From the Guidelines
Umbilical cord prolapse is a serious obstetric emergency that requires immediate recognition and intervention, and prompt diagnosis and delivery are crucial to prevent fetal compromise and improve outcomes. It occurs in two forms: overt prolapse, where the cord descends ahead of the fetal presenting part into the cervical canal or beyond, and nonovert (occult) prolapse, where the cord lies alongside the presenting part. Both types can lead to cord compression, compromising fetal oxygenation through complete occlusion, partial occlusion, or vasospasm of the umbilical vessels. Risk reduction strategies should focus on identifying high-risk patients, including those with non-cephalic presentations (transverse or oblique lie), unstable lie, or other risk factors, as highlighted by Wong et al. 1. These patients should be advised to seek immediate medical attention when labor begins or membranes rupture. For patients with risk factors, vaginal examination should be performed after spontaneous membrane rupture to exclude cord prolapse, especially if fetal heart rate decelerations are noted. Recent studies have shown improved outcomes with prompt recognition and management, highlighting the importance of awareness and preparedness among healthcare providers, as noted by Gibbons et al. [@3@]. Some key points to consider in the management of umbilical cord prolapse include:
- Identifying high-risk patients and advising them to seek immediate medical attention when labor begins or membranes rupture
- Performing vaginal examination after spontaneous membrane rupture to exclude cord prolapse, especially if fetal heart rate decelerations are noted
- Prompt diagnosis and delivery to prevent fetal compromise and improve outcomes
- Manual elevation of the presenting part to reduce cord compression until delivery can be accomplished, as part of the management of cord prolapse. The importance of prompt recognition and management of umbilical cord prolapse is further emphasized by the potential consequences of delayed intervention, including perinatal morbidity and mortality, as discussed by Behbehani et al. [@4@]. Maintaining vigilance and awareness of the risk factors and clinical presentation of cord prolapse is crucial to providing optimal care for high-risk patients.
From the Research
Umbilical Cord Prolapse
Umbilical cord prolapse is a rare but life-threatening obstetric emergency that can have significant neonatal morbidity and/or mortality 2. The condition occurs when the umbilical cord slips ahead of the fetal presenting part and prolapses into the cervical canal, vagina, or beyond, or when it slips alongside but not ahead of the presenting part 3.
Risk Factors
Several risk factors have been identified for umbilical cord prolapse, including:
- Fetal malpresentation or abnormal lie
- Prematurity
- Multifetal gestation
- Polyhydramnios 3, 4
- Iatrogenic causes such as amniotomy, fetal blood sampling, and insertion of a cervical ripening balloon 4
Diagnosis and Management
Diagnosis of umbilical cord prolapse is largely made by examination and is often prompted by fetal heart rate decelerations 3. The management of umbilical cord prolapse is expedited delivery, usually by cesarean section, although vaginal or instrumental delivery may be attempted if deemed quicker, particularly in the second stage of labor 4, 2.
Anticipation and Risk Reduction
Awareness of patients at high risk of prolapse may help facilitate prompt diagnosis and delivery when prolapse occurs 3. Patients with transverse, oblique, or unstable lie should present to the hospital urgently when they begin labor or rupture membranes. Measures to relieve cord compression, such as manual elevation of the presenting part and Vago's method (bladder filling), should be attempted if delivery is expected to be delayed 4, 2.
Outcome
The perinatal outcome largely depends on the location where the prolapse occurred and the gestational age/birthweight of the fetus 4. Prompt diagnosis and interventions, as well as the positive impact of neonatal management, have significantly improved the neonatal outcome 4, 2. The diagnosis-to-delivery interval should ideally be less than 30 minutes, and efforts should be made to relieve cord compression until delivery can be achieved 4, 2.