Umbilical Cord Prolapse
Definition
Cord prolapse is descent of the umbilical cord through the cervix, alongside (occult) or past (overt) the presenting part, with ruptured membranes. Reported incidence is approximately 1 in 500 pregnancies.
Risk Factors
General/antenatal: malpresentation (breech ~1% incidence; transverse/oblique/unstable lie carry higher risk), multiparity, low birthweight (<2.5 kg)/prematurity, polyhydramnios, second twin, unengaged presenting part, low-lying placenta, fetal congenital anomalies. Male fetal sex has also been noted as a predisposing factor.
Procedure-related: artificial rupture of membranes (especially with a high presenting part), vaginal manipulation of the fetus with ruptured membranes, external cephalic version, fetal scalp electrode/intrauterine pressure catheter placement, cervical ripening balloon insertion, amnioinfusion, and stabilising induction of labour.
Prevention
Artificial rupture of membranes with a high presenting part should only be performed with arrangements for immediate delivery in place should prolapse occur. Upward pressure on the presenting part during vaginal examinations and interventions after membrane rupture should be minimised, as it risks displacing the presenting part and precipitating prolapse.
Immediate Emergency Management
- Call for help — obstetric emergency call; alert obstetric, anaesthetic, neonatal, and midwifery teams.
- Minimise handling of the cord (risk of vasospasm); if prolapsed beyond the introitus, keep it warm and moist within the vagina rather than actively pushing it back.
- Relieve cord compression by manual elevation of the presenting part — a hand in the vagina sustains upward pressure continuously until delivery.
- Positioning: knee–chest (all-fours) position, or exaggerated Sims (left lateral) with head-down tilt/pillow under the hip, to use gravity to reduce cord pressure.
- Bladder filling with ~500–750 mL warm saline via Foley catheter is an alternative/adjunct, particularly during transfer; empty the bladder again immediately before caesarean section.
- Tocolysis (e.g. terbutaline) may be used to reduce contractions while preparing for delivery.
- Maintain continuous fetal heart rate monitoring and sustained manual elevation throughout transfer to theatre until the baby is delivered.
Mode and Urgency of Delivery
Cord prolapse is an obstetric emergency. Unless vaginal birth is imminent and achievable quickly and safely, delivery should be by category 1 caesarean section, targeting a decision-to-delivery interval of 30 minutes (sooner where feasible). If the cervix is fully dilated with a low presenting part, instrumental vaginal delivery (ventouse or forceps) may be faster than caesarean section and is appropriate.
Outcomes
Perinatal mortality has historically been reported as high (one large study cited 91 per 1000) but has fallen substantially with prompt recognition and expedited hospital delivery. Prematurity and congenital malformation account for a disproportionate share of adverse outcomes. Outcomes are worse with delayed access to delivery, including planned home births, where delay in transfer to hospital is an important contributing factor to perinatal death.
High-Yield Exam Points
- Cord prolapse = descent of cord through the cervix (alongside = occult, past = overt) with ruptured membranes.
- Key risk factors: malpresentation (breech, transverse/oblique lie), multiparity, prematurity/low birthweight, polyhydramnios, second twin, and ARM with a high presenting part.
- First-line compression relief: manual elevation of the presenting part (do not push the cord back in); knee–chest or exaggerated Sims position; bladder filling with warm saline as an adjunct, especially during transfer.
- Minimal handling of the exposed cord — risk of vasospasm; keep it warm/moist if outside the vagina.
- Category 1 caesarean section is the default mode of delivery unless the cervix is fully dilated and instrumental vaginal delivery would be faster.
- Tocolysis (terbutaline) is a recognised adjunct to reduce contractions while preparing for delivery.
- Perinatal mortality has fallen with prompt hospital management, but remains higher where transfer/delivery is delayed (e.g. planned home birth).
Source: RCOG Green-top Guideline No. 50 (2nd edition published November 2014; reviewed December 2024 and current validity extended by 2 years (no substantive content revision confirmed at time of writing — verify against the live RCOG page before citing as current).)
Read the original on rcog.org.uk
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