Umbilical Cord Prolapse

Marina Boushra; Alicia Stone; Kimberly M. Rathbun.

Author Information and Affiliations

Last Update: May 8, 2023.

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Continuing Education Activity

Umbilical cord prolapse is when the umbilical cord exits the cervical os before the fetal
presenting part. Compression of the cord results in vasoconstriction and resultant fetal hypoxia,
which can lead to fetal death or disability if not rapidly diagnosed and managed. This activity
reviews the diagnosis and management of patients with umbilical cord prolapse in the emergency
department and highlights the role of early recognition and interprofessional involvement in
improving patient outcomes.
Objectives:
• Describe the clinical presentation of umbilical cord prolapse.
• Outline the key steps in the acute management of umbilical cord prolapse.
• Review alternative management strategies that can be utilized after initial attempts at
funic decompression have failed or in cases where obstetric care is not immediately
available.
• Explain strategies to improve care coordination between the interprofessional teams
caring for patients with umbilical cord prolapse to improve outcomes.
Access free multiple choice questions on this topic.
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Introduction
Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before
the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal
morbidity and mortality. Resultant compression of the cord by the descending fetus during
delivery leads to fetal hypoxia and bradycardia, which can result in fetal death or permanent
disability. Early recognition and intervention are paramount to the reduction of adverse outcomes
in the fetus.
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Etiology
Certain features of pregnancy increase the risk for the development of umbilical cord prolapse by
preventing appropriate engagement of the presenting part with the pelvis. These include fetal
malpresentation, multiple gestations, polyhydramnios, preterm rupture of membranes,
intrauterine growth restriction, preterm delivery, and fetal and cord abnormalities.[1] Nearly half
of the cases of umbilical cord prolapse can be attributable to iatrogenic causes.[2] Iatrogenic risk
factors include amniotomy without an engaged fetal presenting part, attempted external cephalic
version in the setting of ruptured membranes, amnioinfusion, placement of a fetal scalp electrode
or intrauterine pressure catheter, or the use of a cervical ripening balloon.[1]
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Epidemiology
Estimates of the incidence of umbilical cord prolapse range from 1.4 to 6.2 per 1000.[3] The
majority of cases of umbilical cord prolapse occur in single gestation pregnancies; in twin
gestations, the incidence increases in the second twin.[2] Most prolapses occur shortly after
rupture of membranes; one study estimates that 57% occur within five minutes of membrane
rupture while 67% occur within one hour of rupture.[2] The incidence of umbilical cord prolapse
is on a downward trend, which is thought to be secondary to the widespread use of cesarean
sections for many of the risk factors of cord prolapse, such as fetal
malpresentation.[4][5] Decreasing rates of grand multiparity worldwide are also thought to
contribute to the reduced incidence.[5]
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History and Physical

The occurrence of fetal bradycardia in the setting of ruptured membranes should prompt
immediate evaluation for potential cord prolapse. There are two forms of umbilical cord
prolapse.[1] The first, overt prolapse, occurs when the cord exits the cervix before the fetal
presenting part; the second, occult prolapse, occurs when the cord exits the cervix with the fetal
presenting part.[1] In overt prolapse, the cord is palpable as a pulsating structure in the vaginal
vault. In occult prolapse, the cord is not visible or palpable ahead of the fetal presenting part. In
overt prolapse, the diagnosis is clinical and made by palpation of a pulsating structure in the
vaginal vault or visibly protruding from the vaginal introitus; this is typically accompanied by
fetal bradycardia or severe variable decelerations, though fetal heart rate changes only present in
approximately two-thirds of cases.[2][6] In occult prolapse, only fetal heart rate abnormalities
may appear, as the cord will not be palpable or visible on examination. The diagnosis should be a
consideration in cases of unexplained fetal heart rate changes in the setting of recent membrane
rupture or other maneuvers that increase the risk of prolapse (for example, placement of a fetal
scalp electrode).[1]
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Evaluation
Umbilical cord prolapse is a clinical diagnosis and should be considered in the case of fetal
bradycardia or recurrent variable decelerations, especially if they occur immediately after rupture
of membranes. The diagnosis is confirmed by palpation of a pulsatile mass in the vaginal vault.
No radiographic or laboratory confirmation is available, and funic decompression should be
attempted as soon as the diagnosis is suspected. Antenatal ultrasound for cord presentation has
been demonstrated to be a poor predictor of umbilical cord prolapse.[7]
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Treatment / Management
The definitive management of umbilical cord prolapse is expedient delivery; this is usually by
cesarean section. In rare cases, vaginal delivery or operative vaginal delivery may be faster and,
thus, preferable, but this should only occur under the presence and guidance of an experienced
obstetrician.[1]
Until delivery is possible, the cornerstone of management of umbilical cord prolapse is funic
decompression, relieving the pressure on the cord by elevation of the fetal presenting part.
Studies suggest that the interval to funic decompression may be more important to outcomes than
interval to delivery.[8] Decompression should be done manually by the medical provider through
the placement of their finger or hand in the vaginal vault and gentle elevation of the presenting
part off the umbilical cord. The provider should be conscientious not to place any additional
pressure on the cord, as this can cause vasospasm and worsen outcomes.[9] Placement of the
mother in a steep Trendelenburg or knee-chest position can also aid in cord decompression. In
cases of a potentially prolonged interval to delivery (i.e., the need for transfer to a hospital with
obstetric capabilities), saline infusion into the bladder may aid in funic decompression and
remove the need for continuous manual elevation by the provider.[10][11] If fetal decelerations
persist and delivery is not imminent, the administration of a tocolytic can be attempted to relieve
pressure on the umbilical vessels and to improve placental perfusion, thereby improving blood
flow to the fetus.[12][13] Reduction of the cord into the os, which was common before the
widespread availability of cesarean sections, has been associated with increased fetal mortality
and is not routinely recommended except in cases of an expected long interval to delivery where
other maneuvers have failed.[1]
If the cord is visibly protruding from the introitus, it should remain warm and moist because the
ambient temperature is significantly colder than the temperature in the uterus and can result in
vasospasm of the umbilical arteries, contributing to fetal hypoxia.[1] One method described as
preventing this is the replacement of the cord into the vaginal vault followed by insertion of a
moist tampon to keep it in place.[14]
In very rare cases of umbilical cord prolapse in peri-viable pregnancies, case studies demonstrate
that conservative management may allow the continuation of the pregnancy until reaching a
more desirable gestational age.[9][15] However, a frank discussion should take place with the
patient regarding the experimental nature of this treatment and its potential risks.
Pre-viable gestational age, lethal fetal abnormalities, or fetal demise are not indications for
expedient delivery, and instead, a dilation and evacuation or labor induction should be the
therapeutic choice, dependent on gestational age or maternal preference.[5]
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Differential Diagnosis
Potential causes of a palpable mass in the vaginal vault include fetal malpresentation.[1] Possible
causes of severe, prolonged fetal bradycardia include maternal hypotension, uterine rupture, vasa
previa, and abruptio placentae.[1]
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Prognosis
The rate of fetal mortality in umbilical cord prolapse is estimated to be less than
10%.[9][2][4] This reduction is a drastic decrease from earlier estimates of mortality, which
ranged from 32 to 47%, which researchers hypothesize is due to the increased availability of
cesarean sections and advances in neonatal resuscitation.[1][9] Gestational age and location of
prolapse (inside versus outside the hospital) are the two significant determinants of outcome in
umbilical cord prolapse.[5] Cord prolapse that occurs outside the hospital carries an 18-fold
increased risk of mortality.[6] Premature infants and those with low birth weights have an
increased risk of perinatal complications and twice the mortality.[9] Death in these infants
appears to be attributable to their underlying conditions and the preterm delivery necessitated by
the prolapse rather than complications of the prolapse itself.
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Complications
Outcomes for umbilical cord prolapse have drastically improved in recent years.[4] Still, a
diagnosis of umbilical cord prolapse carries a risk of fetal mortality. Though rare, surviving
infants may develop complications secondary to asphyxia, including neonatal encephalopathy
and cerebral palsy.[16][17][18]
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Consultations
Emergent obstetric consultation is necessary for umbilical cord prolapse occurring in the
emergency department. The attending clinicians should attempt maneuvers for funic
decompression until definitive management is available.
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Deterrence and Patient Education

Many patients in resource-rich countries are opting for childbirth at home under the supervision
of a non-physician attendant such as a midwife. Cases of umbilical cord prolapse that occur
outside the hospital carry a nearly 20 times increased rate of mortality. As such, patients with
increased risk of prolapses, such as those with fetal malpresentation or umbilical cord
abnormalities, should be strongly discouraged from delivering outside of the hospital.
Concentration on other portions of their birth plan, such as a silent birth or minimal
pharmacologic intervention, may help these patients decide to deliver in the hospital. Since
umbilical cord prolapse may happen in patients without risk factors, training for non-physician
birth attendants in the early recognition and intervention in umbilical cord prolapse may lead to
improved fetal outcomes in these cases.
Patients themselves should also be counseled to recognize cord prolapse in the scenario of a gush
of fluid followed by the feeling of vaginal pressure or something in the vagina. The patient
should be instructed to call an ambulance and assume a knee-chest position while waiting for
help to arrive.
Given the iatrogenic risk factors for umbilical cord prolapse, physician education also has a role
to play in decreasing the frequency of this condition. The American College of Obstetricians and
Gynecologists recommends against routine amniotomy in normally progressing labor unless
needed for fetal monitoring.[19] If performing an amniotomy, engagement of the fetal head
should be confirmed. In cases with risk of cord prolapse, for example, polyhydramnios or high
fetal station, the amniotic sac may be ruptured with a needle rather than a hook to slow the flow
of the amniotic fluid, though the efficacy of this technique has not been well-studied.[20]
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Enhancing Healthcare Team Outcomes

Knowledge of the risk factors for umbilical cord prolapse does not decrease its occurrence [2],
but such knowledge can help both healthcare providers, including midwives, labor and delivery
nurses, and the patient prepare for potential umbilical cord prolapse. In patients with risk factors
for developing umbilical cord prolapses, such as breech presentation with desired vaginal
delivery, frank discussion with the patient and her partner regarding the risk should be
undertaken, and the recommendation is to plan the delivery at a healthcare center where
emergent cesarean delivery is available. Patient counseling by the clinician and nurse regarding
the expected course of events in the case of umbilical cord prolapse in delivery may help the
patient better understand the urgent nature of management before occurrence. Simulation team
training exercises have been shown to decrease the time from diagnosis to delivery and improve
fetal outcomes.[21][22][23]
Umbilical cord prolapse cases require an interprofessional team approach to care. This team
includes physicians and specialists, as well as specialty-trained neonatal nursing staff. Through
collaborative team communication, optimal care can be the result, with the best possible patient
outcomes for both the mother and the neonate. [Level 5]