1995;15:1035-1050.
• Johnson RL, Anderson JC, Irsik RD et.al. Duplex ultrasound diagnosis of umbilical cord prolapse. J Clin Ultrasound 1987;15:282-284.
• Kanayama MD, Gaffey TA, Ogburn PL Jr. Constriction of the umbilical cord by an amniotic band, with fetal compromise illustrated by reverse diastolic flow in the umbilical artery. A case report. J Reprod Med 1995 Jan;40(1):71-73.
• Boughizane S, Zhioua F, Jedoui A, Kattech R, Gargoubi N, Srasra M, Ben Romdhane K, Meriah S. Swallowing of an amniotic string by a fetus at term. J Gynecol Obstet Biol Reprod (Paris) 1993;22(4):409-410.
• Heifetz SA. Strangulation of the umbilical cord by amniotic bands: report of 6 cases and literature review. Pediatr Pathol 1984;2(3):285-304.
• Reles A, Friedmann W, Vogel M, Dudenhausen JW. Intrauterine fetal death after strangulation of the umbilical cord by amniotic bands. Geburtshilfe Frauenheilkd 1991 Dec;51(12):1006-1008.
• Sherer DM, Anyaegbunam A. Prenatal ultrasonographic morphologic assessment of the umbilical cord: a review. Part I. Obstet Gynecol Surv 1997 Aug;52(8):506-514
• Hallak M, Pryde PG, Qureshi F, Johnson MP, Jacques SM, Evans MI. Constriction of the umbilical cord leading to fetal death. A report of three cases. J Reprod Med 1994 Jul;39(7):561-565.

More From Forbes

Real talk: owning your 'ums' and 'you knows'.

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As the VP of Digital Marketing for HALO , Cord Himelstein is a growth-driven B2B marketer with a passion for connecting people with brands.

Presenting can be both exhilarating and terrifying. Throughout my career, I've nailed presentations and missed some others. The thrill of nailing a presentation feels great, but missing really sucks. Interestingly, some of my best presentations have been when I thought I did my worst. While I am confident and know my stuff, a nagging voice in my head makes me question it every time I open my mouth.

Embrace The Chaos

"Um," slips out, then "you know," follows. It's like a reflex I can't control. Each "um" feels like nails on a chalkboard to my ears. Every time I hear myself say it, I cringe. It's not about lacking knowledge or not being prepared; it's just one of those things that happens. Thanks, brain. Really helpful. The worst part? I often lead with it. "Um" is the first thing out of my mouth, and I hate it. But here's the thing: I've learned to embrace the chaos. There's a realness to imperfections. Maybe my "ums" and "you knows" make me more relatable, more human. After all, we live in a world that craves authenticity. So, if sounding like I don't have all the answers makes me real, then so be it.

Those moments of self-doubt are just part of the ride. They add authentic flavor to otherwise forgettable presentations. Public speaking is a common fear. According to the National Institute of Mental Health , about 73% of people experience anxiety related to public speaking, known as glossophobia. Even without a clinical phobia, most people fear public speaking more than death .

Notes Vs. Authenticity: The Eternal Struggle

When I use notes, they often feel like a crutch that leads me away from authenticity. Every audience is different, and while you should stay true to your message, looking up and connecting is crucial. Reading from notes isn't the enemy—losing authenticity is. There's a balance to strike. I still glance at my notes, but I make sure to engage with my audience to be present and real.

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Authenticity rules. It's better to stumble over a word or two than to sound like a robot reciting a script. The audience can tell when you're being genuine, and they appreciate it. They're looking for a connection. So, if you need your notes, use them, but don't let them use you. Be real, be you.

Finding My Groove

Over the years, I've found my groove. I've learned to balance the dread and joy of presenting, to laugh at my quirks, and to own my knowledge (even if it comes with a side of "ums"). Each presentation is a new adventure, a chance to connect with an audience and share something meaningful. And hey, if I can sprinkle in some humor and keep things lively, then I'm doing something right.

One thing that's helped me is training myself to pause. It's a natural reaction to want to fill the silence, but instead of rushing, I take a moment to reset myself. I even provide myself with reminders within my transition notes that say, "NO UMMMS." This helps reduce the frequency of filler words and reinforces my confidence and control.

I've also continued to embrace the storytelling approach. It's no secret that stories make your message more engaging and memorable. By weaving personal anecdotes into my presentations, I create a connection with the audience, making the content more interesting and relatable.

Lastly, I remind myself that the audience is on my side. They're not there to judge every misstep but to learn, be inspired and be entertained. This mindset shift reduces my anxiety and allows me to focus on delivering value rather than obsessing over every “um.”

So, to all my fellow marketers out there who dread and enjoy presenting in equal measure, remember these tips: Train yourself to pause and reset, understand that your audience is there to learn and not to catch your mistakes, and always lean into storytelling. Doing so can make your presentations more authentic, relatable and impactful.

Now, if you'll excuse me, I have a presentation to prepare for. Um, wish me luck!

Forbes Communications Council is an invitation-only community for executives in successful public relations, media strategy, creative and advertising agencies. Do I qualify?

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Ali abbasi’s ‘the apprentice’ launches kickstarter campaign in hopes of expanded distribution, as carriage fight with disney continues, directv cfo calls for pay-tv bundle a fraction of the size of today’s “bloated” packages.

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DirecTV CFO Ray Carpenter says the pay-TV bundle should have between 10 and 50 of the “most engaging” channels, a fraction of the “hundreds” of offerings crammed into “bloated,” high-priced packages.

Smaller bundles would be “much more reflective of what customers watch,” he said Tuesday during a conference call with Wall Street analysts.

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At the center of the conflict is the concept of slimmer packages of channels, something that price-sensitive consumers and cord-cutting-hit programmers and distributors all seem to support. DirecTV claims Disney rejected its efforts to put forward a number of smaller packages, including a sports-focused one; Disney has pushed back strongly on that assertion, claiming that DirecTV “failed to engage” on several such proposals despite its “spin” to the contrary.

Carpenter’s remarks and the presentation deck focused on a “brighter” future for pay-TV. In the current setup, he said, consumers “are asked to manage this increasingly complex set of subscriptions and applications.” The result is higher rates of churn. As it has assessed its options even before the Disney standoff, the exec added, DirecTV has gravitated toward the idea of trading off potentially lower profit margins with lower rates of churn given the long-term potential.

Disney is a stakeholder with Fox and Warner Bros. Discovery in a pay-TV joint venture, Venu Sports, whose launch was recently blocked by a New York federal judge on antitrust grounds. MoffettNathanson’s Craig Moffett, a respected analyst who has tracked the cable industry for decades, sees the combination of the Venu legal defeat and the DirecTV-Disney clash as a “potentially apocalyptic” for the traditional TV business.

“It is not an overstatement to say that bundling is everything for the pay-TV industry,” Moffett wrote in a note to clients Tuesday. “Without it, what’s left of linear TV (or, at least, its economics) would rapidly unravel, replaced by a punishing a la carte model that, even at stratospheric prices for the ‘must have’ networks wouldn’t come close to replacing the lost revenues of the current model.”

Asked during the call about the Venu ruling, Carpenter said he was “not surprised” by it. Even if the service doesn’t end up launching, he said, the plans for it and the antitrust suit filed by Fubo to block it “helps bring to a larger audience the understanding of what’s broken” in the pay-TV system.

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