Prolapsed Umbilical Cord

!!! OBSTETRIC EMERGENCY!!!

When the membranes have ruptured, the umblilical cord is present below the fetal presentation. 

Pathophysiology

The result of cord prolapse is essentially fetal hypoxia. This occurs in 2 ways: 

• Compression (umbilical vein occlusion)– blood flow is occluded to the uterus as a result of the presenting part of the fetus pressing on the cord

• Arterial vasospasm – due to exposure of the umbilical cord to the cold atmosphere - reduced blood flow to foetus 

!! Prolonged or total compression results in death of fetus !!

Risk Factors

• Artificial rupture of membranes (amniotomy)

• Malpresentation eg. footling breech 

• Unstable lie - consider admission >37 weeks due to high risk of prolapse 

• Prematurity 

• Small for gestational age 

Presentation

• CTG: non reassuring HR pattern - variable decelerations/bradycardia during contractions (due to cord compression)

• Visualisation of cord 

• Digital palpation of cord 

• Visualisation on ultrasound 

Management

• If the cord is palpable above the level of the introitus but not visible, the presenting part of the fetus should be pushed back into the uterus to avoid compression of the cord 

• Avoid handling the cord itself as may increase risk of vasospasm 

• Relieve pressure off cord by either:

  • • Maternal knee chest positioning with raised buttocks

    • Left lateral position with pillow placed under left hip and head down 

    • Filling bladder (via catheter) with (preferably warmed) saline 

• Caesarean recommended when fetal heart beat is present and cervix is not fully dilated (Exception: primigravida women recommended a caesarean regardless of stage). 

  • • Consider tocolysis (eg. terbutaline) in order to stop contractions and take pressure off the cord whilst transferring to theatre 

• Vaginal delivery continued if cervix fully dilated in multigravida women and fetus is descending (always keep theatre ready for caesarean incase there is any failure to progress)