3. DEFINITION
The cord is lying inside the vagina or outside the vulva in
front of the presenting part following rupture of the
membrane.
3
4. Incidence
The incidence of cord prolapse is about 1 in 300
deliveries. It occurs mostly in parous women
especially in higher parities.
4
5. Etiology /risk factors-
✘ Mal presentation- transverse or breech
✘ Contracted pelvis
✘ Prematurity
✘ Twins
✘ Hydramnios
✘ Placental factor-minor degree of placenta previa with
marginal insertion of cord for long cord
✘ Iatrogenic-low rupture of membrane, manual rotation of
head
✘ Stabilizing induction 5
6. Classification
There are three types of umbilical prolapse that can occur:
✘ Overt umbilical cord prolapse: Descent of the umbilical cord
past the presenting fetal part. In this case, the cord is through
the cervix and into or beyond the vagina. Overt umbilical cord
prolapse requires rupture of membranes. This is the most
common type of cord prolapse.
✘ Occult umbilical prolapse: Descent of the umbilical cord
alongside the presenting fetal part, but has not advanced past
the presenting fetal part. Occult umbilical prolapse can occur
with both intact or ruptured membranes.
6
7. ✘ Funic (cord) presentation: Presence of the umbilical
cord between the presenting fetal part and fetal
membranes. In this case, the cord has not passed the
opening of the cervix. In funic presentation, the
membranes are not yet ruptured.
7
8. Diagnosis
✘ Cord is palpated directly by the fingers and its pulsation can
be felt if fetus is alive.
✘ It may cease during uterine contraction and return after the
contraction passes off.
✘ An abnormal heart rate particularly bradycardia following
rupture of membranes.
✘ A loop of cord may be visible at the vulva. the cord is more
commonly felt in the vagina or in cases where the
presenting part is very high it may be felt in cervical os.
✘ Ultrasonography
8
9. Immediate care
✘ Call for immediate assistance.
✘ Explain to mother and family the findings and measures that
will be needed.
✘ If an oxytocin infusion is in progress it should be stopped.
✘ Check if the cord is pulsating, if so it should be handled as little
as possible as spasm may occur through handling.
✘ If cord is outside the vagina, it should be replaced gently to
maintain temperature.
✘ Relieve pressure on the cord during contractions by keeping a
finger of the midwife in the vagina and holding the presenting
part of the umbilical cord. 9
10. ✘ Position the mother with the pelvis and buttocks elevated.
✘ Place the women in knee-chest position which causes the
fetus to gravitate towards the diaphragm relieving the
compression on the cord.
✘ Keep the foot of the bed raised until the delivery of the baby
either vaginally or by cesarean section.
10
11. Assisted vaginal
delivery- If the cervix is
fully dilated, or almost
fully dilated in a multi
para assisted vaginal
delivery by forceps or
vacuum extraction is
indicated where the
presentation is vertex.
Management
Replacement of the
umbilical cord and
positioning- If the mother is
not in a hospital or the cervix
is only partially dilated,
replacement of the cord and
elevation of the hips in
lateral position must be
carried out until she is
transferred to a hospital.
11
12. Cesarean section
✘ Immediate cesarean section is the management of choice in
instances where the fetus is alive and delivery is not imminent
or vaginal birth cannot be initiated.
Risks to the fetus
✘ The risk to the fetus are hypoxia and death as a result of cord
compression. The average fetal mortality is 50%.
✘ The risks are greater with prematurity and low birth weight.
✘ The risk is less in multi para than in primary gravida because
of shorter labor in the former.
12
