Learning objectives

• Define umbilical cord prolapse
• Describe the risk factors for developing umbilical cord prolapse
• Umbilical cord prolapse management

Definition and mechanisms

• 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

• Overt prolapse: Cord exits the cervix before the fetal presenting part
• Occult prolapse: Cord exits the cervix with the fetal presenting part

Complications

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

Risk factors

• Maternal age ≥35 years
• Premature rupture of membranes
• Preterm delivery
• Low birth weight
• Multiple gestation pregnancies
• Placenta praevia
• Polyhydramnios
• Fetal malpresentation (i.e., breech presentation)
• External cephalic version procedure
• Intrauterine growth restriction
• Fetal and cord abnormalities

Diagnosis

• 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

Management

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

See also cesarean section considerations

Suggested reading

• Boushra M, Stone A, Rathbun KM. Umbilical Cord Prolapse. [Updated 2022 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542241/ 
• Sayed Ahmed WA, Hamdy MA. Optimal management of umbilical cord prolapse. Int J Womens Health. 2018;10:459-465. 

Clinical updates

Galvan et al. (2024, BJA Education) emphasize that umbilical cord prolapse remains a time-critical obstetric emergency, with fetal heart rate abnormalities present in up to 60% of cases, requiring simultaneous cord decompression maneuvers and preparation for urgent delivery. The review reinforces that cesarean section is the preferred mode of delivery unless vaginal birth is immediately imminent, and highlights the anesthetist’s key role in early risk stratification, neuraxial readiness, and rapid escalation to general anesthesia to achieve optimal decision-to-delivery intervals.