Cord prolapse

Umbilical cord prolapse occurs in 0.2 – 0.4% of births._¹

Definitions

Cord Prolapse is when the umbilical cord lies in front of or beside the presenting part in the presence of ruptured membranes.

Cord presentation is the presence of the umbilical cord between the presenting part of the fetus and the cervix with the membranes intact.

Occult umbilical cord presentation/ prolapse is when the cord lies trapped beside the presenting part, rather than below it.

In both conditions, a loop of the cord is below the presenting part. The difference is in the condition of the membranes; if intact it is cord presentation and if ruptured it is cord prolapse.

Pathophysiology

Predisposing factors for cord prolapse include:

1. High / ill fitting presenting part
2. High parity
3. Prematurity
4. Multiple pregnancy
5. Polyhydraminos
6. Malpresentations, (i.e breech)
7. Obstetric manipulation.

Clinical Assessment

The diagnosis of cord prolapse is made on:

1. Visual inspection
   Or
2. Palpation: on vaginal examination, the umbilical cord is felt below or beside the presenting part.

Investigations

Ultrasound:

• Identify risk factors
• Diagnose a cord prolapse, when this is not obvious clinically.

CTG:

CTG abnormalities such as bradycardia or severe variable decelerations occurring soon after spontaneous or artificial rupture of membranes may suggestive a cord prolapse.

Management

1. Take note of the time, call for assistance
2. Administer oxygen to the woman via a mask (oxygenation pre caesarean section)
3. There should be an immediate assessment of clinical circumstances including the gestation, presentation, cervical dilatation and fetal wellbeing
4. Place the woman in either:
   • Knee to chest position
   • Exaggerated Sims’ position (left lateral supported with 2 pillows).
   • Deep Trendelenburg position (bed tilted head-down), utilising gravity to elevate the fetus off the cord
5. Prevent cord compression:
   • Replace the cord in the vagina
   • The presenting part should be pushed upward, out of the pelvis by fingers in the vagina to relieve pressure on the cord by the presenting part.
     • Continue until delivery
     • Note if the cord is pulsating, (indicting fetal viability).
     • Avoid excessive handling of the umbilical cord as this may result in vasospasm.
6. Monitor and document the fetal heart rate. 
7. Discontinue oxytocics if these are being given.     
8. Prepare for theatre                                                        
9. If there is to be a significant delay to delivery:
   • Consider tocolysis with terbutaline if there is a significant delay to caesarean section.
   • Consider filling the urinary bladder with fluid to help elevate the presenting part off the compressed cord.

Immediate delivery is necessary when the fetus is viable.

Delivery must be expedited to reduce morbidity and mortality to the fetus.

• Undertake immediate LUSCS if vaginal birth not imminent
• Undertake assisted vaginal birth if conditions are suitable (e.g. fully dilated, MG, presenting part at spines or below).

Disposition

Urgent notification of:

• Obstetrician
• Anaesthetist / theatre
• Paediatrician

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References

FOAMed

Publications

• RWH Clinical Practice Guidelines 16 May 2017
• Carlin A, Alfirevic Z. Intrapartum fetal emergencies. Seminars in Fetal & Neonatal Medicine. 2006;11:150-57.
• Royal College of Obstetricians and Gynaecologists. Umbilical cord prolapse: Green-top guideline No.502014.
• Women’s Hospital Australasia. Clinical Practice Guidelines: Cord prolapse. 2005