Cord Prolapse

Cord Prolapse

The descent of the umbilical cord through the cervix, either alongside (occult) or past (overt) the presenting part, in the presence of ruptured membranes.

Cord Presentation

The presence of the umbilical cord between the fetal presenting part and the maternal cervix, with or without intact membranes.

Incidence of cord prolapse

Ranges from 0.1% to 0.6% of all births. In breech presentations 1%

Cord prolapse most commonly occurs after rupture of membranes and the fetal presenting part is poorly applied to the maternal cervix. The umbilical cord slips below the presenting part and may subsequently be compressed, compromising the fetal blood supply. 

There are certian risk factors, however the occurance of cord prolapse remains extremely unpredictable. 

A common feature of all the risk factors is a poorly applied fetal presenting part.

Induction of labour with prostaglandins is not associated with a higher risk of cord prolapse.

• Breech presentation
• Multiparity
• Fetal congenital abnormalalities 
• Unstable lie
• Oblique or transverse
• Polyhydramnious
• External cephalic version (ECV)
• Low birth weight (less that 2500g)

• ARM
• Unengaged presenting part
• Prematurity
• Breech presentation
• Internal Podalic Version (fetus turned, feet present)
• Second twin
• Disimpaction of fetal head during rotational operative vagial birth or other manipulation of the fetal head
• Fetal scalp electrode application
• Stabilising induction of labour
• Large balloon catheter induction of labour

RCOG recommends that women with non-cephalic presentations and preterm pre-labour rupture of membranes (PPROM) should be offered admission to hospital after 37 weeks (or sooner if there are signs of labour or suspician of rutured membranes) before elective caesarean at term. This will not prevent cord prolapse but if it does occur while the woman is in hospital, then immediate diagnoisis and treatment is possible. 

If umbilical cord is palpated below the presenting part, ARM should be avoided.

Any obstetric intervention once membranes have been ruptured, carries a risk of cord prolapse.

ARM should be avoided when possible, if the presenting part is not engaged and/or mobile. If ARM is abssolutely necessary, it should be performed with facilities to perform an immediate emergency c-section if required. Fundal pressure and/or stabilisation of longitudinal lie may reduce the risk of a cord prolapse in the situation.

Maternal mortality rate fallen over past century.

Perinatal mortality rate remains high (91 per 1000) and cases of cord prolapse consistently feature in perinatal mortality enquiries.

The interval between diagnosis and birth is a contributing factor to stillbirth and perinatal death. 

Cord prolapse outside of the hospital carries a significantly worse prognosis, with the risk of perinatal death increased 10-fold. Delays associated with transfer to hospital have been identified as an important factor.

Infants may suffer birth asphyxia (deprevation of oxygen) due to cord compression and/or arterial vasospasm of the umbilical cord. Birth asphyxia may result in hypoxic-ischaemic encephalopathy (HIE), cerebral palsy or neonatal death. 

However perinatal death after umbilical cord prolapse has been shown to relate more to complications of prematurity and low birth weight (the pre-disposing cause) rather than to intrapartum asphyxia. 

• Early diagnosis important. May be obvious when a loop of umbilical cord is protruding through the *****. However not always apparent and may only be found on VE.
• Cord prolapse should be excluded at every VE. Asculate the fetal heart rate if not on CTG, after every VE and after SROM or ARM.
• Cord prolapse should be suspected when there is an abnormal fetal heart rate pattern (e.g. bradycardia, decelerations) in the presence of ruptured membranes
• Speculum and/or a digital vaginal examination should be performed when cord prolapse id suspected, regardless of gestation

• As soon as cord prolapse is diagnosed, call for help
• Senior midife, additional midwifery staff, experienced obstetrian, anaesthetist, theatre team and neonatal team
• If outside of hosiptal- emergency ambulance called immediately to transfer woman. Even if birth appears imminent, in case of neonatal compromise
• When help arrives, state problem CORD PROLAPSE 
• If not in hospitalm should inform obstetric unit so they can prepare for arrival

As soon as cord prolapse has been recognised, cord compression should be minimised by elevating the presenting part. This can be achieved by:

• Maternal positioning
• Digital elevation of the presenting part
• Bladder filling 
• Tocolysis may also be used to reduce uterine contractions

• Knee-chest face-down position
• If in ambulance or on trolley: exaggerated sims position (left lateral with a pillow underneath the left hip) with or without Trendelenburg (tilted bed so that the womans head is lower than her pelvis).

• If cord prolapse is recognised at the time of rupture of membranes, the clinician's gloved fingers should be kept within the vagina to elevate the presenting part. 
• Reduces compression on the cord, particularly during contractions
• If the umbilical cord has prolapsed out from the vagina, attempt to gently replace it into the vagina using a dry pad and with minimal handling
• Any handling of the cord may cause vasospasm, therefore trying to replace the cord above the presenting part is not recommended

There is no evidence to support the practice of covering the exposed cord with sterile gauze soaked in warm saline. 

• If oxytocin infusion running-stop immediately
• Tocolysis has been used to reduce contractions and improve fetal bradycardia when cord prolapse
• Terbutaline 0.25mg subcutaneously

• If the decision-to-birth interval is likely to be prolonged, particularly if ambulance transfer into hospitalm elevation of the presenting part through bladder filling may be considered.
• Proposed by Vago in 1970.
• Bladder filling raises the presenting part of the fetus off the compressed cord for an extended period of time, therefore eliminating the need for someones fingers to displace presenting part

1. Insert Foley catherter into urinary bladder

2. Fill bladder via the catherter with sterile 0.9% sodium chloride, using an intravenous infusion set. The catheter should be clamped once 500mls has been instilled.

3. Leave bag of fluid attached for transfer to hospital or labour ward (reminds staff to empyty). Important that IV giving set is a good fit with catheter, so no leakage.

4. Essential that bladder empty just before any method of birth is attempted. Done by detaching giving set and allowing fluid from bladder to drain out. If catheter to remain in situ for c-section, then catheter bag can be attached. However if vaginal birth anticipated, catheter should be removed.

Continous electronic fetal monitoring should be performed. 

If the fetal heart is not audible, an ultrasound scan shpuld be perfomed.

Cord prolapse should be managed in a unit with full anaesthetic and neonatl service.

If occurs out of labour ward, immediate transfer is essential 

Theatre staff should be on standby

If no intravenous access, site a wide-bore cannula (14/16-gauge) and take bloods (FBC and group and save)

• If cervix not fully dilated then c-section
• CAT 1- Within 30 minutes or less if cord prolapse is associated with a suspicious or pathological fetal heart rate pattern. (verbal consent satisfactory for cat 1)
• CAT 2- For when the fetal heart is normal, but continous fetal monitoring is still essential. Re-categorise to cat 1 if concerns with CTG.
• If cervix is fully dilated, consider operative vaginal birth as long as it is anticipated that will be accomplished quickly and safely. Ventous or forceps should be considered.
• At birth, delayed cord clamping may be considered as long as baby is not compromised
• For births at the threshold of viability (23+0-24+6), expectant management should be discussed with the parents. Woman should be counselled on both contiuation and termination of pregnancy following cord prolapse in these circumstances
• Breech extraction may be performed until some circumstances for example after internal podalic version of the second twin

Poor fetal outcomes associated with more difficult attempts at achieving vaginal birth. 

An experiences neonatal team must be present at birth to ensure full cardiorespiratory support is given to the neonate, if required.

Post birth: 

Umbilical cord gases should be taken after birth to aid assessemnt of the neonatal condition 

• Time prolapse occurred ]
• Time help was called and arrived 
• Methods used to alleviate cord compression
• Time of the decision to assist the birth
• Method and time of birth

A pro forma may aid documentation

If possible have one of the team allocated to communicate with the parents as they can relay specific instructions if needed and provide a running commentary of events as they happen. This may help mother and partner cope with emergency situation.

An opportunity to discuss events after birth should also be offered to the mother and relatives.