What is the immediate action for a patient in the second stage of labor with a protracted labor who experiences an umbilical cord prolapse after artificial rupture of membranes (amniotomy)?

Immediate Management of Umbilical Cord Prolapse After Amniotomy

Use your examining hand to elevate the fetal head off the umbilical cord (Option C) immediately upon diagnosis of cord prolapse. This is the critical first-line intervention that must be performed without delay to prevent fetal hypoxia and death. 1, 2, 3

Why Manual Elevation is the Priority Action

Umbilical cord prolapse causes acute fetal hypoxia and rapid acidosis development when the presenting part compresses the cord. 1 The immediate goal is to relieve this compression while preparing for definitive delivery. 2, 3

The Correct Immediate Response:

• Manually elevate the fetal presenting part off the cord using your examining hand and maintain this position continuously until delivery. 1, 2, 3
• This maneuver provides immediate relief of cord compression and is the standard of care for umbilical cord prolapse management. 3
• Keep your hand in place—this is not a brief intervention but must be sustained throughout transport to the operating room. 2

Alternative Temporizing Measures (if additional help is available):

• Place the patient in knee-chest position or steep Trendelenburg position to use gravity to reduce pressure on the cord. 4
• Bladder filling with 500-700 mL of saline can elevate the presenting part, though manual elevation remains essential. 3

Why the Other Options Are Wrong

Option A (Assess maternal oxygenation):

• This addresses the wrong patient. The emergency is fetal, not maternal—the fetus is experiencing acute hypoxia from cord compression, not the mother. 1, 2

Option B (Attempt cord repositioning):

• Funic reduction (manual replacement of prolapsed cord) is NOT the initial intervention. 5 While one small case series reported success with this technique, it is not standard practice and should never delay manual elevation of the presenting part. 5
• The priority is relieving compression, not repositioning the cord. 2, 3

Option D (Emergent forceps delivery):

• Forceps are contraindicated in cord prolapse management. 1 Forceps require complete cervical dilation (10 cm) and are inappropriate for this emergency. 1
• Your patient is in the second stage but may not be fully dilated, and even if she were, cesarean section is the definitive management for cord prolapse, not operative vaginal delivery. 2, 3

Definitive Management Algorithm

1. Immediately elevate the fetal head manually (already discussed—this is step one). 1, 2, 3

2. Call for emergency cesarean section with a goal of diagnosis-to-delivery interval under 30 minutes, as this significantly reduces fetal mortality. 4

3. Ensure pediatric team presence for immediate neonatal resuscitation at delivery. 1

4. Maintain manual elevation continuously until the moment of delivery—do not remove your hand. 2, 3

Critical Timing Considerations

Diagnosis-to-delivery interval under 30 minutes is protective against fetal death (RR 0.79, CI 0.74-0.85). 4 Every minute of cord compression increases the risk of severe fetal morbidity and mortality. 2, 3

Cesarean section reduces perinatal mortality by a factor of 2 compared to other delivery methods in cord prolapse. 4

Common Pitfalls to Avoid

• Do not waste time attempting to reposition the cord when you should be elevating the presenting part and mobilizing for cesarean delivery. 2, 3
• Do not attempt operative vaginal delivery even if the patient is fully dilated—cesarean section provides better outcomes. 1, 4
• Do not remove your examining hand to perform other tasks—this is your primary job until the patient reaches the operating room. 2, 3
• Do not delay for additional monitoring or assessment—this is a "diagnose and act" emergency requiring immediate intervention. 6, 2