Obstetric Emergencies
Cord prolapse occurs when the umbilical cord slips below or alongside the presenting part of the fetus after rupture of membranes, leading to compression of the cord and interruption of fetal blood flow. If unrecognized or untreated promptly, it can cause acute fetal hypoxia and death within minutes.
Definition
Cord prolapse occurs when the umbilical cord slips below or alongside the presenting part of the fetus after rupture of membranes, leading to compression of the cord and interruption of fetal blood flow.
If unrecognized or untreated promptly, it can cause acute fetal hypoxia and death within minutes.
Types of Cord Prolapse
| Type | Description |
|---|---|
| 1. Overt (Visible) Cord Prolapse | The cord lies below the presenting part and may be seen or felt in the vagina or at the vulva after membrane rupture. (Most dangerous form) |
| 2. Occult Cord Prolapse | The cord lies alongside the presenting part but not visible or palpable; detected only by fetal heart abnormalities. |
| 3. Funic Presentation | Cord lies between the presenting part and membranes, detected before membrane rupture. (Warning sign for possible prolapse) |
Incidence
- Occurs in 0.1–0.6% of all deliveries.
- Fetal mortality can be as high as 15–50%, depending on how fast it is managed.
Pathophysiology
When the umbilical cord becomes compressed between the fetus and the maternal pelvis, blood flow through the cord stops.
This rapidly leads to:
- Acute fetal hypoxia → bradycardia → asphyxia → death if not relieved.
The longer the compression, the worse the fetal outcome.
Hence the rule: ⏱️ "Every minute counts."
Predisposing (Risk) Factors
Maternal
- Multiparity (lax uterus)
- Polyhydramnios
- Premature rupture of membranes
- Multiple pregnancy
Fetal / Placental
- Malpresentations (breech, transverse lie, face presentation)
- Prematurity or low birth weight (small fetus)
- Long umbilical cord
- Placenta previa or high presenting part
Iatrogenic
- Artificial rupture of membranes (ARM) when the presenting part is high
- External cephalic version
- Manual rotation or manipulation during labour
Diagnosis
A. Clinical Suspicion
- Sudden fetal bradycardia or variable decelerations on CTG immediately after membrane rupture.
- Loss of station of presenting part (moves upward).
B. On Examination
- Visible cord at vulva (overt).
- Palpable cord pulsating in the vagina.
- If cord is not pulsating, it indicates fetal compromise or death.
Always check for cord prolapse when there's sudden fetal distress after membrane rupture.
A. Clinical Suspicion
- Sudden fetal bradycardia or variable decelerations on CTG immediately after membrane rupture.
- Loss of station of presenting part (moves upward).
B. On Examination
- Visible cord at vulva (overt).
- Palpable cord pulsating in the vagina.
- If cord is not pulsating, it indicates fetal compromise or death.
Always check for cord prolapse when there's sudden fetal distress after membrane rupture.
Management
Cord prolapse is a true obstetric emergency.
The goal is to relieve pressure on the cord and expedite delivery.
Step 1 – Call for Help
- Alert the obstetric, anesthetic, and neonatal teams immediately.
- Continuous fetal heart rate monitoring if possible.
Step 2 – Relieve Cord Compression
While preparing for delivery, prevent further cord compression by:
A. Maternal Positioning
- Knee–chest position: mother on her knees, chest flat on bed, buttocks elevated.
- Or steep Trendelenburg (head down, hips elevated).
→ Uses gravity to shift the fetus upward, relieving pressure.
B. Manual Elevation of Presenting Part
- Insert a sterile gloved hand into the vagina and lift the presenting part upward off the cord.
- Maintain pressure continuously until delivery or definitive intervention.
- Do NOT push the cord back into the uterus.
C. Bladder Filling Technique
- Insert Foley catheter and instill 500–700 mL warm saline into bladder.
- Clamp catheter → distended bladder elevates the presenting part.
D. Keep Cord Moist
- If cord protrudes externally, cover it with warm sterile saline-soaked gauze to prevent vasospasm.
Step 3 – Expedite Delivery
Delivery must be immediate once fetal distress is confirmed.
| Condition | Recommended Delivery Method |
|---|---|
| Fully dilated cervix + head low | Assisted vaginal delivery (forceps/vacuum) |
| Cervix not fully dilated / presentation high | Emergency Cesarean Section (CS) |
| Fetus dead | Allow vaginal delivery |
Do not attempt ARM or internal maneuvers that worsen compression.
Step 4 – After Delivery
- Resuscitate neonate immediately (may require neonatal team).
- Assess cord blood gases if available.
- Observe mother for PPH or shock.
- Document time of diagnosis, interventions, and delivery interval.
Step 1 – Call for Help
- Alert the obstetric, anesthetic, and neonatal teams immediately.
- Continuous fetal heart rate monitoring if possible.
Step 2 – Relieve Cord Compression
While preparing for delivery, prevent further cord compression by:
A. Maternal Positioning
- Knee–chest position: mother on her knees, chest flat on bed, buttocks elevated.
- Or steep Trendelenburg (head down, hips elevated).
→ Uses gravity to shift the fetus upward, relieving pressure.
B. Manual Elevation of Presenting Part
- Insert a sterile gloved hand into the vagina and lift the presenting part upward off the cord.
- Maintain pressure continuously until delivery or definitive intervention.
- Do NOT push the cord back into the uterus.
C. Bladder Filling Technique
- Insert Foley catheter and instill 500–700 mL warm saline into bladder.
- Clamp catheter → distended bladder elevates the presenting part.
D. Keep Cord Moist
- If cord protrudes externally, cover it with warm sterile saline-soaked gauze to prevent vasospasm.
A. Maternal Positioning
- Knee–chest position: mother on her knees, chest flat on bed, buttocks elevated.
- Or steep Trendelenburg (head down, hips elevated).
→ Uses gravity to shift the fetus upward, relieving pressure.
B. Manual Elevation of Presenting Part
- Insert a sterile gloved hand into the vagina and lift the presenting part upward off the cord.
- Maintain pressure continuously until delivery or definitive intervention.
- Do NOT push the cord back into the uterus.
C. Bladder Filling Technique
- Insert Foley catheter and instill 500–700 mL warm saline into bladder.
- Clamp catheter → distended bladder elevates the presenting part.
D. Keep Cord Moist
- If cord protrudes externally, cover it with warm sterile saline-soaked gauze to prevent vasospasm.
Step 3 – Expedite Delivery
Delivery must be immediate once fetal distress is confirmed.
| Condition | Recommended Delivery Method |
|---|---|
| Fully dilated cervix + head low | Assisted vaginal delivery (forceps/vacuum) |
| Cervix not fully dilated / presentation high | Emergency Cesarean Section (CS) |
| Fetus dead | Allow vaginal delivery |
Do not attempt ARM or internal maneuvers that worsen compression.
Step 4 – After Delivery
- Resuscitate neonate immediately (may require neonatal team).
- Assess cord blood gases if available.
- Observe mother for PPH or shock.
- Document time of diagnosis, interventions, and delivery interval.
Prognosis
- Fetal survival depends on interval from diagnosis to delivery:
- <15 minutes → good prognosis
- 20–25 minutes → high risk of hypoxic injury or death
- With prompt action and cesarean within 10–15 minutes, perinatal mortality <10%.
Prevention
- Avoid ARM if presenting part is high or mobile.
- Confirm fetal head engagement before rupturing membranes.
- Ultrasound screening for cord presentation when risk factors exist.
- Careful monitoring of fetal heart after membrane rupture.
Summary (High-Yield Points)
- Cord prolapse = cord below/alongside presenting part after ROM.
- Types: overt, occult, funic presentation.
- Classic sign: visible/palpable pulsating cord + fetal bradycardia.
- Immediate management:
- Call for help.
- Relieve compression (manual elevation, knee–chest, bladder filling).
- Keep cord moist.
- Deliver urgently — CS if not imminent vaginal birth.
- Never push cord back into uterus.
- Outcome depends on speed of intervention.