With an umbilical cord prolapse, the cord presents ahead of the presenting part of the fetus into the cervical canal or vagina. This prolapse is an obstetrical emergency because the prolapsed cord can be compressed, leading to umbilical vein occlusion and umbilical artery vasospasm, which can compromise fetal oxygenation. Membranes are usually ruptured before this occurs. Cord prolapse is rare, and the cause is not always known. However, some factors that increase the risk are malpresentation (breech, transverse, oblique, or unstable lie), prematurity, low birth weight, low lying placentation, uterine malformations/tumors, multiparity, polyhydramnios, long umbilical cord, and unengaged presenting part (UpToDate, 2019). Cord prolapse usually presents with an abrupt, severe, prolonged fetal bradycardia or moderate to severe variable decelerations. This complication usually occurs after membrane rupture or an obstetric intervention that dislodges the presenting part. The provider or nurse also may palpate a pulsating cord incidentally during a vaginal examination performed to assess labor progress, or a patient with ruptured membranes may report seeing or feeling an overt cord prolapse (UpToDate, 2019).
The optimal obstetric management of acute cord prolapse is prompt delivery to avoid fetal compromise or death from compression of the cord between the presenting fetal part and the birth canal. There are no data from prospective studies or randomized trials on which to base management recommendations because of this problem's infrequent and urgent nature. When a cord prolapse is detected, call for assistance, and prepare for an emergency delivery. Initiate maneuvers for intrauterine resuscitation, primarily targeted at moving the fetus off the cord. Intrauterine resuscitation may include maneuvers such as manually elevation of the presenting part or retro filling the bladder, placing the patient in Trendelenburg or knee-chest position, and administering a tocolytic may reduce pressure on the cord. Monitor the fetal heart rate to determine whether resuscitative interventions are effective, impacting the delivery urgency. Minimize manipulating an overtly prolapsed cord and avoid exposing it to a cold environment. Instead, gently replace an overtly prolapsed cord in the vagina and keep it moist with wet gauze. Perform emergency delivery by the most rapid and safe route, typically a cesarean (UpToDate, 2019b).