Cord Prolapse

Descent of the umbilical cord through the cervix, alongside or ahead of the presenting part, following rupture of membranes, an obstetric emergency given the risk of cord compression between the presenting part and the maternal pelvis, causing acute fetal hypoxia.

Risk factors include malpresentation (particularly footling breech and transverse lie), polyhydramnios, prematurity, multiple pregnancy, and a high or ill-fitting presenting part at the time of membrane rupture (spontaneous or artificial).

• Sudden, severe, and often prolonged fetal bradycardia or other severe CTG abnormality immediately following rupture of membranes is frequently the first sign.

• The cord may be visible at or beyond the introitus, or palpable on vaginal examination below the presenting part, pulsating if the fetus remains alive.

Clinical, confirmed by direct visualization or palpation of the cord vaginally.

Should be actively considered whenever a sudden severe fetal heart rate abnormality follows membrane rupture, and a vaginal examination performed promptly to exclude it in this situation.

This is an obstetric emergency requiring immediate action to relieve cord compression while preparing for expedited delivery:

• Call for immediate senior help: obstetric, anesthetic, and neonatal teams
• Relieve pressure on the cord: the examiner's fingers remain in the vagina, elevating the presenting part off the cord, maintained continuously until delivery; the mother is positioned in knee-chest position or left lateral with a pillow under the hip (exaggerated Sims position) to use gravity to reduce pressure on the cord
• Bladder filling: instilling 500 to 750 mL of saline into the maternal bladder via a catheter can further elevate the presenting part off the cord, particularly useful during transfer to theatre
• Tocolysis (terbutaline 250 mcg SC, or an equivalent agent) may be used to reduce contractions and further relieve pressure while preparing for delivery
• Immediate delivery: category 1 emergency cesarean section is the standard approach if vaginal delivery is not imminent; if the cervix is fully dilated and delivery by instrumental vaginal birth is immediately achievable and safe, this may be preferred given the speed advantage
• Avoid handling the cord unnecessarily, since manipulation can precipitate vasospasm and worsen fetal compromise
• Continuous attempt to keep the cord warm and moist if it is exteriorized, though the priority remains relief of compression and expedited delivery rather than cord management itself

Referral: maximum obstetric emergency requiring immediate activation of the full emergency delivery team.