What is the immediate management for a pregnant woman with a cord prolapse?

Immediate Management of Umbilical Cord Prolapse

When umbilical cord prolapse is diagnosed, immediately elevate the fetal presenting part manually and place the mother in knee-chest position while preparing for emergency cesarean delivery within 30 minutes if fetal bradycardia is present. 1, 2

Immediate Recognition and Initial Actions

Diagnose cord prolapse by vaginal examination when fetal heart rate decelerations occur after membrane rupture, palpating the umbilical cord below or beside the presenting part. 3, 1

First 60 Seconds: Relieve Cord Compression

• Manually elevate the fetal presenting part by inserting your hand vaginally and pushing the presenting part upward to relieve pressure on the cord—this is the single most critical intervention and must be maintained continuously until delivery. 1, 2

• Position the mother in knee-chest position immediately, as this provides the greatest elevation effect of the presenting part compared to all other maneuvers. 1, 2

• Do NOT attempt to replace the prolapsed cord (funic reduction) unless you have specific expertise, as this is rarely successful and delays definitive management. 4

Concurrent Interventions While Preparing for Delivery

Maintain Cord Viability

• Fill the maternal bladder with 500 mL of sterile saline via Foley catheter if knee-chest position alone is insufficient—this provides the second-best elevation effect after knee-chest positioning. 1

• Cover any externally prolapsed cord with warm, saline-soaked gauze to prevent vasospasm, but avoid handling or manipulating the cord excessively. 3, 1

• Administer tocolytics (terbutaline 0.25 mg subcutaneously) to reduce uterine contractions and decrease cord compression if contractions are present. 1

Prepare for Emergency Delivery

• Activate emergency cesarean delivery protocol immediately—the goal is delivery within 30 minutes if fetal bradycardia is present, as cord arterial pH declines at 0.009 per minute during sustained bradycardia. 1

• Maintain manual elevation of the presenting part continuously during transport to the operating room and until the moment of cesarean incision. 1, 2

Delivery Timing Based on Fetal Heart Rate Pattern

Fetal Bradycardia (Most Urgent)

• Deliver within 30 minutes maximum—sustained bradycardia indicates persistent cord compression with irreversible pathology developing, requiring the most urgent intervention. 1

• Cord arterial pH correlates directly with bradycardia-to-delivery interval, making every minute critical in this scenario. 1

Recurrent Decelerations (Urgent but Less Critical)

• Prepare for cesarean delivery urgently but recognize that intermittent compression is reversible—cord arterial pH does NOT correlate with deceleration-to-delivery interval, indicating the fetus can tolerate brief periods of compression. 1

• Continue elevation maneuvers while expediting delivery preparation. 1

Normal Fetal Heart Rate (Rare)

• Proceed with urgent cesarean delivery but recognize slightly more time is available for optimal surgical preparation. 1

Vaginal Delivery Consideration

• Proceed with immediate vaginal delivery ONLY if delivery is truly imminent (complete dilation, +2 station or lower, and delivery achievable within 5 minutes). 3, 4

• Cesarean section reduces perinatal mortality by a factor of 2 compared to vaginal delivery in cord prolapse, so err on the side of cesarean if any doubt exists about immediacy of vaginal delivery. 2

Critical Pitfalls to Avoid

• Never delay for additional monitoring or testing—diagnosis by palpation of the cord is sufficient to proceed with emergency delivery. 3, 1

• Do not remove your hand from the vagina once you begin manually elevating the presenting part—continuous elevation must be maintained until cesarean incision. 1

• Avoid Trendelenburg position as the primary maneuver—it provides inferior elevation compared to knee-chest position and should only be used if knee-chest is not feasible. 1

• Do not attempt funic reduction unless you have specific training and experience, as the 87.5% success rate reported in one small series is not generalizable and delays definitive management. 4

Special Circumstances

Prehospital or Resource-Limited Settings

• Maintain knee-chest position and manual elevation during transport—these require no equipment and are the most effective interventions. 5, 2

• If cesarean delivery is not immediately available, continue elevation maneuvers and consider bladder filling while arranging urgent transfer to a facility with surgical capability. 5, 2

• In low-resource settings where diagnosis-to-delivery interval <30 minutes and knee-chest position were protective against fetal death, these basic maneuvers are lifesaving even without advanced interventions. 2