What are the considerations for managing a prolapsed umbilical cord?

Management of Umbilical Cord Prolapse

Umbilical cord prolapse is an obstetric emergency requiring immediate cesarean delivery in most cases, with a diagnosis-to-delivery interval ideally under 30 minutes, while simultaneously implementing maneuvers to relieve cord compression until delivery is achieved. 1, 2

Immediate Recognition and Diagnosis

• Diagnose by visualizing or palpating the prolapsed cord outside or within the vagina, typically accompanied by abnormal fetal heart rate patterns (bradycardia or recurrent decelerations). 1, 2
• The urgency of delivery depends critically on the fetal heart rate pattern—bradycardia represents the most urgent scenario because cord arterial pH declines at a rate of 0.009 per minute during bradycardia-to-delivery interval, potentially indicating irreversible pathology such as vasospasm or persistent cord compression. 2
• Recurrent decelerations without bradycardia indicate intermittent, reversible cord compression and carry less immediate risk, though delivery should still be expedited. 2

Classification and Risk Stratification

• Cord prolapse (highest risk): cord descends below the presenting part through the cervix 2
• Cord presentation (moderate risk): cord lies between the presenting part and cervix 2
• Compound cord presentation (lowest risk): cord lies alongside the presenting part, replacing the outdated term "occult cord prolapse" 2
• All three conditions can occur with either ruptured or intact membranes. 2

Immediate Management Algorithm

Step 1: Call for Help and Prepare for Emergency Delivery

• Activate emergency cesarean delivery immediately unless vaginal delivery is truly imminent (particularly in second stage of labor). 1, 2
• Target diagnosis-to-delivery interval of less than 30 minutes. 1
• Prepare for neonatal resuscitation, including volume resuscitation and possible blood transfusion. 3

Step 2: Relieve Cord Compression (While Preparing for Delivery)

Apply maneuvers in order of effectiveness:

1. Knee-chest position provides the greatest elevation effect of the presenting part off the cord 2
2. Bladder filling with 500 mL of fluid (Vago's method) is the second most effective maneuver 1, 2
3. Manual elevation of the presenting part through vaginal examination 1, 2
4. Trendelenburg position (15°) as an adjunct 2

Critical pitfall: Avoid excessive cord manipulation, which can cause cord vasospasm and worsen fetal compromise. 1

Step 3: Consider Funic Reduction in Select Cases

• Manual replacement of the prolapsed cord back above the presenting part can be attempted if the patient is remote from delivery and conditions are favorable. 4
• This technique achieved successful vaginal delivery in 87.5% of cases in one series, though it requires specific expertise. 4
• This is not standard practice and should only be attempted by experienced providers in specific circumstances. 4

Delivery Mode Decision

• Cesarean delivery is the delivery mode of choice in the vast majority of cases. 1, 2
• Vaginal or instrumental delivery should only be attempted if deemed quicker than cesarean, particularly when the patient is in second stage of labor with imminent delivery. 1, 2

Cord Management After Delivery

• If the infant requires resuscitation, place between the mother's legs and start positive pressure ventilation with the umbilical cord intact. 3
• Delay cord clamping for at least 60 seconds if possible, even in emergency situations, to improve hematological outcomes. 5, 3
• For preterm infants <37 weeks who do not require immediate resuscitation, defer cord clamping for at least 60 seconds. 5
• Administer oxytocin immediately after delivery to reduce maternal blood loss in the third stage of labor. 3, 6

Risk Factors to Recognize

Iatrogenic causes (up to 50% of cases): 1

• Amniotomy
• Fetal blood sampling
• Insertion of cervical ripening balloon

Patient-related factors: 1, 7

• Multiparity with malpresentation
• Polyhydramnios
• Multiple pregnancies
• Prematurity
• Abnormal fetal lie

Outcomes and Prognosis

• Perinatal mortality ranges from 6-10% in high-income countries to 23-27% in low-income countries. 2
• Outcome depends primarily on the location where prolapse occurred, gestational age/birthweight, and the bradycardia-to-delivery interval. 1, 2
• Prompt diagnosis and intervention, combined with improved neonatal management, have significantly improved outcomes. 1

Critical Pitfalls to Avoid

• Do not delay delivery while attempting multiple maneuvers—the goal is to relieve compression while simultaneously preparing for immediate delivery. 1, 2
• Do not manipulate the cord excessively, as this causes vasospasm. 1
• Do not assume a normal fetal heart rate means the situation is not urgent—proceed with expedited delivery regardless. 2
• In cases with bradycardia, every minute counts due to progressive acidosis. 2