What is the management of a prolapsed umbilical cord in a pregnant woman, likely in labor or at term, in the Emergency Department (ED)?

Management of Umbilical Cord Prolapse in the Emergency Department

Immediately elevate the fetal presenting part manually and prepare for emergency cesarean delivery—this is a life-threatening obstetric emergency requiring delivery within 30 minutes to prevent fetal death or severe neurologic injury. 1, 2, 3

Immediate Recognition and Diagnosis

• Diagnose by visualizing or palpating the umbilical cord at or beyond the cervical os, typically discovered after membrane rupture or prompted by sudden fetal heart rate decelerations (bradycardia or recurrent variable decelerations). 1, 2, 3
• The urgency is highest with fetal bradycardia, as cord arterial pH declines at 0.009 per minute during bradycardia-to-delivery interval, indicating potentially irreversible vasospasm or persistent compression. 3
• Recurrent decelerations without bradycardia indicate intermittent, reversible cord compression and are slightly less urgent but still require immediate action. 3

Critical Initial Maneuvers to Relieve Cord Compression

While arranging cesarean delivery, you must immediately relieve cord compression using the following hierarchy:

1. Manual elevation of the presenting part (most universally applicable): Insert two fingers vaginally and push the fetal presenting part upward away from the pelvis to relieve pressure on the cord. 1, 3

2. Position the mother in knee-chest position (provides greatest elevation effect): Have the patient assume hands-and-knees with chest down and buttocks elevated—this position provides superior fetal head elevation compared to all other positions. 4, 3

3. Bladder filling (Vago's method) if knee-chest position is not feasible: Instill 500-700 mL of sterile saline via Foley catheter to elevate the presenting part; this is the second most effective maneuver and allows the mother to remain supine during transport. 1, 3

4. Trendelenburg position (15°) as an alternative if the above are not possible, though less effective than knee-chest or bladder filling. 3

Critical pitfall: Avoid excessive manipulation of the prolapsed cord itself, as this can cause vasospasm and worsen fetal compromise. 1

Delivery Planning Algorithm

The decision pathway depends on fetal heart rate pattern and proximity to vaginal delivery:

• If fetal bradycardia is present: Proceed to emergency cesarean delivery immediately—target delivery within 10-15 minutes as pH deteriorates rapidly. 3

• If recurrent decelerations without bradycardia: Proceed to cesarean delivery urgently but with slightly less time pressure (still aim for <30 minutes decision-to-delivery). 3

• If in second stage of labor with imminent vaginal delivery: Consider operative vaginal delivery (forceps/vacuum) if this achieves faster delivery than cesarean section. 1, 3

• If cesarean delivery will be delayed >30 minutes (e.g., awaiting anesthesia, transport): Maintain manual elevation and/or bladder filling continuously until delivery. 1, 3

Anesthetic Considerations in the ED

• For morbidly obese patients or those with difficult airways, spinal anesthesia can be performed in the knee-chest position if this is the position providing cord pulse relief, then immediately turn supine with left lateral tilt for surgery. 4
• This avoids the risks of general anesthesia in high-risk airways while maintaining fetal perfusion during the critical pre-delivery period. 4

Coordination and Transport

• Activate obstetric and neonatal resuscitation teams immediately upon diagnosis—perinatal outcome depends heavily on rapid multidisciplinary response. 1, 2
• If the patient presents to an ED without obstetric capabilities, maintain manual elevation or bladder filling during transport to a facility with cesarean capability. 5
• The diagnosis-to-delivery interval should be less than 30 minutes for optimal neonatal outcomes, though longer intervals with effective cord compression relief can still result in good outcomes. 1, 3

Neonatal Preparation

• Prepare for neonatal resuscitation including possible need for volume resuscitation and blood transfusion, as significant fetal blood loss or hypoxic injury may have occurred. 6
• Ensure neonatal team is present at delivery with full resuscitation equipment available. 1, 2

Key Pitfalls to Avoid

• Do not delay for "complete evaluation"—once diagnosed, the only acceptable delay is the time required to prepare for safe delivery. 2, 3
• Do not remove your hand from elevating the presenting part until the moment of delivery, even during patient positioning or transport. 1, 3
• Do not attempt to replace the cord above the presenting part—this is ineffective and wastes critical time. 1
• Do not use excessive force or manipulation on the exposed cord itself, as vasospasm can occur. 1