Umbilical Cord Prolapse
RCOG Umbilical Cord Prolapse (Green-top Guideline No. 50). Last reviewed: Nov 2014.
Definition
Umbilical cord prolapse occurs when the umbilical cord descends through the cervix ahead of or alongside the presenting part, after the membranes have ruptured.
- Overt: cord past the presenting part, visible at or beyond the vaginal opening
- Occult: cord lies alongside the presenting part, but not visible externally
A closely related condition is cord presentation, which refers to the presence of the umbilical cord between the fetal presenting part and the cervix, and this can occur with or without intact membranes.
Aetiology
The underlying aetiology is associated with factors that prevent the close application of the fetal presenting part to the lower uterus and/or pelvic brim.
Key risk factors:
| Pregnancy-related |
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| Procedural-related |
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Clinical Manifestation
The mother typically does not experience any specific symptoms or physical sensations to indicate that a cord prolapse has occurred.
Key manifestations:
- Abnormal fetal heart rate patterns – first and most critical indicator
- Onset is often shortly after the membranes rupture
- Specifically, bradycardia or variable fetal heart rate decelerations are strongly associated with cord prolapse
- Palpable or visible umbilical cord
Importantly, cord prolapse may occur without any signs and with a completely normal fetal heart rate pattern.
Complications
Umbilical cord prolapse is a critical obstetric emergency associated with birth asphyxia
- The asphyxia is primarily caused by cord compression and umbilical arterial vasospasm → restricted blood flow between the mother and fetus
- Restricted blood flow can lead to fetal hypoxic acidosis
Investigation and Diagnosis
Umbilical cord prolapse is primarily a clinical diagnosis.
- Definitive diagnosis is made via a speculum and/or digital vaginal examination
- +ve Finding: umbilical cord felt or seen below the fetal presenting part
Following a birth complicated by cord prolapse → perform paired cord blood samples to measure pH and base excess
Given that the manifestations can be subtle or absent, RCOG emphasises that it should be actively excluded at every vaginal examination in labour and after spontaneous rupture of membranes if the patient has any clinical risk factors.
Management
Umbilical cord prolapse is an obstetric emergency.
Immediate Management
Call for help immediately.
While awaiting help and/or delivery, perform the following immediate actions (but they must not result in unnecessary delay of the birth):
| Action | Description / notes |
|---|---|
| Elevate the fetal presenting part | This can be achieved via 2 ways:
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| Adopt protective maternal positioning | Either of the following is recommended:
Aim: to reduce cord compression |
| Minimise handling of the prolapsed cord | Do NOT attempt to manually replace the cord above the presenting part
Aim: to prevent reactive umbilical arterial vasospasm |
| Consider tocolysis (e.g. terbutaline) | Aim: to reduce contractions while preparing for a Caesarean section if there are persistent fetal heart rate abnormalities, particularly if birth will be delayed |
If the patient is in a community / out-of hospital setting → emergency ambulance transfer to the nearest consultant-led maternity unit (unless spontaneous vaginal birth is imminent).
- While waiting for an ambulance, advise the woman to assume the knee-chest face-down position (“all fours”).
- During ambulance transfer, the knee–chest position is considered potentially unsafe in a moving ambulance. Therefore, the exaggerated Sims position (left lateral with a pillow under the hip) should be used during the emergency transfer.
Mode of Delivery
There are 2 main scenarios:
| Scenario | Recommended management |
|---|---|
| Vaginal birth is imminent (e.g. full cervical dilatation) | Vaginal birth can be attempted
Rationale: When vaginal birth is imminent, outcomes are similar to, or even better than, those for a caesarean section |
| Vaginal birth is NOT imminent (e.g. only rupture of membranes, or early labour) | Caesarean section is recommended
Urgency depends on fetal status:
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