Umbilical cord prolapse occurs when the umbilical cord delivers before or alongside the fetus. It has an incidence of 0.1-0.6% and can lead to perinatal mortality in 91 per 1000 cases due to asphyxia from cord compression. Risk factors include multiparity, prematurity, and breech presentation. Management involves preventing cord compression through elevating the presenting part, filling the bladder, or tocolysis. Delivery is typically by emergency caesarean section if not imminent vaginally. Vaginal delivery may be attempted if full dilation and can be accomplished quickly. Neonatal outcomes are improved by measures to prevent cord compression and asphyxia.

1. UMBILICAL CORD PROLAPSE
RCOG, 2008
Aboubakr Elnashar
Prof . Obs Gyn, Benha University Hospital
Aboubakr Elnashar

2. Definition
Cord prolapse:
cord through the cervix alongside (occult) or
past the presenting part (overt) in the presence of
ruptured membranes.
Cord presentation:
cord below presenting part with intact membranes
Aboubakr Elnashar

3. Aboubakr Elnashar

4. Incidence
Cord prolapse:
0.1% - 0.6%.
Breech presentation:
1%.
Aboubakr Elnashar

5. Perinatal mortality rate
91/1000.
 Prematurity
congenital malformations
birth asphyxia
Asphyxia:
{cord compression and umbilical arterial vasospasm:
preventing venous and arterial blood flow to and from
the fetus}:
hypoxic–ischaemic encephalopathy and
cerebral palsy.
Aboubakr Elnashar

6. General
•Multiparity
•Low birth weight (<2.5 kg)
•Prematurity (<37 w)
•Fetal congenital anomalies
•Breech presentation
•Transverse, oblique and unstable
lie
•Polyhydramnios
•Low-lying placenta, other
abnormal placentation
•Unengaged presenting part
•Second twin
Procedure related 50%
•ARM
•Vaginal manipulation of
the fetus with ruptured
membranes
•ECV (during procedure)
•Internal podalic version
•Stabilising induction of
labour
•Insertion of uterine
pressure transducer
Risk factors
Aboubakr Elnashar

7. How:
1. Preventing close application of the presenting
part to the lower part of the uterus and/or pelvic
brim.
2. Rupture of membranes
3. Cord abnormalities: true knots or low content of
Wharton’s jelly: may alter the turgidity of the cord
4. Fetal hypoxia–acidosis may alter the turgidity of
the cord
Induction of labour with prostaglandins is not
associated with cord prolapse.
Aboubakr Elnashar

8. Detection of cord presentation antenatally
Routine US:
not sufficiently sensitive or specific:
should not be performed
Aboubakr Elnashar

9. Prevention of cord prolapse or its effects
1. Admission if
a. Transverse, oblique or unstable lie after 37+6 w
Refused: advise to present quickly if there are signs
of labour or suspicion of membrane rupture
{Inpatient care minimises delays in diagnosis and
management of cord prolapse.
Labour or ruptured membranes in the context of an
abnormal lie is an indication for CS} .
b. Noncephalic presentations and preterm
prelabour rupture of the membranes
Aboubakr Elnashar

10. 3. Avoid ARM if
a. presenting part is mobile.
ARM necessary:
performed with arrangements for immediate CS.
Upward pressure on the presenting part should be
kept to a minimum .
b. cord is felt below the presenting part.
4. CS
When cord presentation in established labour
Aboubakr Elnashar

11. Suspicion of cord prolapse
Abnormal FHR pattern
bradycardia, variable decelerations, prolonged
deceleration
particularly after membrane rupture, spontaneously
or with amniotomy.
Aboubakr Elnashar

12. Speculum and/or digital vaginal examination should
be performed
1. At preterm gestations when cord prolapse is
suspected.
2. In labour:
after spontaneous rupture of membranes if
risk factors are present or if
CTG abnormalities commence soon thereafter.
No need:
With spontaneous rupture of membranes in the
presence of a normal FHR patterns and the
absence of risk factors for cord prolapse,
liquor is clear.
Aboubakr Elnashar

13.  Do not handle cord too much.
 Assess: cervical dilatation
 pulsating or not?.
 If non pulsating:
Check fetal heart sounds
US: assess heart activity
Aboubakr Elnashar

14. Initial management of cord prolapse in
hospital
1. Assistance should be immediately called
2. Preparations made for immediate delivery
Manual replacement of the prolapsed cord above
the presenting part to allow continuation of labour is
not recommended.
3. Prevent vasospasm:
minimal handling of loops of cord lying outside the
vagina.
Aboubakr Elnashar

15. 4. Prevent cord compression:
presenting part be elevated either
manually or by
filling the urinary bladder.
knee–chest position or
head-down tilt (preferably in left-lateral position).
5. Tocolysis
while preparing for CS if there are
persistent FHR abnormalities after attempts to
prevent compression mechanically and when the
delivery is likely to be delayed.
Aboubakr Elnashar

16. Aboubakr Elnashar

17. Swabs soaked in warm saline are wrapped
around the cord: unproven benefit.
Manual elevation:
By inserting a gloved hand or two fingers in the
vagina and pushing the presenting part upwards.
A variation is to remove the hand from the vagina
once the presenting part is above the pelvic brim
and apply continuous suprapubic pressure
upwards.
Excessive displacement may encourage more
cord to prolapse.
Aboubakr Elnashar

18. Bladder filling
If the decision-to-delivery interval is likely to be
prolonged, particularly if it involves ambulance
transfer
Moderate Trendelenburg position.
By inserting the end of a blood giving set into a
Foley’s catheter. The catheter should be clamped
once 500–750 ml has been instilled.
Empty the bladder again just before any delivery
attempt, be it vaginal or CS.
Aboubakr Elnashar

19. Tocolysis
{reduce contractions and abolish bradycardia}
Terbutaline: 0.25 mg SC
Aboubakr Elnashar

20. Mode of delivery with cord prolapse
1. CS
when vaginal delivery is not imminent
{prevent hypoxia–acidosis}.
2. Vaginal:
When vaginal birth is imminent {outcomes are
similar or better when compared with CS}.
Aboubakr Elnashar

21. CS:
Category 1:
Delivering within 30 min or less if there is
suspicious or pathological FHR
but without unduly risking maternal safety.
Verbal consent is satisfactory.
Category 2:
FHR is normal.
The outcome for emergency CS is not worse for
deliveries occurring up to 60 min from decision,
provided that the situation is not immediately life-
threatening for the fetus
Aboubakr Elnashar

22. Category 1=Emergency
Immediate threat to the life of a woman or fetus.
Category 2=Urgent
Maternal or fetal compromise but not immediately life
threatening.
Category 3=Scheduled
Needing early delivery but no maternal or fetal
compromise.
Category 4 =Elective
At a time to suit the woman and CS team.
Aboubakr Elnashar

23. Regional anaesthesia
may be considered in consultation with an
experienced anaesthetist. {With modern
techniques, the complications of general
anaesthesia are rare but still higher than for
regional anaesthesia.
The use of temporary measures, as described
above, can reduce cord compression, making
regional anaesthesia the technique of choice.}
Repeated attempts at regional anaesthesia
should be avoided.
Aboubakr Elnashar

24. Vaginal birth
Most cases operative
Very favourable characteristics:
full cervical dilatation
delivery would be accomplished quickly and safely.
Decision-to-delivery interval: 30 min or less.
Continuous CTG during labour
US: of F heart {audible heart tones and cord
pulsation may cease prior to delivery even though
the f remains alive}
Aboubakr Elnashar

25. Breech extraction:
±Performed after internal podalic version for the
second twin.
Forceps or ventouse:
Depend on clinical circumstances and level of skill.
No difference in neonatal outcomes for fetal
distress
Aboubakr Elnashar

26. Neonatal care
Neonatologist should attend
Paired cord blood samples for pH and base
excess measurement
{strong predictive value of a normal paired cord
blood gas for the exclusion of intrapartum related
hypoxic–ischemic brain damage}
Aboubakr Elnashar

27. Management in community settings
1. Waiting for hospital transfer:
knee–chest face-down position
2. During ambulance transfer:
left-lateral position
Elevate presenting part: manual or bladder filling
Prevent vasospasm: minimal handling of loops of
cord lying outside the vagina.
Aboubakr Elnashar

28. Management of cord prolapse before viability
Women should be counselled on both continuation and
termination of pregnancy
Expectant management
Gestational age at the limits of viability.
Uterine cord replacement may be attempted.
Prolongation of pregnancy at such gestational ages
creates a chance of survival but morbidity from prematurity
remains a frequent serious problem.
Delivery:
signs of severe fetal compromise
once viability has been reached or
gestational age associated with a reasonable neonatal
outcome is achieved.
,
Aboubakr Elnashar

29. Training
All staff involved in maternity care should receive at
least annual training in the management of
obstetric emergencies including the management
of cord prolapse.
Updates on the management of obstetric
emergencies (including the interpretation of fetal
heart rate patterns) are a proactive approach to
risk management.
All staff involved in maternity care should attend
annual multidisciplinary rehearsals (skill drills)
including the management of cord prolapse.
Aboubakr Elnashar

30. Clinical incident reporting
Clinical incident forms should be submitted for all
cases of cord prolapse.
Auditable standards
1. Proportion of staff receiving annual training in
cord prolapse.
2. Audit of the management of cord prolapse in
hospital settings.
3. Audit of the management of cord prolapse in
community settings.
4. Diagnosis–delivery interval for spontaneous and
assisted vaginal deliveries and CS in cases of cord
prolapse.
5. Critical analysis of adverse outcomes
(compliance with guidance).
Aboubakr Elnashar

31. Thanks
Aboubakr Elnashar