Umbilical cord prolapse

In umbilical cord prolapse the cord slips down ahead of or beside the baby after the membranes rupture, where it can be squeezed and cut off the baby's oxygen. It is an obstetric emergency that usually needs delivery within minutes, most often by cesarean.

Key symptoms

• Cord felt in the vagina or seen at the vulva, often right after the water breaks
• Sudden drop in fetal heart rate just after rupture of membranes
• Risk setting: breech or transverse lie, preterm labor, twins, too much amniotic fluid
• Often no pain or warning signs for the mother

What you find on exam

• Fetal heart rate: sudden prolonged slowing or repeated variable decelerations
• Sterile vaginal exam: pulsating cord felt in the vagina or ahead of the presenting part
• Look at the perineum for a visible loop of cord
• Cervical dilation and fetal station to choose the fastest route to delivery

Tests

• Continuous fetal heart rate monitoring
• Diagnosis is clinical; never delay delivery to wait for tests
• Quick bedside ultrasound for fetal heartbeat and presentation only if it costs no time
• Umbilical cord blood gases after birth

Treatment basics

• Call for help and the obstetric, anesthesia and newborn teams right away
• Lift the presenting part off the cord with a gloved hand in the vagina and keep it there
• Knee-chest or steep head-down position; fill the bladder with saline through a catheter if delivery is delayed
• Handle the cord as little as possible; cover an exposed loop with warm moist gauze
• Fastest safe delivery: usually emergency cesarean, or assisted vaginal birth if fully dilated and birth is imminent

Practice it in Making Synapses

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Related guides

Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.