Overview
Umbilical Cord Prolapse
Topic Overview
Summary
Umbilical cord prolapse is an obstetric emergency where the umbilical cord descends through the cervix alongside or ahead of the presenting part after membrane rupture. Cord compression causes acute fetal hypoxia and death if not rapidly managed. It requires immediate action: relieve cord compression by elevation of the presenting part, avoid cord manipulation, and proceed to emergency caesarean section (usually within 15-30 minutes).
Key Facts
- Incidence: 0.1-0.6% of deliveries
- Presentation: Visible/palpable cord, acute fetal bradycardia after membrane rupture
- Immediate action: Elevate presenting part (hand in vagina or knee-chest position), call for help
- Definitive treatment: Emergency caesarean section (Category 1)
- Fetal mortality: 10% overall; much lower with rapid response
- Risk factors: Malpresentation, polyhydramnios, prematurity, multiple pregnancy
Clinical Pearls
If you feel cord on VE → keep examining hand in place, push presenting part UP to relieve compression, call for help
Do NOT attempt to push cord back — this causes spasm and further occlusion
Knee-chest position or filling bladder can help elevate presenting part while preparing for CS
Why This Matters Clinically
Cord prolapse is one of the most time-critical obstetric emergencies. The window to prevent fetal death or brain injury is measured in minutes. Every member of the labour ward team must know the immediate actions.
Visual Summary
Visual assets to be added:
- Cord prolapse anatomy diagram
- Knee-chest position photograph
- Emergency algorithm flowchart
- Mannequin demonstrating manual elevation
Epidemiology
Incidence
- 0.1-0.6% of deliveries (1 in 200-1000)
- More common with artificial rupture of membranes (ARM)
- More common in hospitals than home births (selection bias)
Fetal Outcomes
- Perinatal mortality: ~10% overall
- Can be reduced to under 5% with rapid response (under 30 min to delivery)
- Neurological morbidity in survivors if delay
Risk Factors
| Risk Factor | Mechanism |
|---|---|
| Malpresentation (breech, transverse) | Presenting part doesn't fill pelvis |
| Polyhydramnios | Cord floats, washes down with SROM |
| Prematurity | Small baby, high presenting part |
| Multiple pregnancy | Especially after delivery of first twin |
| Long umbilical cord | More likely to prolapse |
| Artificial rupture of membranes (ARM) | Sudden drainage; cord washes past |
| Low-lying placenta | Cord inserts low |
| Male fetus | Slightly higher risk (unknown mechanism) |
Pathophysiology
Mechanism
- Membranes rupture (spontaneously or artificially)
- Cord descends past presenting part
- Presenting part compresses cord against pelvis
- Blood flow to fetus interrupted → hypoxia → death within minutes if unrelieved
Types
| Type | Description |
|---|---|
| Overt cord prolapse | Cord visible at or beyond vulva |
| Occult cord prolapse | Cord beside presenting part, not visible, but palpable on VE |
| Cord presentation | Cord below presenting part but membranes intact (antepartum diagnosis) |
Time to Injury
- Fetal hypoxia begins immediately on cord compression
- Irreversible brain injury begins within 5-10 minutes of complete occlusion
- "Decision-to-delivery" interval ideally under 30 minutes (Category 1 CS target)
Clinical Presentation
How Cord Prolapse is Detected
| Presentation | Context |
|---|---|
| Visible cord | Cord seen at vulva or vagina |
| Palpable cord | Felt on vaginal examination |
| Acute fetal bradycardia | Sudden drop in FHR after SROM or ARM |
| Variable or prolonged decelerations | CTG changes after membrane rupture |
Typical Scenario
Red Flags After Membrane Rupture
| Finding | Action |
|---|---|
| Acute bradycardia | Immediate VE to exclude cord prolapse |
| Cord visible/palpable | Emergency protocol |
| Abnormal CTG pattern | Consider cord prolapse among differentials |
Artificial or spontaneous rupture of membranes
Common presentation.
Immediate or rapid onset fetal heart rate abnormality
Common presentation.
VE reveals pulsating cord
Common presentation.
Clinical Examination
Indications for VE
- Abnormal CTG after membrane rupture
- High presenting part
- Risk factors for cord prolapse
What You May Find
| Finding | Significance |
|---|---|
| Pulsating cord | Confirms diagnosis; fetus alive |
| Non-pulsating cord | Cord occlusion or fetal death — urgent delivery still indicated |
| High presenting part | Risk factor; may allow cord descent |
| Closed cervix | May make VE difficult; consider USS |
DO NOT
- Attempt to replace cord into uterus (causes spasm)
- Handle cord excessively (vasospasm)
Investigations
Diagnosis is Clinical
- No time for investigations
- Diagnosis made on VE or direct visualisation
CTG
- Acute bradycardia or prolonged deceleration
- Variable decelerations
- Often the first indication before VE
Ultrasound (If Time Permits — Rarely)
- Can confirm cord presentation before membranes rupture
- Not appropriate in emergency situation with ruptured membranes
Classification & Staging
By Membrane Status
| Type | Definition |
|---|---|
| Cord presentation | Cord below presenting part; membranes intact |
| Cord prolapse | Cord below presenting part; membranes ruptured |
By Visibility
| Type | Description |
|---|---|
| Overt | Cord visible at vulva |
| Occult | Cord palpable on VE but not visible |
Management
Immediate Actions (ABCDE → CORD)
C — Call for help
- Pull emergency buzzer
- Request senior obstetric, anaesthetic, paediatric presence
- Prepare theatre for emergency CS
O — Only remove hand from vagina if bladder filling or all-fours position takes over
- Keep hand in vagina, push presenting part UP off cord
- Do NOT attempt to replace cord
R — Relieve pressure on cord
- Manual elevation of presenting part (most effective)
- Knee-chest position (all-fours, head down)
- Bladder filling (500ml saline via catheter) — elevates presenting part
D — Deliver promptly
- Emergency Category 1 caesarean section
- Decision-to-delivery interval under 30 minutes (target: 15-20)
- Vaginal delivery only if fully dilated and immediate delivery possible
In Theatre
- General anaesthesia often fastest
- Regional may be appropriate if already sited
- Paediatric team for resuscitation
If Fetal Death Confirmed
- No indication for emergency CS for maternal benefit
- Vaginal delivery appropriate
- Bereavement support
Post-Delivery
- Cord gases (document asphyxia)
- Paediatric review of neonate
- Debrief with parents
- Incident documentation and review
Complications
Fetal/Neonatal
- Stillbirth
- Hypoxic-ischaemic encephalopathy (HIE)
- Neonatal death
- Long-term neurological disability
Maternal
- Emergency CS complications (bleeding, infection, injury)
- Psychological trauma
- Future pregnancy concerns
Prognosis & Outcomes
Perinatal Mortality
- 10% overall
- Under 5% with rapid response (decision-to-delivery under 30 min)
- Higher with out-of-hospital births, delayed diagnosis
Neurological Outcomes
- Majority of survivors have normal outcomes if delivered rapidly
- HIE and cerebral palsy associated with prolonged cord compression
Recurrence Risk
- Low if no underlying anatomical risk factor
- Counsel about cord presentation if risk factors persist in future pregnancy
Evidence & Guidelines
Key Guidelines
- RCOG Green-top Guideline No. 50: Umbilical Cord Prolapse (2014)
- PROMPT Course Guidelines
Key Evidence
- Decision-to-delivery under 30 min associated with better outcomes
- Bladder filling is a temporising measure, not a substitute for delivery
- Manual elevation remains most effective immediate intervention
Patient & Family Information
What is Cord Prolapse?
Cord prolapse is an emergency during labour when the umbilical cord slips down past the baby before the baby is born. If the cord is squashed, the baby's oxygen supply is reduced.
What Happens?
- This is usually discovered when checking you during labour
- Staff will push the baby up inside to take pressure off the cord
- You will need an emergency caesarean section very quickly
Is My Baby at Risk?
- If treated quickly, most babies do well
- The risk is higher if there is a delay in delivery
After Delivery
- Your baby will be checked by a paediatrician
- Staff will explain what happened and answer your questions
Resources
References
Primary Guidelines
- RCOG. Umbilical Cord Prolapse (Green-top Guideline No. 50). 2014. rcog.org.uk
Key Studies
- Murphy DJ, MacKenzie IZ. The mortality and morbidity associated with umbilical cord prolapse. Br J Obstet Gynaecol. 1995;102(10):826-830. PMID: 7547738
- Kahana B, et al. Umbilical cord prolapse and perinatal outcomes. Int J Gynaecol Obstet. 2004;84(2):127-132. PMID: 14871513