Umbilical Cord Prolapse

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Umbilical Cord Prolapse occurs when the umbilical cord descends through the cervix alongside or ahead of the presenting part of the fetus. This can lead to cord compression, which compromises fetal oxygenation and can be life-threatening if not promptly managed.

Aetiology

The exact cause of umbilical cord prolapse is not always clear, but several factors can increase the risk, including:

• Malpresentation: Breech or transverse lie can predispose to cord prolapse.
• Prematurity: Smaller fetuses have more room to move, increasing the risk of cord prolapse.
• Polyhydramnios: Excess amniotic fluid allows greater fetal movement, which can result in cord prolapse.
• Multiple Pregnancy: The presence of more than one fetus increases the risk of cord prolapse.
• High Parity: Women who have had multiple pregnancies may have a more relaxed uterus, increasing the risk.
• Rupture of Membranes: Spontaneous or artificial rupture of membranes, particularly if the presenting part is not well engaged, can precipitate cord prolapse.

Pathophysiology

Umbilical cord prolapse occurs when the umbilical cord slips through the cervix and presents either alongside or ahead of the fetal presenting part. This can lead to cord compression between the fetus and the maternal pelvis, compromising blood flow and oxygen delivery to the fetus. The longer the cord is compressed, the greater the risk of fetal hypoxia, acidosis, and death.

Risk Factors

• Malpresentation (e.g., breech, transverse lie).
• Premature rupture of membranes (PROM).
• Polyhydramnios.
• Multiple pregnancies.
• High parity.
• Prematurity (gestation <37 weeks).
• Long umbilical cord.

Signs and Symptoms

• Visible or palpable umbilical cord in the vagina following rupture of membranes.
• Fetal bradycardia or variable decelerations on cardiotocography (CTG).
• Sudden fetal distress following rupture of membranes.

Investigations

Diagnosis of umbilical cord prolapse is primarily clinical, based on the presence of a visible or palpable cord and/or sudden fetal distress:

• Physical Examination: Immediate vaginal examination to identify a prolapsed cord.
• Cardiotocography (CTG): Monitoring fetal heart rate for signs of distress, such as bradycardia or decelerations.
• Ultrasound: May be used to assess fetal position and confirm diagnosis if the cord is not immediately visible or palpable.

Management

Umbilical cord prolapse is a medical emergency requiring immediate intervention to prevent fetal hypoxia and death:

• Initial Management:
  • Manual Elevation: The presenting part should be manually elevated off the cord to relieve compression. The woman should be placed in a position that reduces pressure on the cord, such as knee-chest or left lateral position with the pelvis elevated.
  • Oxygen: Administer high-flow oxygen to the mother to maximise fetal oxygenation.
  • Filling the Bladder: If immediate delivery is not possible, filling the bladder with saline via a Foley catheter can help to lift the presenting part off the cord.
  • Minimise Handling of the Cord: Avoid handling the cord to prevent vasospasm and further compromise to blood flow.
• Definitive Management:
  • Immediate Delivery: If vaginal delivery is imminent, assist with the delivery. If not, prepare for an emergency caesarean section to deliver the baby as quickly as possible.
  • Continued Fetal Monitoring: Monitor the fetal heart rate continuously until delivery is achieved.
  • Neonatal Care: Immediate neonatal resuscitation may be necessary depending on the condition of the newborn at delivery.

References

1. NHS (2024) Umbilical Cord Prolapse. Available at: https://www.nhs.uk/conditions/umbilical-cord-prolapse/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Intrapartum Care for Women with Complex Pregnancies. Available at: https://www.nice.org.uk/guidance/ng121 (Accessed: 24 June 2024).
3. Royal College of Obstetricians and Gynaecologists (2024) Green-top Guideline No. 50: Umbilical Cord Prolapse. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg50/ (Accessed: 24 June 2024).
4. British Medical Journal (2024) Management of Umbilical Cord Prolapse. Available at: https://www.bmj.com/content/350/bmj.h681 (Accessed: 24 June 2024).

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