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• Cord presentation
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• Funic presentation
• Cord (funic) presentation

A cord presentation (also known as a funic presentation or obligate cord presentation ) is a variation in the fetal presentation  where the umbilical cord points towards the internal cervical os or lower uterine segment.

It may be a transient phenomenon and is usually considered insignificant until ~32 weeks. It is concerning if it persists past that date, after which it is recommended that an underlying cause be sought and precautionary management implemented.

On this page:

Epidemiology, radiographic features, treatment and prognosis, differential diagnosis.

• Cases and figures

The estimated incidence is at ~4% of pregnancies.

Associations

Recognized associations include:

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

multifetal pregnancy

long umbilical cord

Color Doppler interrogation is extremely useful and shows cord between the fetal presenting part and the internal cervical os. However, unlike a vasa previa , the placental insertion is usually normal.

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As the complicating umbilical cord prolapse can lead to catastrophic consequences, most advocate an elective cesarean section delivery for persistent cord presentation in the third trimester 3 .

Complications

It can result in a higher rate of umbilical cord prolapse .

For the presence of umbilical cord vessels between the fetal presenting part and the internal cervical os on ultrasound consider:

vasa previa

• 1. Ezra Y, Strasberg SR, Farine D. Does cord presentation on ultrasound predict cord prolapse? Gynecol. Obstet. Invest. 2003;56 (1): 6-9. doi:10.1159/000072323 - Pubmed citation
• 2. Kinugasa M, Sato T, Tamura M et-al. Antepartum detection of cord presentation by transvaginal ultrasonography for term breech presentation: potential prediction and prevention of cord prolapse. J. Obstet. Gynaecol. Res. 2007;33 (5): 612-8. doi:10.1111/j.1447-0756.2007.00620.x - Pubmed citation
• 3. Raga F, Osborne N, Ballester MJ et-al. Color flow Doppler: a useful instrument in the diagnosis of funic presentation. J Natl Med Assoc. 1996;88 (2): 94-6. - Free text at pubmed - Pubmed citation
• 4. Bluth EI. Ultrasound, a practical approach to clinical problems. Thieme Publishing Group. (2008) ISBN:3131168323. Read it at Google Books - Find it at Amazon

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INTRODUCTION

Funic or cord presentation is defined as one or more loops of umbilical cord floating between the fetal presenting part and the internal cervical os, typically with the membranes are intact. With normal amniotic fluid volume, funic presentation is often a dynamic process that can appear and disappear with fetal movement, especially earlier in gestation. The clinical significance of funic presentation is that as gestational age advances and the fetal head becomes engaged, the cord can become wedged between the uterine wall and fetal presenting part, creating an occult or overt prolapse upon membrane rupture.

Of note, an alternative nomenclature has been proposed whereby classification is based on the positional relationship among the cord, the fetal presenting part, and the cervix [ 1 ]. In this system, "cord prolapse" refers to an umbilical cord that has prolapsed past the fetal presenting part and beyond the internal cervical os, "cord presentation" refers to an umbilical cord ahead of the fetal presenting part but above the internal cervical os, and "compound cord presentation" refers to both the cord and fetus presenting above the internal cervical os. Any of the three clinical scenarios can occur with either intact or ruptured membranes.

This topic will discuss the frequency, pathogenesis, risk factors, clinical findings, diagnosis, management, potential prevention, and outcome of umbilical cord prolapse.

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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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.

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

• Access the PDF version of the guideline

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.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Umbilical cord prolapse.

Marina Boushra ; Alicia Stone ; Kimberly M. Rathbun .

Affiliations

Last Update: May 8, 2023 .

• Continuing Education Activity

Umbilical cord prolapse is when the umbilical cord exits the cervical os before the fetal presenting part. Compression of the cord results in vasoconstriction and resultant fetal hypoxia, which can lead to fetal death or disability if not rapidly diagnosed and managed. This activity reviews the diagnosis and management of patients with umbilical cord prolapse in the emergency department and highlights the role of early recognition and interprofessional involvement in improving patient outcomes.

• Describe the clinical presentation of umbilical cord prolapse.
• Outline the key steps in the acute management of umbilical cord prolapse.
• Review alternative management strategies that can be utilized after initial attempts at funic decompression have failed or in cases where obstetric care is not immediately available.
• Explain strategies to improve care coordination between the interprofessional teams caring for patients with umbilical cord prolapse to improve outcomes.
• Introduction

Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal morbidity and mortality. Resultant compression of the cord by the descending fetus during delivery leads to fetal hypoxia and bradycardia, which can result in fetal death or permanent disability. Early recognition and intervention are paramount to the reduction of adverse outcomes in the fetus.

Certain features of pregnancy increase the risk for the development of umbilical cord prolapse by preventing appropriate engagement of the presenting part with the pelvis. These include fetal malpresentation, multiple gestations, polyhydramnios, preterm rupture of membranes, intrauterine growth restriction, preterm delivery, and fetal and cord abnormalities. [1] Nearly half of the cases of umbilical cord prolapse can be attributable to iatrogenic causes. [2] Iatrogenic risk factors include amniotomy without an engaged fetal presenting part, attempted external cephalic version in the setting of ruptured membranes, amnioinfusion, placement of a fetal scalp electrode or intrauterine pressure catheter, or the use of a cervical ripening balloon. [1]

• Epidemiology

Estimates of the incidence of umbilical cord prolapse range from 1.4 to 6.2 per 1000. [3] The majority of cases of umbilical cord prolapse occur in single gestation pregnancies; in twin gestations, the incidence increases in the second twin. [2] Most prolapses occur shortly after rupture of membranes; one study estimates that 57% occur within five minutes of membrane rupture while 67% occur within one hour of rupture. [2] The incidence of umbilical cord prolapse is on a downward trend, which is thought to be secondary to the widespread use of cesarean sections for many of the risk factors of cord prolapse, such as fetal malpresentation. [4] [5] Decreasing rates of grand multiparity worldwide are also thought to contribute to the reduced incidence. [5]

• History and Physical

The occurrence of fetal bradycardia in the setting of ruptured membranes should prompt immediate evaluation for potential cord prolapse. There are two forms of umbilical cord prolapse. [1] The first, overt prolapse, occurs when the cord exits the cervix before the fetal presenting part; the second, occult prolapse, occurs when the cord exits the cervix with the fetal presenting part. [1] In overt prolapse, the cord is palpable as a pulsating structure in the vaginal vault. In occult prolapse, the cord is not visible or palpable ahead of the fetal presenting part. In overt prolapse, the diagnosis is clinical and made by palpation of a pulsating structure in the vaginal vault or visibly protruding from the vaginal introitus; this is typically accompanied by fetal bradycardia or severe variable decelerations, though fetal heart rate changes only present in approximately two-thirds of cases. [2] [6] In occult prolapse, only fetal heart rate abnormalities may appear, as the cord will not be palpable or visible on examination. The diagnosis should be a consideration in cases of unexplained fetal heart rate changes in the setting of recent membrane rupture or other maneuvers that increase the risk of prolapse (for example, placement of a fetal scalp electrode). [1]

Umbilical cord prolapse is a clinical diagnosis and should be considered in the case of fetal bradycardia or recurrent variable decelerations, especially if they occur immediately after rupture of membranes. The diagnosis is confirmed by palpation of a pulsatile mass in the vaginal vault. No radiographic or laboratory confirmation is available, and funic decompression should be attempted as soon as the diagnosis is suspected. Antenatal ultrasound for cord presentation has been demonstrated to be a poor predictor of umbilical cord prolapse. [7]

• Treatment / Management

The definitive management of umbilical cord prolapse is expedient delivery; this is usually by cesarean section. In rare cases, vaginal delivery or operative vaginal delivery may be faster and, thus, preferable, but this should only occur under the presence and guidance of an experienced obstetrician. [1]

Until delivery is possible, the cornerstone of management of umbilical cord prolapse is funic decompression, relieving the pressure on the cord by elevation of the fetal presenting part. Studies suggest that the interval to funic decompression may be more important to outcomes than interval to delivery. [8] Decompression should be done manually by the medical provider through the placement of their finger or hand in the vaginal vault and gentle elevation of the presenting part off the umbilical cord. The provider should be conscientious not to place any additional pressure on the cord, as this can cause vasospasm and worsen outcomes. [9] Placement of the mother in a steep Trendelenburg or knee-chest position can also aid in cord decompression. In cases of a potentially prolonged interval to delivery (i.e., the need for transfer to a hospital with obstetric capabilities), saline infusion into the bladder may aid in funic decompression and remove the need for continuous manual elevation by the provider. [10] [11] If fetal decelerations persist and delivery is not imminent, the administration of a tocolytic can be attempted to relieve pressure on the umbilical vessels and to improve placental perfusion, thereby improving blood flow to the fetus. [12] [13] Reduction of the cord into the os, which was common before the widespread availability of cesarean sections, has been associated with increased fetal mortality and is not routinely recommended except in cases of an expected long interval to delivery where other maneuvers have failed. [1]

If the cord is visibly protruding from the introitus, it should remain warm and moist because the ambient temperature is significantly colder than the temperature in the uterus and can result in vasospasm of the umbilical arteries, contributing to fetal hypoxia. [1] One method described as preventing this is the replacement of the cord into the vaginal vault followed by insertion of a moist tampon to keep it in place. [14]

In very rare cases of umbilical cord prolapse in peri-viable pregnancies, case studies demonstrate that conservative management may allow the continuation of the pregnancy until reaching a more desirable gestational age. [9] [15]  However, a frank discussion should take place with the patient regarding the experimental nature of this treatment and its potential risks. 

Pre-viable gestational age, lethal fetal abnormalities, or fetal demise are not indications for expedient delivery, and instead, a dilation and evacuation or labor induction should be the therapeutic choice, dependent on gestational age or maternal preference. [5]

• Differential Diagnosis

Potential causes of a palpable mass in the vaginal vault include fetal malpresentation. [1] Possible causes of severe, prolonged fetal bradycardia include maternal hypotension, uterine rupture, vasa previa, and abruptio placentae. [1]

The rate of fetal mortality in umbilical cord prolapse is estimated to be less than 10%. [9] [2] [4] This reduction is a drastic decrease from earlier estimates of mortality, which ranged from 32 to 47%, which researchers hypothesize is due to the increased availability of cesarean sections and advances in neonatal resuscitation. [1] [9] Gestational age and location of prolapse (inside versus outside the hospital) are the two significant determinants of outcome in umbilical cord prolapse. [5]  Cord prolapse that occurs outside the hospital carries an 18-fold increased risk of mortality. [6] Premature infants and those with low birth weights have an increased risk of perinatal complications and twice the mortality. [9]  Death in these infants appears to be attributable to their underlying conditions and the preterm delivery necessitated by the prolapse rather than complications of the prolapse itself. 

• Complications

Outcomes for umbilical cord prolapse have drastically improved in recent years. [4] Still, a diagnosis of umbilical cord prolapse carries a risk of fetal mortality. Though rare, surviving infants may develop complications secondary to asphyxia, including neonatal encephalopathy and cerebral palsy. [16] [17] [18]

• Consultations

Emergent obstetric consultation is necessary for umbilical cord prolapse occurring in the emergency department. The attending clinicians should attempt maneuvers for funic decompression until definitive management is available. 

• Deterrence and Patient Education

Many patients in resource-rich countries are opting for childbirth at home under the supervision of a non-physician attendant such as a midwife. Cases of umbilical cord prolapse that occur outside the hospital carry a nearly 20 times increased rate of mortality. As such, patients with increased risk of prolapses, such as those with fetal malpresentation or umbilical cord abnormalities, should be strongly discouraged from delivering outside of the hospital. Concentration on other portions of their birth plan, such as a silent birth or minimal pharmacologic intervention, may help these patients decide to deliver in the hospital. Since umbilical cord prolapse may happen in patients without risk factors, training for non-physician birth attendants in the early recognition and intervention in umbilical cord prolapse may lead to improved fetal outcomes in these cases. 

Patients themselves should also be counseled to recognize cord prolapse in the scenario of a gush of fluid followed by the feeling of vaginal pressure or something in the vagina. The patient should be instructed to call an ambulance and assume a knee-chest position while waiting for help to arrive.

Given the iatrogenic risk factors for umbilical cord prolapse, physician education also has a role to play in decreasing the frequency of this condition. The American College of Obstetricians and Gynecologists recommends against routine amniotomy in normally progressing labor unless needed for fetal monitoring. [19] If performing an amniotomy, engagement of the fetal head should be confirmed. In cases with risk of cord prolapse, for example, polyhydramnios or high fetal station, the amniotic sac may be ruptured with a needle rather than a hook to slow the flow of the amniotic fluid, though the efficacy of this technique has not been well-studied. [20]

• Enhancing Healthcare Team Outcomes

Knowledge of the risk factors for umbilical cord prolapse does not decrease its occurrence  [2] , but such knowledge can help both healthcare providers, including midwives, labor and delivery nurses, and the patient prepare for potential umbilical cord prolapse. In patients with risk factors for developing umbilical cord prolapses, such as breech presentation with desired vaginal delivery, frank discussion with the patient and her partner regarding the risk should be undertaken, and the recommendation is to plan the delivery at a healthcare center where emergent cesarean delivery is available. Patient counseling by the clinician and nurse regarding the expected course of events in the case of umbilical cord prolapse in delivery may help the patient better understand the urgent nature of management before occurrence. Simulation team training exercises have been shown to decrease the time from diagnosis to delivery and improve fetal outcomes. [21] [22] [23]

Umbilical cord prolapse cases require an interprofessional team approach to care. This team includes physicians and specialists, as well as specialty-trained neonatal nursing staff. Through collaborative team communication, optimal care can be the result, with the best possible patient outcomes for both the mother and the neonate. [Level 5]

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Disclosure: Marina Boushra declares no relevant financial relationships with ineligible companies.

Disclosure: Alicia Stone declares no relevant financial relationships with ineligible companies.

Disclosure: Kimberly Rathbun declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Boushra M, Stone A, Rathbun KM. Umbilical Cord Prolapse. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Fetal demise and associated factors following umbilical cord prolapse in Mulago hospital, Uganda: a retrospective study. [Reprod Health. 2014] Fetal demise and associated factors following umbilical cord prolapse in Mulago hospital, Uganda: a retrospective study. Wasswa EW, Nakubulwa S, Mutyaba T. Reprod Health. 2014 Feb 1; 11(1):12. Epub 2014 Feb 1.
• Review Umbilical cord prolapse: revisiting its definition and management. [Am J Obstet Gynecol. 2021] Review Umbilical cord prolapse: revisiting its definition and management. Wong L, Kwan AHW, Lau SL, Sin WTA, Leung TY. Am J Obstet Gynecol. 2021 Oct; 225(4):357-366. Epub 2021 Jun 26.
• Review Umbilical cord prolapse. [Obstet Gynecol Clin North Am. ...] Review Umbilical cord prolapse. Holbrook BD, Phelan ST. Obstet Gynecol Clin North Am. 2013 Mar; 40(1):1-14.
• Bradycardia-to-delivery interval and fetal outcomes in umbilical cord prolapse. [Acta Obstet Gynecol Scand. 2021] Bradycardia-to-delivery interval and fetal outcomes in umbilical cord prolapse. Wong L, Tse WT, Lai CY, Hui ASY, Chaemsaithong P, Sahota DS, Poon LC, Leung TY. Acta Obstet Gynecol Scand. 2021 Jan; 100(1):170-177. Epub 2020 Sep 14.
• Review Optimal management of umbilical cord prolapse. [Int J Womens Health. 2018] Review Optimal management of umbilical cord prolapse. Sayed Ahmed WA, Hamdy MA. Int J Womens Health. 2018; 10:459-465. Epub 2018 Aug 21.

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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.

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Cord Presentation and Prolapse

Definitions

In both conditions a loop of the cord is below the presenting part. The difference is in the condition of the membranes; if intact it is cord presentation and if ruptured it is cord prolapse.

Incidence : 1:200.

As long as the membranes are intact there is no risk. In cord prolapse, the foetal perinatal mortality is 25-50% from asphyxia due to:

• mechanical compression of the cord between the presenting part and bony pelvis and
• spasm of the cord vessels when exposed to cold or manipulations.

The prognosis is worse when the cord is more liable for compression as in:

• Primigravida than multipara.
• Cephalic than breech presentation or transverse lie.
• Partially than fully dilated cervix.
• Generally contracted than flat pelvis.
• Anterior than posterior position of the cord.

The presenting part is not fitting in the lower uterine segment due to:

• Malpresentations: e.g. complete or footling breech, transverse and oblique lie.
• Prematurity.   
• Anencephaly.     
• Polyhydramnios.    
• Multiple pregnancy.
• Contracted pelvis.   
• Pelvic tumours.

Predisposing factors:

• Placenta praevia. 
• Long cord.   
• Sudden rupture of membranes in polyhydramnios.
• It is diagnosed by vaginal examination . If the cord is prolapsed it is necessary to detect whether it is pulsating i.e. living foetus or not i.e. dead foetus but this should be documented by auscultating the FHS.
• Ultrasound: occasionally can diagnose cord presentation.

Cord presentation

Caesarean section: for contracted pelvis.

In other conditions the treatment depends upon the degree of cervical dilatation:

• putting the patient in Trendelenburg position,
• avoiding high enema,
• avoiding repeated vaginal examination.
• When the cervix is fully dilated manage as mentioned later .
• Rupture of the membranes and forceps delivery: in engaged vertex presentation.
• Rupture of the membranes and breech extraction: in breech presentation.
• Rupture of the membranes + internal podalic version + breech extraction: may be tried in transverse lie otherwise,
• Caesarean section: is indicated as well as for non-engaged vertex and other cephalic malpresentations.

Cord prolapse

Management depends upon the foetal state:

• manual displacement of the presenting part higher up,
• if the cord protrudes from the vulva, handle it gently and wrap it in a warm moist pack.
• giving oxygen to the mother.
• Fully dilated cervix: the foetus should be delivered immediately as in cord presentation.
• Spontaneous delivery is allowed.
• Caesarean section: is the safest procedure in obstructed labour as destructive operations are out of modern obstetrics.
• Dystocia : Guidelines, reviews
• Labor, delivery : Guidelines, reviews

Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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• Leptospirosis in Animals
• Information for Health Care Providers

About Leptospirosis

• Leptospirosis is a disease caused by bacteria that affects people and animals.
• It's spread in the urine (pee) of infected animals.
• Leptospirosis risk often increases after a hurricane or flood when people have contact with contaminated water or soil.
• If you or your animals may have leptospirosis, see a healthcare provider.

Leptospirosis is a disease caused by the bacterium Leptospira that can be found in contaminated water or soil. It affects many different kinds of animals and people.

Without treatment, leptospirosis in people can lead to kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, trouble breathing, and even death.

About 1 million cases in people occur around the world each year, with nearly 60,000 deaths. Leptospirosis has been reported throughout the United States.

Just like people, animals can become infected through contact with contaminated urine or other body fluids in water or soil. Signs and symptoms in infected animals can vary widely, and some animals don't show symptoms at all.

Signs and symptoms

In people, leptospirosis can cause a wide range of symptoms, including:

• Body or muscle aches
• Vomiting or nausea
• Yellowed skin and eyes (jaundice)
• Stomach pain

Many of these symptoms can be mistaken for other diseases. Some people have no symptoms.

It generally takes 2-30 days to get sick after having contact with the bacteria that cause leptospirosis. The disease may occur in two phases:

• In the first phase, people may have fever, chills, headache, muscle aches, vomiting, or diarrhea. The person may feel better for a while but become ill again.
• Some people may suffer a more severe second phase with kidney or liver failure, or inflammation of the membrane around the brain and spinal cord (meningitis).

The illness can last from a few days to several weeks. Without treatment, getting better may take several months.

If you think you may have leptospirosis, see a healthcare provider right away so that they can run tests and start you on effective medicine to treat it.

Exposure risks

The bacteria that cause leptospirosis are spread through the urine (pee) of infected animals. The bacteria can survive in contaminated water or soil for weeks to months. Many different kinds of wild and domestic animals carry the bacteria, including:

• Livestock (cows, pigs, horses, sheep, goats, etc,)
• Rodents (rats, mice, etc.)
• Marine mammals (sea lions, seals, etc.)
• Wild animals (zoo animals, wild pigs, etc.)

When these animals are infected, they may have no symptoms of the disease. Infected animals may continue to urinate the bacteria into the environment for several months or years.

It's rare for people to spread leptospirosis to other people.

People can become infected through:

• Contact with water or soil containing urine or body fluids from infected animals, especially after hurricanes, flooding, or heavy rainfall.
• Directly touching body fluids from an infected animal.
• Eating food or drinking water contaminated by the urine of an infected animal.

If you're involved in activities that put you in contact with water, soil or animals, you may be at increased risk for infection. These activities include:

• Water recreation like swimming, kayaking, canoeing, or rafting in rivers, swamps, or creeks
• Hiking or hunting
• Gardening, yardwork, outdoor cleaning and maintenance
• Jobs like working at a veterinary clinic, dairy farming, or butchering

If you are experiencing homelessness or living in a shelter or other facility that has a lot of people living closely together, you may also have a higher risk of getting leptospirosis.

Leptospirosis and Flooding‎

Lower your risk of getting leptospirosis:

• Don't swim or wade in water that might be contaminated with animal urine, especially after hurricanes, floods, or heavy rainfall.
• Avoid contact with animals that may be infected .
• Cover your cuts or scratches with waterproof bandages.
• Wear waterproof protective clothing, shoes or boots near floodwater or other water or soil that may be contaminated with animal urine.

If you take part in water recreation activities like swimming, boating, fishing, and adventure racing, some tips to avoid leptospirosis include:

• Research the location you'll be in the water for possible leptospirosis infections for that area. In the US, check your local health department in the US. If you're traveling internationally, check CDC Traveler's Health .
• Cover scrapes and wounds with waterproof bandaging and wear shoes if leptospirosis or other diseases are known in the area.

If you may be exposed as a result of your job (veterinarians, veterinary staff, raising farm animals, dairy workers, animal control, butcher or slaughterhouse workers, sewage and sanitation workers, military and first responders):

• Wash hands frequently
• Use personal protective equipment (gloves, footwear, eye protection)
• Clean and disinfect surfaces and equipment
• Vaccinate animals against leptospirosis, and isolate sick animals
• Control the rodent population around your work area

Treatment and recovery

Leptospirosis is treated with antibiotics, such as doxycycline or penicillin. Antibiotics should be given as early as possible if a healthcare professional thinks you may have leptospirosis.

Intravenous (IV) antibiotics may be needed for people who have more severe leptospirosis symptoms.

Early treatment with antibiotics may help prevent severe illness and decrease how long you're sick.

• Hurricanes, Floods, and Leptospirosis fact sheet
• Hurricanes, Floods, and Leptospirosis en Español
• Protect Yourself from Leptospirosis Poster
• Leptospirosis Advice for Travelers – CDC Yellow Book
• OSHA - Agricultural Operations - Hazards & Controls
• Severe Leptospirosis Similar to Pandemic (H1N1) 2009, Florida and Missouri, USA
• Surveillance for Waterborne Disease and Outbreaks Associated with Recreational Water Use and Other Aquatic Facility-Associated Health Events—United States, 2005–2006 . MMWR September 12, 2008;57(SS09):1-29.
• Levett PN. Leptospirosis . Clin Microbiol Rev 2001; 14: 296-326.
• Stern E, Galloway R, Shadomy S, Wannemuehler K, Atrubin D, Blackmore C, Wofford T, Wilkins P, Ari M, Harris L, Clark T. (2010) Outbreak of Leptospirosis among Adventure Race Participants in Florida, 2005 . Clinical Infectious Diseases ; 50: 843-849.

Leptospirosis

More information about leptospirosis, a disease caused by bacteria that is more common after hurricanes, floods, and heavy rainfall.

For Everyone

Health care providers.

Green computing (also known as green IT or sustainable IT) is the design, manufacture, use and disposal of computers, chips, other technology components and peripherals in a way that limits the harmful impact on the environment, which include reducing carbon emissions and energy consumption by manufacturers,  data centers  and end-users. Green computing also encompasses choosing sustainably sourced raw materials, reducing electronic waste and promoting sustainability through the use of renewable resources.

The potential for green computing to have a positive impact on the environment is considerable. The information and communication technology (ICT) sector is responsible for between 1.8% and 3.9% of global greenhouse gas emissions. Moreover, data centers account for 3% of annual total energy consumption—an increase of 100% in the last decade.

“The energy demands and carbon output of computing and the entire ICT sector must be dramatically moderated if climate change is to be slowed in time to avoid catastrophic environmental damage,” according to a  report published by the Association for Computing Machinery  (link resides outside ibm.com).

Every aspect of modern information technology—from the smallest chip to the largest data center—carries a carbon price tag and green computing seeks to reduce just that. Technology makers play a role in green computing, as do the corporations, organizations, governments and individuals that use technology. From massive data centers instituting policies to cut energy consumption to individuals choosing to not use screen savers, green IT is multifaceted and involves myriad decisions at every level.

The decisions regarding going green begin long before products reach consumers. For example, product design and manufacturing are prime areas to lessen the impact of technology on the environment.

Chips that are more energy efficient—such as  the chip designed by IBM® and Samsung  that can be stacked vertically or the  IBM 2nm chip —are examples of innovative design that improves sustainability in computing. The energy consumption of a single computer chip may seem negligible, but when you multiply that by millions, it is possible to make significant reductions.

IBM has also identified systems that can reduce energy usage. Heterogenous structures, for instance, bring together frameworks like CPUs and graphics processing units (GPUs) to optimize power and energy efficiency.

One example is a computer named AiMOS (which stands for Artificial Intelligence Multiprocessing Optimized System), developed as part of a collaboration between IBM, Empire State Development and NY CREATEs. AiMOS is one of the most energy-efficient computers in existence, and it is used to develop more advanced and efficient computing chips, along with many other initiatives.

When designers take steps to reduce the amount of energy each product uses in operation and reduce the amount of heat those products produce, the carbon price tag of computing gets lower. For instance, sleep mode is one of the earliest examples of designers applying the concept of green computing to conserve energy.

Material selection is crucial as well. Design that avoids using hazardous materials keeps those materials out of landfills later. Generating less waste in manufacturing devices and components, too, lessens the burden created by technology on the environment. Green manufacturing is a separate, but related, category of green technology that governs how the factory itself operates.

Other green computing actions manufacturers can take include lengthening the lifespan of computing devices and components so they don’t need to be replaced as frequently, increasing users’ ability to reuse products and making devices recyclable when they do need to be replaced.

The largest gains in making IT more sustainable may be made by corporations, governments and other large organizations. Data centers, server rooms and data storage areas have a significant opportunity to run more efficiently.

In such areas, setting up hot and cold aisles is an important step toward greener computing because it reduces energy consumption and optimizes heating, ventilation and cooling. When automated systems designed to control temperature and similar conditions are combined with hot and cold aisles, emissions are further lowered. Cost savings from reducing energy use may eventually be realized, as well.

One simple step toward efficiency is to make sure things are turned off. Central processing units (CPUs) and peripheral equipment such as printers should be powered down when not in use. Scheduling blocks of time for specific tasks like printing means peripherals are only in use when they are needed.

Purchasing departments have a role to play in green computing, too. Choosing equipment that will last and consumes the least amount of energy necessary for the task to be performed are both ways to reduce the carbon footprint of IT. Notebooks use less energy than laptops, and laptops use less energy than desktop computers, for example.

Green computing isn’t only for large organizations; you can also play an important part in improving sustainability in the world of IT. When many individuals make the choice to use functions like hibernate or sleep mode, the impact can be huge.

Whatever the device, employing the power management features and adjusting screen brightness help reduces energy consumption. Other ways to use less energy include turning off computers at the end of the day and keeping peripherals like speakers or printers turned off unless they are being used.

Refilling printer cartridges rather than purchasing new ones produces less waste and buying refurbished equipment rather than buying new reduces environmental impact. Safe disposal of electronic equipment  improves sustainability and has security advantages  (link resides outside ibm.com).

Just as purchasing departments should choose the most efficient equipment for the tasks to be performed, so should you. If a notebook or laptop can perform necessary tasks as well as a desktop computer, opt for the more efficient device. Energy Star ratings are a good guide for individuals purchasing new equipment.

In 1992, the Environmental Protection Agency (EPA) began the  Energy Star Program  (link resides outside ibm.com) in the United States, which aimed to promote and recognize energy efficiency. That program was the impetus for the adoption of the sleep mode function across the IT industry, and it brought about numerous other initiatives to increase efforts toward green computing. Energy Star-certified products must meet certain operation standards and have power management features that non-certified products may lack.

The program was furthered by a grant from the EPA to the Global Electronics Council, which resulted in the  Electronic Product Environmental Assessment Tool  (link resides outside ibm.com) (EPEAT). EPEAT is a product registry for products that are held to specific performance criteria, including materials used, greenhouse gas emissions from transportation, product longevity, energy use and end-of-lifecycle management.

Before green computing, the IT industry tended to focus on producing smaller and faster devices, rather than on improving sustainability or reducing emissions. On-premises physical servers and hardware are associated with traditional computing, whereas cloud computing represents a move toward a more eco-friendly approach, with a stronger focus on efficiency.

Multiple initiatives to improve green computing standards through the creation of industry metrics related to sustainability exist, as do various certifications. The  Green500  (link resides outside ibm.com) is a sub-list of the Top500, which lists supercomputers and the applications for which those computing systems are used. The Green500 ranks the supercomputers by energy efficiency. The Transaction Processing Performance Council (TCP) is a nonprofit organization that develops benchmarks for performance in the transaction processing industry. SPECPower also creates benchmarks, but for the power and performance characteristics of single- and multi-node servers with the goal of improving efficiency.

Perhaps one of the greatest barriers to advancing green computing is a lack of concern. Few people think of the IT industry when they think about climate change. Along with a general lack of concern, the IT market has developed in a way that prioritizes the development of smaller and faster components and devices rather than environmentally friendly ones.

The fact that technology evolves and changes very rapidly presents challenges in extending the lifecycle of products and requires technology makers to ensure each iteration continues to meet eco-friendly standards. Switching from a conventional set up in a factory, data center or corporate office to a green configuration requires an often-substantial up-front capital investment that represents an additional potential barrier.

Fragmented data and varying needs make decision-making difficult across the spectrum of IT end users. For example, speed and performance have a different value in a large data center than they do for a user at home.

At any given point in the lifecycle of a computing device, users must weigh various concerns. For a large organization, security may be a greater concern than environmental impact when it comes to servers. And for a college student, a smaller device that is easier to carry may be more important than having one that is fully recyclable.

Green computing has the power to lessen the impact of computing on the environment. However, the ICT industry has an opportunity to do much more by using technology to benefit the environment through programs and systems designed to reduce power consumption, improve water management and embrace virtualization as a way to conserve energy.

Wherever you are on the path to green IT and sustainability within your organization, one practical first step that can make a noticeable and immediate impact on energy consumption is to make sure that your applications only consume the resources they need and nothing more. This materially reduces waste (cost and carbon footprint) in data centers and the public cloud.

To help realize that goal, a solution like  IBM Turbonomic® Application Resource Management  can help you continuously analyze applications’ resource utilization to ensure applications get what they need to perform, while adhering to business policies. With a complete understanding of the application and infrastructure stack, you can automate actions and prevent resource congestion across a hybrid cloud environment, while initiating broader investments in sustainability.

IBM is committed to green IT across the ecosystem of the business , including green design, operations and the use of its technology. The company has received numerous awards for  sustainable products, energy use and environmental excellence . IBM’s first corporate policy regarding environmental affairs was issued in 1971, and protecting the environment remains a key issue in worldwide operations.

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