CORD PROLAPSE

Cord prolapse has been defined as the

descent of the umbilical cord through
the cervix alongside (occult) or past
the presenting part (overt) in the
presence of ruptured membranes.
Cord presentation is the presence of
the umbilical cord between the fetal
presenting part and the cervix, with or
without membrane rupture. The
overall incidence of cord prolapse
ranges from 0.1% to 0.6%. In the case
of breech presentation, the incidence
is slightly higher than 1%. It has been
reported that male fetuses appear to
be predisposed to cord prolapse. The
incidence is influenced by population
characteristics and is higher where
there is a large percentage of multiple
gestations.

Cases of cord prolapse appear

consistently in perinatal mortality
enquiries, and one large study found
a perinatal mortality rate of 91/1000.
Prematurity and congenital
malformations account for the
majority of adverse outcomes
associated with cord prolapse in
hospital settings1 but birth asphyxia is
also associated with cord prolapse.
Perinatal death has been described
with normally formed term babies,
particularly with planned home birth.
Delay in transfer to hospital appears
to be an important contributing factor.
Asphyxia may also result in hypoxic–
ischaemic encephalopathy and
cerebral palsy.

The principal causes of asphyxia in

this context are thought to be cord
compression and umbilical arterial
vasospasm preventing venous and
arterial blood flow to and from the
fetus. There is a paucity of long-term
follow-up data of babies born alive
after cord prolapse in both hospital
and community settings.
In general, these factors predispose to
cord prolapse by preventing close
application of the presenting part to
the lower part of the uterus and/or
pelvic brim. Rupture of membranes in
such circumstances compounds the
risk of prolapse.

Some authorities have also speculated

that cord abnormalities (such as true
knots or low content of Wharton’s
jelly) and fetal hypoxia–acidosis may
alter the turgidity of the cord and
predispose to prolapse. Interventions
can result in cord prolapse with about
50% of cases being preceded by
obstetric manipulation.

The manipulation of the fetus with or

without prior membrane rupture
(external cephalic version, internal
podalic version of the second twin,
manual rotation, placement of
intrauterine pressure catheters) and
planned artificial rupture of
membranes, particularly with an
unengaged presenting part, are the
interventions that most frequently
precede cord prolapse.

Can cord presentation be

detected antenatally?

Routine ultrasound examination is not

sufficiently sensitive or specific for
identification of cord presentation
antenatally and should not be
performed to predict increased
probability of cord prolapse, unless in
the context of a research setting.

Can cord prolapse or its effects be

avoided?

With transverse, oblique or unstable

lie, elective admission to hospital after
37+6 weeks of gestation should be
discussed and women should be
advised to present quickly if there are
signs of labour or suspicion of
membrane rupture. Women with
noncephalic presentations and
preterm prelabour rupture of the
membranes should be offered
admission.

Artificial membrane rupture should

be avoided whenever possible if the
presenting part is mobile. If it
becomes necessary to rupture the
membranes, this should be performed
with arrangements in place for
immediate caesarean delivery.

Vaginal examination and obstetric

intervention in the context of ruptured
membranes and a high presenting
part carry the risk of upward
displacement and cord prolapse.
Upward pressure on the
presenting part should be kept to a
minimum in such women.
Rupture of membranes should be
avoided if, on vaginal examination, the
cord is felt below the presenting part.
When cord presentation is diagnosed
in established labour, caesarean
section is usually indicated.

When should cord prolapse be

suspected?

Cord presentation and prolapse may

occur without outward physical signs
and with a normal fetal heart rate
pattern. The cord should be examined
for at every vaginal examination in
labour and after spontaneous rupture
of membranes if risk factors are
present or if cardiotocographic
abnormalities commence soon
thereafter.

With spontaneous rupture of

membranes in the presence of a
normal fetal heart rate patterns and
the absence of risk factors for cord
prolapse, routine vaginal examination
is not indicated if the liquor is clear.

Cord prolapse should be suspected

where there is an abnormal fetal heart
rate pattern (bradycardia, variable
decelerations etc), particularly if such
changes commence soon after
membrane rupture, spontaneously or
with amniotomy. Speculum and/or
digital vaginal examination should be
performed at preterm gestations when
cord prolapse is suspected.

What is the optimal initial

management of cord prolapse in
hospital settings?

When cord prolapse is diagnosed

before full dilatation, assistance
should be immediately called and
preparations made for immediate
delivery in theatre. There are
insufficient data to evaluate manual
replacement of the prolapsed cord
above the presenting part to allow
continuation of labour. This practice is
not recommended.

To prevent vasospasm, there should

be minimal handling of loops of cord
lying outside the vagina. To prevent
cord compression, it is recommended
that the presenting part be elevated
either manually or by filling the
urinary bladder. Cord compression can
be further reduced by the mother
adopting the knee–chest position or
head-down tilt (preferably in left-
lateral position).

Tocolysis can be considered while

preparing for caesarean section if
there are persistent fetal heart rate
abnormalities after attempts to
prevent compression mechanically
and when the delivery is likely to be
delayed.
Although the measures described
above are potentially useful during
preparation for delivery, they must not
result in unnecessary delay.

What is the optimal mode of

delivery with cord prolapse?

A caesarean section is the

recommended mode of delivery in
cases of cord prolapse when vaginal
delivery is not imminent, to prevent
hypoxia–acidosis.

A category 1 caesarean section should

be performed with the aim of
delivering within 30 minutes or less if
there is cord prolapse associated with
a suspicious or pathological fetal heart
rate pattern but without unduly risking
maternal safety. Verbal consent is
satisfactory.
Category 2 caesarean section is
appropriate for women in whom the
fetal heart rate pattern is normal.
Regional anaesthesia may be
considered in consultation with an
experienced anaesthetist.

What is the optimal management

in community settings?

Women should be advised, over the

telephone if necessary, to assume the
knee–chest face-down position while
waiting for hospital transfer. During
emergency ambulance transfer, the
knee–chest is potentially unsafe and
the left-lateral position should be
used.

All women with cord prolapse should

be advised to be transferred to the
nearest consultant-led unit for
delivery, unless an immediate vaginal
examination by a competent
professional reveals that a
spontaneous vaginal delivery is
imminent. Preparations for transfer
should still be made.

The presenting part should be

elevated during transfer by either
manual or bladder filling methods. It is
recommended that community
midwives carry a Foley catheter for
this purpose and equipment for
fluid infusion.

To prevent vasospasm, there should

be minimal handling of loops of cord
lying outside the vagina.

Perinatal mortality is increased by

more than ten-fold when cord prolapse
occurs outside hospital compared with
prolapse occurring inside the hospital.
Neonatal morbidity is also increased in
this circumstance
What is the optimal management
of cord prolapse before viability?

Expectant management should be

discussed for cord prolapse
complicating pregnancies with
gestational age at the limits of
viability.
Uterine cord replacement may be
attempted. Women should be
counselled on both continuation and
termination of pregnancy following
cord prolapse at the threshold of
viability.

Clinical governance
Debriefing
Postnatal debriefing should be offered to
every woman with cord prolapse. After
severe obstetric emergencies, women
might be psychologically affected with
postnatal depression, post-traumatic
stress disorder or fear of further childbirth.
Women with cord prolapse
who undergo urgent transfer to hospital
might be particularly vulnerable to
emotional problems.
Debriefing is an important part of
maternity care and should be offered by a
professional competent in counselling