Umbilical Cord Prolapse - Obgyn Key

1/1/22, 3:39 PM Chapter 10 – Umbilical Cord Prolapse | Obgyn Key
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Chapter 10 – Umbilical Cord Prolapse
Abstract
Incidence Varies from 0.1% to 0.6% (1–6 per 1000) [2]. Cord presentation occurs if the cord is below the presenting part but membranes are intact (Figure
10.3).
Chapter 10 Umbilical Cord Prolapse

Malik Goonewardene
Key Facts
Definition Descent of the umbilical cord through the cervix, in the presence of ruptured membranes [1].
Types Overt: If the cord is below the presenting part and in the vagina or outside vulval introitus (Figure 10.1). Occult: If the cord is lying alongside the
presenting part (Figure 10.2).
Figure 10.1 Overt cord prolapse.
https://obgynkey.com/chapter-10-umbilical-cord-prolapse/ 1/16
Figure 10.2 Occult cord prolapse. Arrow on right points to loop of umbilical cord protruding lying alongside the fetal head that may be easily missed on vaginal
examination and hence, it is called ‘occult’ cord prolapse. Arrow on left (centre) shows fetal head (presenting part) lying alongside the umbilical cord.
Incidence Varies from 0.1% to 0.6% (1–6 per 1000) [2]. Cord presentation occurs if the cord is below the presenting part but membranes are intact (Figure
10.3).
Figure 10.3 Cord presentation.
Key Implications
Cord prolapse is an obstetric emergency with a high risk of perinatal mortality (ca. 6%) [1, 2].
Perinatal hypoxia, resulting from prolonged compression and mechanical occlusion of the prolapsed cord (e.g. by the fetal head which is presenting) or by
vasospasm due to the relatively cooler temperatures in the vagina and especially outside the vulval introitus, is the leading cause of perinatal death [3, 4].
Babies who survive may have cerebral palsy resulting from hypoxic ischaemic encephalopathy [5].
Cord prolapse occurring at home is associated with a higher risk of perinatal deaths [5].
Key Pointers
Presenting part of the fetus not fitting into the maternal pelvic inlet (e.g. small preterm baby or twin; especially the second twin, transverse lie, malpresentation
such as footling or flexed breech, and polyhydramnios).
Grande multiparity, maternal pelvic abnormalities, relatively long cord or low placental implantations and male fetuses [1–3].
Obstetric interventions such as amniotomy, stabilising induction, insertion of a supracervical balloon catheter for induction of labour, placement of internal
monitoring devices, external cephalic version (ECV) and internal podalic version [6].
Intrapartum spontaneous rupture of membranes with advanced cervical dilation and high presenting part of fetus.
Key Diagnostic Signs

Prediction
Routine abdominal real-time colour Doppler ultrasound scan examination has not been shown to be effective in antenatal diagnosis of cord presentation and
predicting the possibility of cord prolapse [7].
Selective transvaginal scanning in women with high-risk factors such as a transverse lie, malpresentation (e.g. footling or flexed breech) or high presenting part
of fetus, may be useful [8].
Prevention
Women with a transverse or oblique lie or breech presentation should be offered an ECV at 37 weeks’ gestation.
Women with persistent breech presentation or transverse, oblique or unstable lie should be offered admission to hospital at 38 weeks’ gestation. If this advice is
declined, women should be advised immediate admission with any signs of labour or prelabour (prolonged) rupture of membranes (PROM) [2, 3].
During labour the presence of the cord should be looked for, at each vaginal examination.
Amniotomy is contraindicated if the cord is palpable below or by the side of the presenting part during vaginal examination. Upward pressure and dislodging the
head from the pelvis should be avoided during amniotomy, and amniotomy should be avoided if the presenting part of the fetus is high and mobile [2, 3].
Women with unstable lies should be offered ripening of the cervix and stabilising induction of labour after 39 weeks’ gestation unless the cervix is favourable for
induction by amniotomy and oxytocin infusion at that gestation. This involves external cephalic version (ECV) followed by an intravenous oxytocin infusion to
stimulate uterine contractions that would stabilise the fetal head against the pelvic inlet, and then a careful controlled amniotomy after excluding a palpable cord.
The same procedure could be adopted in cases of mild to moderate hydramnios. An assistant should steady the fetal head against the pelvic inlet during and
after amniotomy. The amniotomy should be by minimal puncture and the fingers should be kept inside the vagina to carefully control the volume of liquor
draining out. This will prevent the liquor gushing out and the fetal head floating away from the inlet, predisposing to cord prolapse.
Diagnosis
The possibility of cord prolapse should always be kept in mind in a woman with a risk factor for cord prolapse because signs of fetal distress may not occur
immediately after cord prolapse.
Women with PROM should be offered a speculum examination irrespective of the period of gestation. A digital vaginal examination is best avoided if there is no
cardiotocograph (CTG) abnormality or risk factors for cord prolapse [2].
A digital vaginal examination is indicated in the presence of PROM or preterm PROM (PPROM) with CTG abnormalities such as variable decelerations,
prolonged decelerations and bradycardia and a suspicion of cord prolapse [3].
The cord may be visible outside the vulva or at the introitus or may be seen on speculum examination or felt on vaginal examination.
Key Actions
Initial Management
Additional help (obstetric colleagues, nurses and midwives) should be called for immediately, and the anaesthesiologist and neonatologist (and the feto-
maternal specialist if the gestational period is 24–28 weeks) informed.
The aim is to prevent or minimise fetal hypoxia, resulting from mechanical compression or vasospasm of the prolapsed cord, until the delivery is achieved.
Establish whether the fetus is alive by palpating for cord pulsations or using the fetal (Pinard’s) stethoscope or hand-held Doppler fetal heart detector or CTG
and ultrasound scan (USS), depending on the facilities available. If USS facilities are available, visualisation of the fetal heartbeat is a possibility even if the fetal
heart sounds cannot be detected [9]. If the fetus is dead, delivery is not urgent and the safest mode of delivery for the mother should be adopted. If the fetus is
alive the measures described in the text that follows should be adopted.
The mother should be placed in a head low (Trendelenburg) position (Figure 10.4) or in the ‘knee–chest’ position (Figure 10.5).
Figure 10.4 Head low position.
Figure 10.5 Knee–chest position.
The mother should be counselled regarding the problem and the plan of action, and verbal consent obtained for further management including caesarean
delivery [2, 3].
If the cervix is not fully dilated and an assisted or operative vaginal delivery is not feasible within the next 15 minutes or so, the following steps are indicated [2,
3, 10–12].
The fetal presenting part should be manually displaced away from the pelvic inlet to prevent the cord being compressed between the pelvic wall and the
presenting part of the fetus. This could be achieved digitally through the vagina (especially if the cord prolapse occurs during vaginal examination or amniotomy)
and maintained abdominally by an assistant thereafter (Figures 10.6 and 10.7).
Figure 10.6 Displacement of the presenting part away from the pelvic inlet.
Figure 10.7 Maintaining displacement of the presenting part away from the pelvic inlet.
The cord should be gently cradled in the hand and replaced within the vagina (Figure 10.8), and a gauze towel, vaginal pack or tampon soaked in warm saline
should be inserted into the vagina below the cord, if it tends to come out of the introitus.
Figure 10.8 Replacement of cord within the vagina.
Using a Foley catheter and an IV infusion set the bladder should be filled with 500–750 mL of normal saline, until it is visibly distended above the pubic
symphysis, and then the catheter should be clamped (Figure 10.9). The full bladder will relieve the pressure on the cord by moving the presenting part away
and may also inhibit uterine contractions.
Figure 10.9 Filling the bladder.
An assistant should insert a 14 or 16 G intravenous cannula if it is not already in place, obtain blood for group and save and full blood count (FBC), and
commence a Ringer’s lactate or normal saline infusion.
If the woman is on an intravenous oxytocin infusion it should be stopped.
Oxygen should be given by face mask, 8 L/minute.
Tocolytics (terbutaline 0.25 mg subcutaneously) may be of value in cases with fetal bradycardia or pathological decelerations.
Measures to relieve compression of the cord should be continued during transfer of the woman to the operating theatre but they should not unduly delay the
transfer.
If the cord prolapse occurs at home:
The woman should adopt the knee–chest position (Figure 10.5) until an ambulance arrives.
Medical assistants need to ensure that the presenting part is displaced away from the pelvic inlet, replace cord within the vagina and fill the bladder (Figures
10.6–10.9).
The woman should be in a head low, left lateral position with pillow under pelvis during transfer (Figure 10.10).
Figure 10.10 Head low left lateral position for transfer to hospital.
Definitive Management
Reconfirmation that the fetus is alive [1, 2].
If suitable for an assisted breech delivery, breech extraction, vacuum or forceps delivery, it should be carried out urgently [2].
Emergency caesarean delivery would be indicated in most instances if the fetus is alive, as cord prolapse frequently occurs prior to full dilation of the cervix [10–
12].
It has been suggested that a calm approach should be taken and intrauterine resuscitation with 100% oxygen, elevation of presenting part and maternal
positioning with head low, left lateral position to enable spinal analgesia, is a suitable procedure and that the ‘emergency’ situation could be converted to an
‘urgent’ situation [13]. This could be the case if there is no acute, severe ‘fetal distress’.
The bladder should be emptied by removing the clamp on the Foley catheter, prior to opening into the peritoneal cavity at caesarean delivery, ideally carried out
within 30 minutes of diagnosis to improve perinatal outcome [2, 3]. Although diagnosis to delivery intervals (DDIs) of more than 60 minutes may be associated
with adverse perinatal outcomes, it has been shown that the perinatal outcomes are poorly correlated with the cord pH of the neonates in women who are
delivered within 30 minutes, even in well-resourced settings [2, 12]. This suggests that in addition to decreasing the DDI, in utero resuscitation may be needed
to reduce the effects of cord compression and improve the perinatal outcome.
Facilities for immediate resuscitation and intensive care should be ready prior to delivery. However, differed cord clamping can be considered if the neonate is
not asphyxiated at birth. Paired umbilical arterial and venous cord blood samples should be obtained immediately after birth for blood gas assessments [2, 3].
Conservative Management: In Cases of Extreme Prematurity
This may be considered with parental consent if the fetus is alive, has no gross fetal anomalies and PPROM with cord prolapse has occurred at the limits of
gestational viability (ca. 24–26 weeks) [2, 3]. Decision depends on neonatal facilities available in the centre. An in-depth discussion involving the obstetrician,
feto-maternal specialist, neonatologist, the woman and her partner is needed regarding chances of unexpected fetal demise, chances of survival if delivered
earlier rather than later and the risks of long-term morbidity due to extreme prematurity.
The cord should be gently cradled in the hand and replaced in the vagina, and the woman placed in the Trendelenburg position and managed as described in
the section on initial management.
In utero transfer to a centre with better neonatal facilities (the concern of cord spasm and fetal demise during the transfer should be explained) is recommended
for all preterm breech presentations admitted in labour. If the woman is in advanced labour, then it is best to deliver, and then arrange an urgent ex utero
transfer to a centre with appropriate neonatal facilities.
A gauze towel or tampon soaked in warm saline should be inserted into the vagina if the cord tends to come out of the vulval introitus (especially during bowel
motions with prolonged conservative management), to keep the cord warm and moist within the vagina and to prevent it going into spasm. The gauze/tampon
needs to be removed just prior to delivery.
Antibiotics, tocolytics and corticosteroids can be administered as per PPROM management if it is decided to have prolonged conservative management [14].
In cases in which a prolonged conservative approach is adopted because of extreme prematurity, maternal wellbeing should have precedence over the fatal
outcome. The mother and fetus need very close monitoring and labour should be induced in cases of fetal demise. A caesarean delivery will be needed if
chorioamnionitis is suspected, fetal distress is detected or spontaneous labour is established.
Post Delivery
Parents, especially the mother, may be greatly affected psychologically.
Adequate debriefing and counselling of parents are needed.
Cord prolapse needs to be documented, reported and discussed at the next risk-management meeting.
Suggested Management of Cord Prolapse in Low-Resource Settings

In Nigerian women with cord prolapse, perinatal mortality rates of up to 68% have been reported, and up to 76% of the associated fetal deaths have been
reported to occur prior to admission to hospital. Inadequate prenatal care was reported to be a high-risk factor for the occurrence of cord prolapse in these
women [15].
The following actions are suggested for the management of cord prolapse in low-resource settings.
Health education in the community and motivation of pregnant women to attend prenatal clinics
Education of all prenatal caregivers regarding the key risk factors for cord prolapse
Education of all maternity caregivers regarding the possible measures that could be taken to prevent cord prolapse
Education of women and any available caregivers in the community that women with PPROM, PROM or in labour should ideally lie flat, in left lateral position
with a pillow under their hips (Figure 10.10) and be transported to hospital as soon as possible
On arrival in hospital, establishing the viability of the fetus and adapting the management algorithm in Figure 10.11 according to the resources available, and
carrying out the most appropriate actions
Training all the staff involved in maternity care in the management of cord prolapse and conducting refresher training courses annually.
Figure 10.11 Algorithm for the management of umbilical cord prolapse.
Key Pitfalls
Failure to appreciate that fetal distress does not always occur immediately after cord prolapse.
Failure to appreciate that the fetus may still be alive although the fetal heart sounds are not detectable.
Failure to carry out a speculum examination in PROM and PPROM.
Carrying out amniotomy with a high head or when the fetal head is not fitting the pelvic inlet or dislodging the head upwards during amniotomy.
Failure to exclude cord presentation or occult cord prolapse during early intrapartum vaginal examination.
Failure to relieve compressions and vasospasm of cord prior to emergency delivery. Multidisciplinary training has been shown to improve overall
management and reduction of decision to delivery interval (DDI)[16].
Key Pearls
Cord prolapse is a life-threatening situation for the fetus.
Immediately call for help and also request that the anaesthesiologist and neonatologist be informed.
Anticipating cord prolapse in women with presenting part away from the pelvic inlet and gently replacing the cord within the vagina are essential primary steps
in the management. Bladder filling maintains displacement of fetal presenting part away from the pelvic inlet and prevents cord compression. Tocolysis may
be useful.
Emergency caesarean delivery is frequently needed but assisted or operative vaginal delivery may be possible if the cervix is fully dilated. Post delivery
debriefing and counselling of parents and risk management discussions are needed.
Immediate displacement of the fetal presenting part is needed.
Regular multiprofessional training programmes on the management of cord prolapse need to be conducted.
Training and Assessment

Courses have been designed to enable simulation training of the multiprofessional obstetric team to manage obstetric emergencies including cord prolapse
[10, 11].
Training has been found to improve clinical knowledge and skills as well as team working and result in better outcomes
A Suggested Training Scenario

A primigravida at 38 weeks’ gestation is admitted to the labour ward in advanced labour. The fetal head is three-fifths palpable abdominally, and the fetal heart
rate is 125 bpm and regular. You proceed with a vaginal examination and find that the cervix is 6 cm dilated and the membranes are bulging. The membranes
spontaneously rupture during your vaginal examination, and the cord prolapses out of the vagina.
The following equipment will be available for the drill:
Delivery bed
Obstetric manikin with perineum, baby with cord
Fetal (Pinard’s) stethoscope
Hand-held Doppler fetal heart detector, CTG machine, US scanner (depends on centre)
Intravenous cannulae without needles, normal saline packs
Blood transfusion set, Foley catheter
Face mask and oxygen source, cushion
Case notes, drug chart
Terbutaline and salbutamol vials, ranitidine and metoclopramide vials, disposable syringes without needles
The trainer will ask the trainee ‘What will you do?’ The expected responses and actions would be:
Call for help.
Relieve compression and prevent vasospasm of cord.
Immediately elevate the fetal head digitally and disimpact it from the pelvic inlet.
While maintaining the above, instruct an assistant to adjust the delivery bed to a head-low position and place the mother in the Trendelenburg position or
place the woman in the knee–chest position.
Instruct an assistant to abdominally ensure that the displacement of the fetal head is maintained.
Cradle the cord gently in the palm and replace it within the vagina.
Insert a Foley catheter and fill the bladder with 500–750 mL of normal saline using an IV infusion set, until the bladder is palpable supra-pubically.
During this time other members of the team should:
Insert a 16 G intravenous cannula and obtain blood for group and save and FBC.
Inform the operating theatre and the anaesthesiologist.
Inform the neonatologist and the neonatal intensive care unit.
Commence oxygen by face mask 8 L/min.
Recheck the fetal condition: palpating for cord pulsations, fetal stethoscope, hand-held Doppler, fetal heart detector, CTG and/or US depending on the
facilities available and confirm that the fetus is alive. Explain to the woman and her partner the problem, the state of the fetus and the proposed plan of action
and obtain verbal consent for a caesarean delivery. Administer terbutaline 0.25 mg subcutaneously.
Administer ranitidine 50 mg and metoclopramide 10 mg intravenously.
Transfer to the operating theatre for emergency caesarean section, maintaining the woman’s head at a lower level than her pelvis.
Chronologically document accurately all the preceding steps.
The training programme should consist of a preliminary lecture based on the key facts, key implications, key pointers, key diagnostic signs, key actions, key
pitfalls and key pearls. This should be followed by the case scenario and drill.
At the end of the drill the participants should be requested to identify what they did well and what they think they should improve on. The trainer should then give
them feedback as to what they did well and what they could improve on. The drill should be repeated after these inputs until the trainer is satisfied that the team
could efficiently manage a cord prolapse. The team too should be confident about their ability to manage a cord prolapse in real life.
An effective training programme will lead to the trainees performing the required clinical tasks in a coordinated manner, communicating with each other well and
working as a team with a clear understanding of individual roles and responsibilities.
Frequent rehearsals will need to be conducted until the multiprofessional team acquires adequate skills. This should be followed by annual refresher training
sessions [2, 3].
Acknowledgements
Doctors Myuru Manawadu and D. V. Priyaranjana of the Department of Obstetrics and Gynaecology, University of Ruhuna, Sri Lanka contributed the figures.
References
1.Lin MG. Umbilical cord prolapse. Obstet Gynaecol Surv. 2006;61(4):269–77.
2.Royal College of Obstetricians and Gynaecologists. Umbilical Cord Prolapse. Green-top Guideline No. 50. London: RCOG, 2014.
3.Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and the Clinical Strategy and Programmes Division, Health Service
Executive. Clinical Practice Guideline Cord Prolapse. Guideline 35. 2015.
4.Gibbons C, O’Herlihy C, Murphy JF. Umbilical cord prolapse: changing patterns and improved outcomes. BJOG. 2014;121:1705–9.
5.Johnson KC, Daviss BA. Outcomes of planned home birth with certified professional midwives: large prospective study in North America. BMJ.
2005;330:1416–22.
6.Dilbaz B, Ozturkoglu E, Dilbaz S, Ozturk N, Akin Sivaslioglu A, Haberal A. Risk factors and perinatal outcomes associated with umbilical cord prolapse. Arch
Gynaecol Obstet. 2006;274:104–7.
7.Ezra Y, Strasberg SR, Farine D. Does cord presentation on ultrasound predict cord prolapse? Gynaecol Obstet Invest. 2003;56:6–9.
8.Kinugasa M, Sato T, Tamura M, Suzuki H, Miyazaki Y, Imanaka M. 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):612–18.
9.Driscoll JA, Sadan O, Van Geideren CJ, Holloway GA. Cord prolapse: can we save more babies? Br J Obstet Gynaecol. 1987;94:594–5.
10.Sowter M, Weaver E, Beaves M, eds. Practical Obstetric Multi-Professional Training (PROMPT) Course Manual. Australian and New Zealand Edition.
Melbourne Australia: PROMPT Maternity Foundation and the Royal College of Obstetricians and Gynaecologists, London, Royal Australian and New Zealand
College of Obstetricians and Gynaecologists; 2014, 117–24.
11.Paterson-Brown S, Howell C, eds. Managing Obstetric Emergencies and Trauma – the MOET Course Manual, 3rd ed. London: Cambridge University Press;
2017, 233–7.
12.Department of Health, Government of South Australia. South Australian Perinatal Practice Guidelines: Cord Presentation and Prolapse, 2014.
13.McKeen D, Geeorge RB, Shukla R. We ‘can do it’ does not mean we ‘should do it’: obesity, umbilical cord prolapse, and spinal anesthesia in the knee-chest
position. Can J Anesthes. 2009;56:168–9.
14.Royal College of Obstetricians and Gynaecologists. Preterm Prelabour Rupture of Membranes. Green-top Guideline No. 44. London: RCOG, 2006.
15.Enakpene CA, Odukogbe AT, Morhason-Bello IO, Omigbodun AO, Arowojulu AO. The influence of health-seeking behavior on the incidence and perinatal
outcome of umbilical cord prolapse in Nigeria. Int J Womens Health. 2010;9(2):177–82.
16.Siassakos D, Hasafa Z, Sibanda T, Fox R, Donald F, Winter C, Draycott T. Retrospective cohort study of diagnosis-delivery interval with umbilical cord
prolapse: the effect of team training. Br J Obstet Gynaecol. 2009;116:1089–96.
You may also need
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Chapter 14 – Instrumental
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Abnormal lie and breech
presentation
Chapter 23 – Breathlessness
in Pregnancy
Chapter 37 – Placenta Accreta

Chapter 9 – Breech Delivery
Spectrum Disorders
(Abnormal Invasion of the
Placenta)
Chapter 8 - Uterine Rupture
Chapter 13 – Twin Delivery
Chapter 20 - Retained
Chapter 32 - General
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Chapter 3 - Management of
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Chapter 28 - Diabetic
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1/1/22, 3:39 PM Chapter 10 – Umbilical Cord Prolapse | Obgyn Key

Chapter 10 – Umbilical Cord Prolapse

Chapter 10 Umbilical Cord Prolapse

Figure 10.1 Overt cord prolapse.

Figure 10.3 Cord presentation.

Key Diagnostic Signs

Figure 10.4 Head low position.

Figure 10.5 Knee–chest position.

Figure 10.8 Replacement of cord within the vagina.

Figure 10.9 Filling the bladder.

If the woman is on an intravenous oxytocin infusion it should be stopped.

Oxygen should be given by face mask, 8 L/minute.

If the cord prolapse occurs at home:

Adequate debriefing and counselling of parents are needed.

Suggested Management of Cord Prolapse in Low-Resource Settings

Figure 10.11 Algorithm for the management of umbilical cord prolapse.

Failure to carry out a speculum examination in PROM and PPROM.

Immediate displacement of the fetal presenting part is needed.

Training and Assessment

A Suggested Training Scenario

The following equipment will be available for the drill:

Obstetric manikin with perineum, baby with cord

Fetal (Pinard’s) stethoscope

Intravenous cannulae without needles, normal saline packs

Blood transfusion set, Foley catheter

Face mask and oxygen source, cushion

Case notes, drug chart

Call for help.

Relieve compression and prevent vasospasm of cord.

During this time other members of the team should:

Inform the operating theatre and the anaesthesiologist.

Inform the neonatologist and the neonatal intensive care unit.

Commence oxygen by face mask 8 L/min.

Administer ranitidine 50 mg and metoclopramide 10 mg intravenously.

Chronologically document accurately all the preceding steps.

You may also need

Chapter 37 – Placenta Accreta

Chapter 13 – Twin Delivery

Chapter 27 - Drug Overdose Ketoacidosis in Pregnancy

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