Umbilical cord prolapse and presentation
The umbilical cord drops (prolapses) through the open cervix
into the vagina ahead of the baby, where it may lie adjacent to
the presenting part (occult cord prolapse) or below the
presenting part (overt cord prolapse).
Cord prolapse – It is associated with rupture of membranes
•In occult prolapse, the umbilical cord cannot be palpated
during pelvic examination, whereas
•Overt cord prolapse is displacement of the umbilical cord
into the vagina, often through the introitus.
Cord or Funic presentation, which is characterized by
prolapse of the umbilical cord below the level of the
presenting part before the rupture of membranes occurs, the
cord often can be easily palpated through the membranes.
Premature delivery of the baby
Multiple gestation (twins, triplets, etc.)
Excessive amniotic fluid (polyhydramnios)
Fetal malpresentation(Breech delivery)
Long umbilical cord:
Premature rupture of the amniotic sac
Consequences- Loss of oxygen to the fetus, brain damage,
ois rarely palpated during pelvic examination.
oThis condition can be inferred only if fetal heart rate changes
- Bradycardia (a heart rate of less than 120 beats per minute).
Overt cord prolapse :
ocan be diagnosed simply by visualizing the cord protruding
from the introitus or by palpating loops of cord in the vaginal
canal by fingers.
ois made by pelvic examination if loops of cord are palpated
through the membranes.
•Patients at risk for umbilical cord prolapse should be treated
as high-risk patients. Patients with mal-presentations or poorly
applied cephalic presentations should be considered for
ultrasonographic examination at the onset of labor to
determine fetal lie and cord position within the uterine cavity.
•Because most prolapses occur during labor as the cervix
dilates, patients at risk for cord prolapse should be
continuously monitored to detect abnormalities of the fetal
•Artificial rupture of membranes should be avoided until the
presenting part is well applied to the cervix.
• At the time of spontaneous membrane rupture, a prompt,
careful pelvic examination should be performed to rule out
• Should amniotomy be required and the presenting part
remains unengaged, careful needling of the membranes and
slow release of the amniotic fluid can be performed until the
presenting part settles against the cervix.
Overt Cord Prolapse
•The diagnosis of overt cord prolapse demands immediate
action to preserve the life of the fetus.
•An immediate pelvic examination should be performed to
determine cervical effacement and dilatation, station of the
presenting part, and strength and frequency of pulsations
within the cord vessels
•If the fetus is viable, the patient should be placed in the knee–
chest position, and the examiner should apply continuous
upward pressure against the presenting part to lift and
maintain the fetus away from the prolapsed cord until
preparations for cesarean delivery are complete.
• Alternatively, 400–700 mL of saline can be instilled into
the bladder in order to elevate the presenting part.
• Oxygen should be given to the mother until the
anesthesiologist is prepared to administer a rapid-acting
inhalation anesthetic for delivery.
• If heart rate changes, should not delay preparation for
cesarean delivery and a pediatric team should be on
standby in the event immediate resuscitation of the
newborn is necessary.
Occult Cord Prolapse
•If occult cord prolapse is suspected, the patient should be
placed in the lateral Sims or trendelenburg position in an
attempt to alleviate cord compression.
•If the fetal heart rate returns to normal, labor can be allowed
to continue, provided no further fetal insult occurs.
•Oxygen should be administered to the mother, and the fetal
heart rate should be continuously monitored electronically.
•If the cord compression pattern persists or recurs to the point
of fetal jeopardy (moderate to severe variable decelerations or
bradycardia), a rapid cesarean section should be accomplished
•The patient at term with funic presentation should be
delivered by cesarean section prior to membrane rupture.
•However, there is no consensus on management if the fetus is
•The most conservative approach is to hospitalize the patient
on bed rest in the Sims or Trendelenburg position in an
attempt to reposition the cord within the uterine cavity.
•Serial ultrasonographic examinations should be performed to
ascertain cord position, presentation, and gestational age.
Route of Delivery
•Vaginal delivery can be successfully accomplished in cases of
overt or occult cord prolapse if, at the time of prolapse, the
cervix is fully dilated, cephalopelvic disproportion is not
anticipated, and an experienced physician determines that
delivery is imminent.
•Cesarean delivery is the preferred route of delivery in most
cases. Vaginal delivery is the route of choice for the previable
or dead fetus.
• Maternal complications include those related to anesthesia,
blood loss, and infection following cesarean section or
operative vaginal delivery. Maternal recovery is generally
• If the diagnosis is made early and the duration of complete
cord occlusion is less than 5 minutes, the prognosis is good.
• If complete cord occlusion has occurred for longer than 5
minutes or if intermittent partial cord occlusion has
occurred over a prolonged period of time, fetal damage or
death may occur. 15