Discussion
Overall quality of clinical practice guidelines on umbilical
cord prolapse
Most maternity units have local protocols for management of UCP.
Conventionally, this emergency is included as part of clinical audits
and drills are regularly conducted to deal with the complication.
Algorithms are based on gestational age, foetal heart patterns and place
of delivery. Expectant management is sensible when severe prematurity is
encountered. Practice guidelines are needed for decision making in term
pregnancies with UCP when the foetus is alive or there is abnormal
foetal heart pattern due to foetal asphyxia. Our search showed three
practice guidelines on the subject that were rigorous enough to be
appraised. This low number could be due to accepted practice algorithms
in most obstetric units, low prevalence of UCP due to easy access to CD
in cases with risk factors, and less controversies in the management of
UCP16.
While the three CPGs provide clinical pathways in effective delivery in
reducing perinatal morbidity and mortality, they could be further
refined, based on the domain scores shown in this study.
Table 2 displays the total score for each domain and the overall quality
of the guidelines. All three had low overall scores; none were above
70% and five of the domains need further review. The RCOG and RCPI
guidelines were recommended for use with modifications. The intraclass
correlation was above 0.9814.
All three guidelines scored the highest in the domain of ‘clarity of
presentation’. Overall, the recommendations were presented well, with a
summary of recommendations and a flowchart on management. Delivery of
the content was clear, precise, and easy to understand. The guideline by
SAPPG also had images regarding the positions to relieve pressure on the
cord.
Three of the 6 domains received an average score below 30%, which is
concerning. The domain of ‘stakeholder involvement’ achieved a mean
score of 28.4%. All the guidelines did not mention the relevant
stakeholders, particularly the target population, and if they were
involved in developing the guideline. It can be assumed that they were
not consulted. RCOG and SAPPG did not mention the qualifications of
their developing committee, and none of the guidelines mentioned the
respective roles of the guideline steering committee.
The ‘applicability’ domain achieved a mean of 14.8%; this could be due
to implicit meaning in developing practice guidelines by professional
bodies i.e., for its members. All the guidelines do not mention the
facilitators and barriers in the application of the suggested
guidelines, and this may be partly due to the lack of feedback from key
stakeholders, and the inability to pilot test the guidelines in view of
the critical nature of the condition. Moreover, none of the guidelines
explicitly state the resource implications that may incur due to the
application of the recommendations, or the presence of any auditing
strategies, to assess the adherence to guidelines and their
implications.
The domain of ‘editorial independence’ scored the lowest among all
domains as none of the guidelines mentioned their funding body; only the
RCOG committee declared ‘no competing interests’. This could be an
oversight as development of guidelines is often initiated as part of
good clinical practice in professional bodies.
Grading of level of evidence
Apart from RCOG, none of the guidelines provide the level of evidence
for their recommendations as shown in Table S1. This was inconvenient
during the appraisal process, as we could only rely on the RCOG
guideline for the grading of a recommendation. Moreover, the absence of
grading makes the guidelines less reliable. Although RCPI does a decent
job elaborating their cited reports, adding the grades to their
recommendations would have added confidence.
Consensus
Glancing through the recommendations listed out in Table S1, a majority
of them are based on weak evidence, including some relying only on
“recommended best practice based on the clinical experience of the
guideline development group”. Strong evidence (2+) is seen in
recommending vaginal examination after SROM in risk cases and with FH
abnormalities. Resort to caesarean delivery and expertise in neonatal
resuscitation also have high recommendations.
Most recommendations are based on weak evidence; a consensus between
different bodies that develop the CPGs can help in determining whether
the recommendations can be considered as ‘best clinical practice’. Table
S2 summarizes and highlights the consensus on the recommendations
listed.
As an example, all 3 CPGs recommended ‘knee chest’ or ‘left lateral’
position for further reduction of cord compression, but the evidence for
this method is considered weak17. This is due to the
uncommon but emergency nature of the condition, resulting in randomized
controlled trials not possible to be conducted. Both knee-chest and left
lateral positions work by elevating the maternal pelvis which will
create a pulling gravitational force on the foetal head. The
gravitational force advantage over manual elevation and bladder filling
was that it will not only help reduce the risk of further prolapse, but
it is also indifferent to the foetal initial station (manual elevation
and bladder filling is less effective when the initial station is
high)18. However, due to the relatively low risk of
the indicated manoeuvres, most clinicians adopt this technique. A recent
study favours knee -chest position as it provides the best elevation
effect19. Although it has a low evidence level, we can
confidently consider it to be a good clinical practice as recommended by
all three CPGs recommended it.
Both RCPI and RCOG did not recommend routine ultrasound screening for
predicting cord prolapse as it is not sensitive or specific to predict
the cord prolapse20. However, ultrasound in mothers
with high risk, such as breech presentation at term, has shown to give
some benefit to the mother who wants to consider vaginal breech
delivery21.
RCOG was the only CPG to recommend avoiding low ARM if the foetal
presenting part is high to avoid triggering cord prolapse. However, as
it also a recommendation with weak evidence (Level 4), it is debatable
whether it should be considered best clinical practice.