Why should a prolapsed umbilical cord not be replaced into the uterus?

Why a Prolapsed Umbilical Cord Should Not Be Replaced Into the Uterus

Attempting to replace a prolapsed umbilical cord back into the uterus (funic reduction) is generally not recommended because it risks causing cord vasospasm, further cord compression, and delays definitive delivery, which can worsen fetal outcomes in this obstetric emergency. 1, 2, 3

Primary Management Principle

The fundamental goal in umbilical cord prolapse is to relieve cord compression while expediting delivery, not to reposition the cord back into the uterus. 1, 2, 4

Why Replacement Is Problematic

• Excessive manipulation of the prolapsed cord can cause vasospasm, which leads to complete cessation of blood flow to the fetus—a potentially irreversible pathology that is worse than intermittent compression. 1, 2

• Manual replacement attempts delay the critical diagnosis-to-delivery interval, which should ideally be less than 30 minutes, particularly when fetal bradycardia is present. 1, 2

• Cord arterial pH declines at a rate of 0.009 per minute during bradycardia, indicating that time is critical and should not be wasted on repositioning maneuvers. 2

Evidence-Based Management Algorithm

Immediate Actions (Do NOT attempt cord replacement)

1. Elevate the fetal presenting part off the cord using manual elevation—this is the most commonly used and effective maneuver. 1, 2, 3

2. Position the mother appropriately: The knee-chest position provides the greatest elevation effect, followed by bladder filling with 500 mL of fluid (Vago's method), then Trendelenburg position (15°). 2

3. Minimize cord handling: Keep the cord moist if visible but avoid excessive manipulation that could trigger vasospasm. 1, 2

Delivery Strategy Based on Fetal Heart Rate

• Fetal bradycardia: Most urgent—proceed immediately to cesarean delivery as this indicates potentially irreversible pathology. 2

• Recurrent decelerations: Less urgent but still requires expedited delivery—the intermittent compression is reversible. 2

• Normal fetal heart rate: Proceed with delivery but with slightly less urgency. 2

• Vaginal delivery imminent (second stage): Consider instrumental vaginal delivery if it can be accomplished faster than cesarean section. 1, 3

The Exception: Historical Context

One small case series from 1991 reported successful funic reduction (manual replacement) in 5 of 8 cases with normal neonatal outcomes. 5 However, this approach has not been adopted in modern practice because:

• The sample size was extremely small (8 cases over 10 years). 5
• Current evidence emphasizes that excessive cord manipulation should be avoided to prevent vasospasm. 1, 2
• Modern management focuses on relieving compression through maternal positioning and presenting part elevation, not cord repositioning. 1, 2, 3, 4

Critical Pitfalls to Avoid

• Do not waste time attempting to replace the cord—every minute of bradycardia worsens fetal acidosis. 2

• Do not handle the cord excessively—gentle handling only to assess pulsations; aggressive manipulation causes vasospasm. 1, 2

• Do not delay cesarean delivery for repositioning attempts—the diagnosis-to-delivery interval is the most critical determinant of outcome. 1, 2, 3

Optimal Outcome Strategy

The best outcomes occur with prompt diagnosis, immediate measures to relieve cord compression (elevation of presenting part, maternal positioning), and expedited delivery—not with attempts to replace the cord. 1, 2, 3, 4 Modern obstetric management has moved away from funic reduction because the risks of cord manipulation outweigh any theoretical benefit of repositioning.