Umbilical cord prolapse

Learning objectives

Umbilical cord prolapse is an obstetric emergency in which the umbilical cord descends through the cervix alongside (occult) or past (overt) the fetal presenting part
It can occur before or during the delivery of the baby, usually close to the end of pregnancy (after 37 weeks)
Compression of, or vasospasm of, the umbilical cord impairs the blood flow between the placenta and fetus, leading to fetal hypoxia and bradycardia
Fetal hypoxia may result in fetal death or permanent disability if not rapidly diagnosed and managed
Early recognition and intervention are important to reduce the adverse outcomes in the fetus

Classification

Surviving infants may develop complications secondary to asphyxia (i.e., neonatal encephalopathy and cerebral palsy)
Stillbirth

Fetal bradycardia (<120 bpm) in the setting of ruptured membranes should prompt immediate evaluation for potential cord prolapse
Umbilical cord prolapse is diagnosed by seeing or palpating the prolapsed cord on pelvic examination

Overt prolapse	Occult prolapse
Diagnosis is clinical and made by palpation of a pulsating structure in the vaginal vault or visibly protruding from the vaginal introitus Typically accompanied by fetal bradycardia or severe variable decelerations	Only fetal bradycardia may appear The cord is not visible or palpable ahead of the fetal presenting part

Goal: Avoid cord compression and vasospasm

Call for help
Establish an intravenous line (if not already placed)
Ensure continuous fetal monitoring
Administer oxygen via a face mask (if needed)
Administer aspiration prophylaxis
Umbilical cord prolapse is an acute obstetric emergency requiring immediate delivery of the baby, usually via cesarean section
- Allow instrumental/vaginal delivery if considered quicker
- Inform the anesthesiologist, pediatrician, and OR staff
- Patient consent
Funic decompression: Elevating the fetal presenting part to aid cord decompression
- Two fingers/hand in the vagina – manual elevation of the presenting part
- Steep Trendelenburg or knee-chest position, lying on the left side is preferred
- Bladder filling with a Foley catheter (≥500 mL of normal saline)
Funic reduction (rarely used): Replacement of the umbilical cord into the uterus
Tocolysis in case of fetal distress or if prolonged interval to delivery is expected
Keep the cord warm and moist if it is protruding from the vagina and delivery is not imminent
Avoid aortocaval compression
Minimize handling of the cord outside of the vagina to prevent vasospasm