Emergency Cesarean delivery for umbilical cord prolapse: The head-down, knee-chest prone position for spinal anesthesia

Objective: Umbilical cord prolapse in a parturient is an emergency, where the need for immediate fetal delivery may conflict with maternal anesthetic risk factors. We describe the anesthetic management of a parturient who was rushed to the operating room, in the knee-chest prone position, because of cord prolapse with variable decelerations of fetal heart rate. Clinical features: A 28-yr-old multiparous patient presented at 37 weeks gestation. Her co-morbidities included morbid obesity and asthma. She had a Mallampati class IV airway. She required emergency Cesarean delivery, in view of umbilical cord prolapse, with evidence of fetal compromise. In light of the airway concerns, the urgency to proceed with delivery, and the presence of a palpable umbilical cord pulse in this position, we performed a spinal anesthetic in the knee-chest prone position, and immediately thereafter turned the patient supine, with lateral uterine displacement. Fetal heart rate was monitored throughout the procedure. The spinal anesthetic required less than five minutes to perform, from the time of skin preparation, until readiness for surgery. The subsequent surgical and anesthetic course was unremarkable. Conclusions: Performing spinal anesthesia in the knee-chest prone position served as an innovative solution for emergency Cesarean delivery in this case. Both the head-down lateral, and the head-down knee-chest prone positions, are compatible with spinal anesthesia, and the maternal position that achieves relief of cord compression, determined by the presence of a palpable umbilical cord pulse, may be the most important factor to determine the optimal approach to spinal anesthesia.