Immediate Management of Umbilical Cord Prolapse
Elevate the baby's head manually off the prolapsed cord (Option C) while calling for emergency obstetric assistance. This is the single most critical intervention to prevent cord compression and maintain fetal oxygenation until emergency cesarean delivery can be performed.
Primary Intervention: Manual Elevation of Presenting Part
The immediate priority is to manually elevate the fetal head off the umbilical cord to relieve compression and restore blood flow. 1, 2, 3, 4, 5
- Insert your hand into the vagina and physically push the fetal presenting part (the head in this case) upward and away from the prolapsed cord 2, 4, 5
- Maintain this manual elevation continuously until the patient is in the operating room and ready for delivery 2, 3, 4
- This maneuver directly addresses the pathophysiology: cord prolapse causes acute fetal hypoxia and rapid acidosis development due to cord compression between the presenting part and maternal pelvis 1
Why Other Options Are Incorrect
Never allow delivery to proceed naturally (Option A) - vaginal delivery with a prolapsed cord and high presenting part will result in sustained cord compression, severe fetal hypoxia, and likely fetal death or permanent neurological injury 1, 2, 3, 4
Never elevate the head of the bed (Option B) - this worsens the situation by increasing gravitational pressure of the fetal head onto the prolapsed cord 4
Never attempt to reduce the prolapsed cord back into the vagina (Option D) - manipulation of the cord can cause vasospasm, which may be irreversible and worsen fetal outcomes 2, 4
Additional Supportive Measures While Awaiting Cesarean Delivery
After establishing manual elevation of the presenting part, implement these secondary interventions:
- Position the mother in knee-chest position if feasible, as this provides the greatest elevation effect and reduces pressure on the cord 4
- Consider bladder filling (Vago's method) with 500-700 mL of sterile saline via catheter as an alternative or adjunct to manual elevation, though this is secondary to manual elevation 2, 4
- Avoid excessive cord manipulation beyond what is necessary to assess pulsations, as this can cause cord vasospasm 2, 4
- Keep the prolapsed cord moist and warm if it extends beyond the vagina, but do not attempt to replace it 2, 3
Delivery Timing and Mode
Cesarean delivery should be performed as an emergency procedure - the diagnosis-to-delivery interval should ideally be less than 30 minutes 2, 3
- Vaginal delivery is only appropriate if delivery is truly imminent (complete dilation, +2 station or lower) and can be accomplished faster than cesarean section 2, 4
- With the fetal head "palpable on vaginal exam" as described in this scenario, the head is likely at a high station, making vaginal delivery inappropriate 4
- Ensure neonatal resuscitation team is present at delivery, as these infants frequently require immediate advanced support 1
Critical Pitfall to Avoid
The most common error is delaying manual elevation while attempting other maneuvers first. The moment you diagnose cord prolapse by palpating the cord on vaginal exam, your hand should remain in the vagina elevating the presenting part - this is not optional and should not be delayed for positioning changes or other interventions 2, 3, 4, 5. Every minute of cord compression causes progressive fetal acidosis, with cord arterial pH declining at approximately 0.009 per minute during sustained compression 4.