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.