Cord Prolapse
Dr Sichone
Definitions
• There are three clinical types
• Cord presentation is the presence of one or more
loops of umbilical cord between the fetal presenting
part and the cervix without ruptured membranes.
• Occult Cord prolapse is descent of the umbilical cord
through the cervix alongside the presenting part in the
presence of ruptured membranes.
• Overt cord prolapse is the descent of the umbilical
cord past the presenting part in the presence of
ruptured membranes
Incidence and significance
• Incidence of cord prolapse ranges between 0.1
to 0.6%
• The significance of cord prolapse is to do with
the increased risk of birth asphyxia and
perinatal mortality as well as increased
operative deliveries
• Asphyxia may result in hypoxic-ischemic
encephalopathy and cerebral palsy
Principles of birth asphyxia
• Cord compression preventing venous return to
the fetus
• Umbilical cord spasms secondary to exposure
to the vaginal fluids and/or air
Risk factors
• Factors that prevents close application of the presenting part to the
lower part of the uterus and/or pelvic brim
– Polyhydramnios
– Unengaged presenting part
– Low lying placenta
– Multiparity
– Breech
– Second twin
– Malpresentation: transverse lie, oblique lie, unstable lie
– Prematurity <37 weeks
– Low birth weight
– Fetal congenital anomalies
– Contracted pelvis
Risk factors
• Cord abnormalities
– True knots
– Long cord
– Reduced content of wharton’s jelly and
• fetal hypoxia-acidosis may alter the turgidity
of the cord
Risk factors
• Manipulation of the fetus in the presence of
ruptured membranes
– External cephalic version
– Internal podalic version
– Stabilising induction of labour
– Applying fetal scalp electrode
– Insertion of uterine pressure transducer
– Artificial rupture of membranes
Diagnosis
• Occult prolapse—is difficult to diagnose. It should be suspected if
there is persistence of variable deceleration of fetal heart rate
pattern detected on CTG
• Cord presentation—The diagnosis is made by feeling the
pulsation of the cord through the intact membranes.
• Cord prolapse—The cord is palpated directly by the fingers and
its pulsation can be felt if the fetus is alive. Cord pulsation may
cease during uterine contraction which, however, returns after
the contraction passes off.
• Fetus may be alive even in the absence of cord pulsation. Prompt
USG for cardiac movements or auscultation for FHS to be done
before fetal death is declared
When should cord prolapse be suspected?
• Cord presentation and cord prolapse may
occur without outward physical signs
1. Cord should be felt for at every vaginal
examination
2. Feel for the cord after spontaneous rupture
of membranes in labour
3. Exclude cord presentation or occult prolapse,
in unexplained fetal distress during labor.
Management
Cord presentation
• The aim is to preserve the membranes and to expedite the
delivery.
• Once the diagnosis is made, no attempt should be made to
replace the cord, as it is not only ineffective but the membranes
inevitably rupture leading to prolapse of the cord.
• If immediate vaginal delivery is not possible or contraindicated,
cesarean section is the best method of delivery.
• During the time of preparing the patient for operative delivery,
she is kept in exaggerated Sims’ position to minimise cord
compression.
Management
Cord prolapse:
• Management protocol considers the following
1. Baby living or dead
2. Maturity of the baby
3. Degree of dilatation of the cervix.
Management of cord prolapse
• Baby dead: Confirm with ultrasound and await
spontaneous vaginal delivery.
• Premature baby: discuss with the parents on
survivor chances and allow them to make an
informed decision
• Fully dilated and head engaged
– Assist delivery with forceps or ventouse if vertex
presentation
– If breech presentation, do breech extraction only if
expert hands available
Management of cord prolapse
• Baby Living and mature immediate vaginal
delivery not possible, Cesarean section is the
best treatment.
• Just prior to making the abdominal incision, the
fetal heart should be auscultated once more to
avoid unnecessary section on a dead baby.
• The operation should be done quickly upto the
delivery of the baby.
Immediate safe vaginal delivery not possible
• If immediate vaginal delivery is not possible
and there is need to transfer patient either to
theatre or the next level where operative
equipment is available, the following measure
must be done to prevent cord compression
and vasospasms
• If an oxytocin infusion is on, this should be
stopped and plain intravenous fluids and
Oxygen by face mask should be given.
1. Bladder filling
• Bladder filling is done to raise the presenting part
off the compressed cord.
• Bladder is filled with 400–750 mL of normal
saline with a Foley’s catheter, the balloon is
inflated and the catheter is clamped.
• Bladder is emptied before cesarean delivery.
• It is more practical if decision to delivery interval
is likely to be prolonged or if it involves
ambulance transfer
2. Elevating the presenting part
• Manually elevating the presenting part off the
cord.
• Its performed by inserting a gloved hand or two
fingers in the vagina and pushing the presenting
part upwards.
• The fingers should be placed inside the vagina till
definitive treatment is instituted.
• Excessive displacement may encourage more
cord to prolapse
3. Postural treatment
• Exaggerated and elevated Sims’ position with
a pillow or wedge under the hip or thigh
• knee-chest position has been traditionally
mentioned but may be tiring and irksome to
the patient
4. Prevent vasospasms
• Minimal handling off the loops of cord outside
the vagina
• Cover with surgical packs soaked in warm
saline
• Can also attempt to replace the cord into the
vagina
