What is the most appropriate immediate management for a patient at 38 weeks' gestation in labor with a 7cm dilated cervix, full effacement, and vertex, who has a loop of the umbilical cord below the fetal head?

Immediate Cesarean Section is Required

This patient has an umbilical cord prolapse—a life-threatening obstetric emergency requiring immediate cesarean delivery to prevent fetal hypoxia, acidosis, and potential perinatal death. 1, 2

Clinical Reasoning

Why This is Cord Prolapse

• The umbilical cord is visualized below the fetal head at 7cm dilation with ruptured membranes (implied by ability to visualize the cord) 1
• This represents an overt cord prolapse where the cord has descended past the presenting part 1
• The fetal heart rate of 120 bpm, while currently reassuring, indicates the fetus is experiencing acute hypoxia that will rapidly progress to acidosis 1

Why Cesarean Section is the Only Option

Vaginal delivery is not feasible in this clinical scenario for multiple critical reasons:

• Cervical dilation is insufficient: At 7cm, the cervix is not fully dilated—vaginal delivery requires 10cm dilation 3
• Time-critical emergency: Cord prolapse causes acute fetal hypoxia requiring delivery within 25 minutes to prevent long-term neurologic injury 2
• Vacuum and forceps are contraindicated: These require full cervical dilation (10cm) and are inappropriate for cord prolapse management 4
• Fetal monitoring alone is dangerous: Expectant management allows progressive fetal acidosis and brain injury 1, 2

Immediate Management Steps

While preparing for emergency cesarean section (decision-to-delivery goal: <25 minutes) 2:

1. Elevate the presenting part: An assistant should immediately place a gloved hand in the vagina to manually elevate the fetal head off the prolapsed cord to restore umbilical blood flow 1
2. Position the mother: Place in Trendelenburg or knee-chest position to use gravity to relieve cord compression 1
3. Avoid cord manipulation: Do not attempt to replace the cord, as this can cause vasospasm 1
4. Continuous fetal monitoring: Maintain continuous assessment while mobilizing to the operating room 1
5. Prepare for neonatal resuscitation: Ensure pediatric team is present for immediate newborn care 4, 1

Why Other Options Are Wrong

• Vacuum extraction (A): Requires 10cm dilation; patient is only 7cm 3
• Forceps delivery (C): Requires 10cm dilation; patient is only 7cm 3
• Fetal monitoring (D): Passive observation in cord prolapse leads to fetal death or severe neurologic injury 1, 2

The only acceptable answer is B: Cesarean section performed emergently within 25 minutes of diagnosis. 2