Umbilical Cord Prolapse

Vern Katz MD
Jacob Meyer MD
Basics
Description
UCP is an obstetric emergency that requires immediate fetal and maternal
assessment and delivery.
Overt: Umbilical cord presents visually between the presenting fetal part and
the cervix following ROM or is in the vagina.

Occult: Umbilical cord can only be palpated but not visualized between the
fetal presenting part and the cervix.

Funic cord presentation: Umbilical cord is between the fetal presenting part
and the cervix before ROM.

Diagnosis
Suspect UCP with the following:
o Persistent fetal bradycardia
o

Moderate to severe variable decelerations on fetal heart monitor

Definitive diagnosis is by palpating cord below fetal presenting part or

visualizing the cord in the vagina during speculum exam.

Alert
Obstetric emergency
Pathophysiology
Cord prolapse leads to either mechanical compression of the cord by the fetal
presenting part or vasospasm from the lower extrauterine temperature. Either
mechanism leads to decreased blood flow to the fetus, subsequent hypoxemia,
eventual hypoxemic encephalopathy, and fetal demise.
Funic presentation can be seen on US with color flow Doppler and thus
diagnosed antepartum. This is mostly seen with malpresentation.
Differential Diagnosis
Vasa previa:
o Palpation of a cord-like structure upon cervical exam could also be
vasa previa.
o

Vaginal bleeding is more common with vasa previa.

Other causes of moderate to severe variable decelerations:

o

Hypoxemia

Cord compression

Nuchal cord

Knot in cord

Other causes of prolonged fetal bradycardia:

Fetal acidosis

Prolonged cord compression

Paracervical block

Epidural or spinal anesthesia

Tetanic uterine contractions

Fetal arrhythmias

Epidemiology
Reported incidence ranges from 0.10.6% of births.
Risk Factors
Malpresentation
Prematurity, especially birth weight <1,500 g

2nd-born twin

Multiparity

Obstetric interventions:

Induction of labor

Amniotomy

External cephalic version

Polyhydramnios

Treatment
Medical Management
Standard of care for management of UCP is delivery without delay. This
means a CD unless VD is imminent. Several temporizing interventions can be
done until delivery to relieve pressure on the cord:
Call for assistance.

Elevate the fetal presenting part:

o

Examiner pushes the presenting part up and out of the pelvis.

Maintained until delivery can be accomplished.

Put bed in Trendelenburg and the mother in a knee-to-chest position.

Bladder filling: Filling the bladder will occupy space in the pelvis and
take pressure off the cord. The bladder is filled with 500700 mL of
normal saline with a Foley catheter while the patient is prepared for
CD. This technique can also be used with a tocolytic to decrease
uterine contractions and assist in reducing pressure on the cord.

Maintain cord at body temperature:

Decreased temperature inside the vagina leads to vasospasm and

decreased delivery of oxygen to the fetus. Therefore, many providers
have advocated keeping the cord warm with either warm gauze or
towels.

Reposition the cord:

o

In 1 series of 5 patients, the cord was positioned away from the fetal
presenting part with successful VD. This is not recommended, as there
is a worry for increased risk of vasospasm of the cord or continued
compression with subsequent decreased oxygenation to the fetus
leading to poor outcomes.

Drugs
Tocolysis in conjunction with bladder filling:
Nifedipine
Magnesium sulfate
Other
Mother may be started on oxygen by nasal canula and placed on her left side
Surgical Management
Emergent delivery via CD or VD is indicated. Surgical approach will depend
on fetal lie and GA.
Prophylactic antibiotics should be given.
Informed Consent
Consent for a CD should be obtained as for any other surgical procedure.
Patient Education
Explain to mother the grave risk to fetus that UCP presents in terms of oxygenation,
and the need for an emergency CD.
Risks, Benefits
The risks to the fetus if CD is not done far outweigh the risks of CD.
Infection:
o

Endometritis risk is higher with emergency CD

All other surgical risks that come with a CD

Alternatives
See Medical Management.
Medical
Elevation of fetal presenting part
Bladder-filling, with tocolysis

Maintain cord at body temperature

Repositioning of cord

Surgical
No surgical alternatives to CD exist.
Followup

Provided there is a good neonatal outcome, no extra follow-up is needed in

addition to normal postpartum care.
With poor neonatal outcomes, it is important to closely follow-up with the
patient and assure she has adequate psychosocial support during her time of
grieving.

Prognosis
Low birth weight and prematurity are associated with worse neonatal
outcomes.
Neonatal mortality in the most recent large series was 10%. This number is
affected by type of prolapse, if it occurs in the hospital, GA, fetal weight,
diagnosis to delivery time, and method of delivery.

A recent community series of 52 patients had a mortality of 2/52; both deaths

were related to extreme prematurity.

FHR: Variable decelerations and persistent bradycardia are associated with

UCP. Those fetuses with reassuring FHR at delivery have a low incidence of
poor outcomes.

CD has been associated with improved outcomes when compared to

unassisted VD.
P.607

Perinatal mortality is undoubtedly worse if UCP is diagnosed outside of the

hospital.
The interval from diagnosis to delivery is ideally as short as possible.

1 series showed that those cases of neonatal asphyxia associated with UCP had
shorter diagnosis to delivery times than those infants with UCP and no
asphyxia. This demonstrates that the diagnosis to delivery time, although
important, is not the only determinant of outcome.

Poorer Apgar scores have been associated with long diagnosis to delivery
times.

1 long-term follow-up study was done of 13 infants whose delivery was

complicated by UCP. 1 infant died from prematurity, and the 12 living infants
had normal neurodevelopment at 2-year follow-up.

Complications
Hypoxemic-ischemic encephalopathy
Neonatal asphyxia and death
Alert
Pediatric Considerations

Another qualified physician must be present in the OR for neonatal resuscitation.

Contact the appropriate personnel as soon as UCP is diagnosed.
Bibliography
Boyle JJ, et al. Umbilical cord prolapse in current obstetric practice. J Reprod Med.
2005;50:303306.
Lin MG. Umbilical cord prolapse. Obstet Gynecol Survey. 2006;61:269277.
Nizard J, et al. Neonatal outcome following prolonged umbilical cord prolapse in
preterm premature rupture of membranes. Br J Obstet Gynaecol. 2005;112:833836.
Qureshi NS, et al. Umbilical cord prolapse. Intern J Gynecol Obstet. 2004;86:2930.
Usta IM, et al. Current obstetrical practice and umbilical cord prolapse. Am J
Perinatol. 1999;16:479484.
Uygur D, et al. Risk factors and infant outcomes associated with umbilical cord
prolapse. Intern J Obstet Gynecol. 2002;78:127130.
Miscellaneous
Synonym(s)
Cord presentation
Prolapsed cord
Abbreviations
CDCesarean delivery
FHRFetal heart rate
GAGestational age
ROMRupture of membranes
UCPUmbilical cord prolapse
VDVaginal delivery
Codes
ICD9-CM
663.0 Prolapse of cord
Patient Teaching
Activity restrictions as normally advised following CD.