Umbilical Cord Prolapse — Recognition & Emergency Management
Cord prolapse occurs when the umbilical cord descends through the cervix alongside or ahead of the presenting
part after the membranes have ruptured. The presenting part then compresses the cord against the pelvis,
cutting off fetal oxygenation. This is a true obstetric emergency — outcome depends on how quickly
compression is relieved and the baby delivered, not on any single clever manoeuvre.
ЁЯОЧ️ AT A GLANCE — WHO'S AT RISK
Risk Drivers
Malpresentation — breech, transverse, or oblique lie; the presenting part doesn't fill the pelvis well
Polyhydramnios — a sudden gush of fluid at membrane rupture can sweep the cord down
Prematurity, multiparity, multiple pregnancy (especially the second twin), long cord
High, unengaged presenting part at the time membranes rupture — spontaneous or artificial
GREEN: cephalic, well-engaged presenting part, membranes intact — low baseline risk
AMBER: risk factors present (malpresentation, polyhydramnios, prematurity, high head) with membranes still intact — avoid artificial rupture of membranes unless the head is well applied
RED: membranes ruptured with a high presenting part and risk factors, or cord felt/seen on examination — emergency
ЁЯФО RECOGNITION
A sudden fetal heart rate abnormality — bradycardia or new variable decelerations — immediately after membranes rupture is cord prolapse until proven otherwise
Overt prolapse: cord visible at, or protruding from, the introitus
Occult prolapse: cord lies alongside the presenting part — not visible, but may be felt as a pulsatile structure on vaginal examination
Any sudden fetal heart rate change after rupture of membranes should prompt an immediate vaginal examination to feel for cord.
ЁЯЪи THIS IS AN EMERGENCY — CALL FOR HELP NOW
Cord visible at the introitus, or felt below the presenting part on exam
Sudden fetal bradycardia or severe variable decelerations after ROM
Alert senior obstetrician, anaesthetist, neonatal team, and theatre simultaneously
Do not wait to "confirm" further — begin emergency actions immediately
ЁЯЫа️ IMMEDIATE ACTIONS — IN THIS ORDER
1
Call for help — obstetrician, anaesthetist, neonatal team, theatre, all at once
2
Stop pushing; avoid handling the cord — if it's outside the vagina, keep it warm and moist, don't force it back
3
Relieve compression — a hand in the vagina elevates the presenting part, kept there until delivery
4
Reposition the mother — knee-chest or exaggerated Sims' / left-lateral with head-down tilt
5
Consider filling the bladder (500–700 mL saline via Foley) to help elevate the presenting part, per protocol
6
Continuous fetal monitoring while moving directly to expedite delivery
ЁЯЧУ️ DELIVERY PLANNING
Category 1 emergency caesarean is the usual mode of delivery, unless vaginal birth is safe and imminent
Immediate vaginal delivery (e.g., low forceps or vacuum for a fully dilated cephalic presentation) may be appropriate if delivery is genuinely imminent and safe
Tocolysis may be considered to reduce contraction-related compression while preparing for theatre, per local protocol
Continue manual elevation of the presenting part en route to theatre and during preparation — do not stop to reassess
Do not delay for a repeat fetal heart check once the decision for delivery is made — continue decompression measures and proceed.
Overt Prolapse
Cord passes beyond the presenting part — visible or protruding
Usually obvious; occurs after membrane rupture
Occult Prolapse
Cord lies alongside, not beyond, the presenting part
May only be suspected from fetal heart changes
Cord Presentation
Cord lies below the presenting part with membranes still intact
Avoid artificial rupture of membranes if suspected on scan/exam
Outside Hospital / In Transit
Same principles apply — manual elevation, positioning, urgent transfer
Call ahead so the receiving team is ready on arrival
Obstetric Emergency
Time Is Everything
30
MINUTES
TYPICAL DECISION-TO-DELIVERY TARGET
Fetal outcome tracks closely with the duration and severity of cord compression — every minute of continuous elevation and swift preparation genuinely counts. Faster is better whenever it's safely achievable.
Keep manual elevation continuous until the baby is delivered — do not remove the hand to "check" progress
Move directly to theatre; prepare anaesthetic and neonatal teams before arrival, not after
Document timings clearly afterward — decision time, delivery time, cord gases, Apgar scores
Debrief the team — cord prolapse drills are one of the highest-yield obstetric emergency simulations
Reminder: even if cord pulsations are felt and reassuring, this does not mean it is safe to wait — continue elevation and proceed to expedite delivery regardless.
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