Umbilical Cord Prolapse
Summary
Umbilical cord prolapse is an obstetric emergency where the umbilical cord descends below or alongside the presenting fetal part after rupture of membranes. Compression of the cord by the presenting part causes acute fetal hypoxia, which can rapidly lead to fetal death or severe neurological injury if not immediately managed. Risk factors include artificial rupture of membranes (ARM) with a high presenting part, malpresentation (breech, transverse lie), polyhydramnios, and multiple pregnancy. Immediate management involves relieving cord compression by manually elevating the presenting part (hand in vagina), positioning the mother (knee-chest or Trendelenburg), and expediting delivery by Category 1 emergency Caesarean section.
Key Facts
- Definition: Cord descends below/alongside presenting part after membrane rupture
- Incidence: 1-3 per 1000 deliveries
- Pathophysiology: Cord compression → Fetal hypoxia
- Key Risk: ARM with high presenting part
- Immediate Action: Hand in vagina to lift presenting part
- Delivery: Category 1 emergency Caesarean section
Clinical Pearls
"Hand In, Baby Out": In cord prolapse, keep your hand in the vagina elevating the presenting part until the baby is delivered by Caesarean section.
"Don't ARM a High Head": Never rupture membranes if the presenting part is high and mobile. This is the most common preventable cause.
"Fill the Bladder": Filling the bladder with 500-700mL saline via catheter can help lift the presenting part off the cord while preparing for delivery.
"Time is Brain": Fetal compromise begins within minutes. Decision-to-delivery interval should be <15 minutes.
Incidence
- 1-3 per 1000 deliveries
- More common with interventions (ARM)
Risk Factors
| Factor | Mechanism |
|---|---|
| ARM with high head | Most common preventable cause |
| Breech presentation | Poor fit of presenting part |
| Transverse/Oblique lie | No presenting part |
| Polyhydramnios | Cord can float past presenting part |
| Prematurity | Small fetus, poor fit |
| Multiple pregnancy | After delivery of first twin |
| Long umbilical cord | Easier to prolapse |
| Unengaged head | At onset of labour |
| SROM with high head | Cord swept down with fluid |
Types
| Type | Description |
|---|---|
| Overt prolapse | Cord below presenting part, visible/palpable at introitus |
| Occult prolapse | Cord alongside presenting part, not visible but compressed |
| Funic presentation | Cord below presenting part but membranes intact |
Mechanism of Harm
- Membranes rupture (spontaneous or artificial)
- Cord descends (gravity, fluid flow)
- Cord trapped between presenting part and pelvis
- Compression → Vasospasm
- Reduced blood flow to fetus
- Fetal hypoxia → Bradycardia
- Without intervention: Fetal death or brain injury
Timeline
- Minutes: Fetal bradycardia
- 5-10 minutes: Significant hypoxic injury
- >15 minutes: High risk of death or severe morbidity
How It Presents
| Scenario | Findings |
|---|---|
| After ARM | Sudden fetal bradycardia on CTG |
| After SROM | Cord visible at introitus; Abnormal CTG |
| Labour ward | Palpable pulsating cord on VE |
| Community | Mother feels cord at vagina; Called ambulance |
CTG Findings
On Examination
Immediate Assessment
- Palpate for pulsation (presence = live fetus; absence may indicate fetal death but still act urgently)
- Assess dilatation (if fully dilated, consider instrumental delivery)
- Assess presenting part (position, station)
Signs
- Pulsating cord on VE
- Visible cord at vagina
- Fetal bradycardia on auscultation/CTG
Immediate (In Emergency)
- CTG: Bradycardia, abnormal pattern
- VE: Palpate cord
No Time for Other Tests
- This is a clinical diagnosis requiring immediate action
- Do not delay for imaging
Emergency Management
┌──────────────────────────────────────────────────────────┐
│ UMBILICAL CORD PROLAPSE - EMERGENCY MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ 1. CALL FOR HELP │
│ • Put out crash call / obstetric emergency │
│ • Inform theatre immediately │
│ • Call senior obstetrician, anaesthetist, paediatrician │
│ │
│ 2. RELIEVE CORD COMPRESSION │
│ • HAND IN VAGINA: Manually elevate presenting part │
│ • Push fetal head back up into uterus │
│ • Keep hand in place until baby delivered │
│ │
│ 3. POSITIONING │
│ • Knee-chest position (bottom in air, head down) │
│ • OR Exaggerated Trendelenburg (head down, legs up) │
│ • Gravity helps lift presenting part off cord │
│ │
│ 4. FILL BLADDER (If time and available) │
│ • Insert Foley catheter │
│ • Fill bladder with 500-700mL saline │
│ • Elevates presenting part │
│ • Clamp catheter │
│ │
│ 5. DO NOT REPLACE CORD │
│ • Do not try to push cord back │
│ • Keep cord warm and moist (saline-soaked swab) │
│ • Reduce handling (can cause vasospasm) │
│ │
│ 6. DELIVERY │
│ • Category 1 Caesarean Section (target <15 mins DDI) │
│ • If fully dilated + favourable: Consider forceps/ │
│ ventouse if faster than CS │
│ │
│ 7. IF IN COMMUNITY │
│ • Call 999 immediately │
│ • Knee-chest position │
│ • Hand in vagina to lift head if trained │
│ • Blue-light transfer to hospital │
│ │
└──────────────────────────────────────────────────────────┘
Decision to Delivery Interval
- Target: <15 minutes
- Every minute counts
If Cord Is Not Pulsating
- May indicate fetal death but cannot be certain
- Still proceed urgently unless confirmed fetal demise
Fetal
- Fetal death
- Hypoxic-ischaemic encephalopathy (HIE)
- Cerebral palsy
- Multi-organ failure
Maternal
- Emergency surgery risks
- Psychological trauma
- Litigation risk (if delay)
With Prompt Treatment
- Perinatal mortality: <10% (if diagnosed and acted upon promptly)
- Good outcome if delivery within 15-20 minutes
Without Treatment
- Fetal death or severe disability
Prognostic Factors
| Good | Poor |
|---|---|
| In-hospital diagnosis | Community/Out-of-hospital |
| Prompt recognition | Delayed recognition |
| Short decision-to-delivery interval | Prolonged DDI |
| Term gestation | Preterm |
Key Guidelines
- RCOG Green-top Guideline No. 50: Umbilical Cord Prolapse
- NICE Intrapartum Care Guidelines
Key Evidence
Management
- Manual elevation and emergency CS are well-established
- Bladder filling shown to be effective adjunct
What is Cord Prolapse?
Cord prolapse is an emergency that can happen during labour when the umbilical cord slips out ahead of the baby. If the cord gets squashed, it can stop blood and oxygen getting to your baby.
Why is it Serious?
The umbilical cord is your baby's lifeline. If it's compressed, your baby can become starved of oxygen very quickly. This needs to be treated immediately.
What Happens If It Occurs?
The medical team will:
- Push the baby's head up inside to take pressure off the cord
- Position you to help relieve pressure (often on all fours with bottom up)
- Perform an emergency Caesarean section as quickly as possible
What Can You Do?
If you're at home and think the cord has come out:
- Call 999 immediately
- Get onto your hands and knees with your chest on the floor and bottom in the air
- Do not push
- Try not to touch the cord
How Common Is It?
Cord prolapse is rare (about 1-3 in every 1000 deliveries). When it's managed quickly, outcomes are usually good.
Primary Guidelines
- Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 50: Umbilical Cord Prolapse. 2014. rcog.org.uk
Key Studies
- Kahana B, et al. Umbilical cord prolapse and perinatal outcomes. Int J Gynaecol Obstet. 2004;84(2):127-132. PMID: 14871514