| Umbilical cord prolapse | |
|---|---|
| Other names | Cord prolapse, prolapsed cord[1] |
 | |
| Cord prolapse, as depicted in 1792; 233 years ago (1792) | |
| Specialty | Obstetrics |
| Risk factors | Abnormal position of the baby,prematurity, twin pregnancy, multiple prior pregnancies[2][3] |
| Diagnostic method | Suspected based on a sudden decrease in baby's heart rate during labor, confirmed by seeing or feeling the cord in the vagina[4] |
| Differential diagnosis | Abruptio placentae[2] |
| Treatment | Rapid delivery, usually bycesarean section.[4] |
| Prognosis | Risk of death of the baby 10%[2] |
| Frequency | < 1% of pregnancies[4] |
Umbilical cord prolapse is when theumbilical cord comes out of theuterus with or before the presenting part of thebaby.[2] The concern with cord prolapse is that pressure on the cord from the baby will compromiseblood flow to the baby.[2] It usually occurs duringlabor but can occur anytime after therupture of membranes.[1][5]
The greatest risk factors are an abnormal position of the baby within the uterus and apremature or small baby.[2] Other risk factors include amultiple pregnancy, more than one previous delivery, andtoo much amniotic fluid.[2][3] Whethermedical rupture of the amniotic sac is a risk is controversial.[2][3] The diagnosis should be suspected if there is a sudden decrease in the baby's heart rate during labor.[4][2] Seeing or feeling the cord confirms the diagnosis.[4]
Management focuses on quick delivery, usually bycesarean section.[4] Filling the bladder or pushing up the baby by hand is recommended until this can take place.[4] Sometimes women will be placed in aknee-chest position or theTrendelenburg position in order to help prevent further cord compression.[2] With appropriate management, the majority of cases have good outcomes.[4]
Umbilical cord prolapse occurs in about 1 in 500 pregnancies.[2] The risk of death of the baby is about 10%.[2] However, much of this risk is due tocongenital anomalies orprematurity.[2] It is considered an emergency.[4]
The first sign of umbilical cord prolapse is usually a sudden and severedecrease in fetal heart rate that does not immediately resolve. Onfetal heart tracing (a linear recording of the fetal heart rate) this would usually look like moderate to severevariable decelerations.[6] In overt cord prolapse, the cord can be seen or felt on thevulva orvagina.[1]
The main issue with cord prolapse is that, once the cord is prolapsed, it is prone to compression by the foetus and the womb. This can cause decrease in oxygen supply to the foetus which can be fatal.
A majority of umbilical cord prolapse cases happen during thesecond stage of labor.[7]
Risk factors that are associated with umbilical cord prolapse tend to make it difficult for the baby from appropriately engaging and filling the maternal pelvis or are related to abnormalities of the umbilical cord. The two major categories of risk factors are spontaneous andiatrogenic (those that result from medical intervention).
Umbilical cord prolapse should always be considered a possibility when there is a sudden decrease in fetal heart rate or variable decelerations, particularly after the rupture of membranes. With overt prolapses, the diagnosis can be confirmed if the cord can be felt on vaginal examination. Without overt prolapse, the diagnosis can only be confirmed after acesarean section, though even then it will not always be evident at time of procedure.[12]
There are three types of umbilical prolapse that can occur:[12]
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The typical treatment of umbilical cord prolapse in the setting of aviable pregnancy involves immediate delivery by the quickest and safest route possible. This usually requires cesarean section, especially if the woman is in early labor. Occasionally, vaginal delivery will be attempted if clinical judgment determines that is a safer or quicker method.[12]
Other interventions during management of cord prolapse are typically used to decrease the chance of complications while preparations for delivery are being made. These interventions are focused on reducing pressure on the cord to prevent fetal complications from cord compression. The following maneuvers are among those used in clinical practice:
If the mother is far from delivery, funic reduction (manually placing the cord back into the uterine cavity) has been attempted,[14] with successful cases reported.[15] However, this is not currently recommended by the Royal College of Obstetricians and Gynaecologists (RCOG), as there is insufficient evidence to support this maneuver.[1]
The primary concern with umbilical cord prolapse is inadequate blood supply, and thus oxygen, to the baby if the cord becomes compressed. The cord can become compressed either due to mechanical pressure (usually from the presenting fetal part) or fromsudden contraction of the vessels due to decreased temperatures in the vagina in comparison to the uterus.[12] This can lead todeath of the baby or other complications.
Historically, the rate of fetal death in the setting of cord prolapse has been as high 40%.[16] However, these estimates occurred in the context of home or births outside of the hospital. When considering cord prolapses that have occurred in inpatient labor and delivery settings, the rate drops to as low as 0-3%,[12] though the mortality rate remains higher than for babies without cord prolapse. The reduction in mortality for hospital births is likely due to the ready availability of immediate cesarean section.
Many other fetal outcomes have been studied, includingApgar score (a quick assessment of a newborn's health status) at 5 minutes and length of hospitalization after delivery. While both measures are worse for newborns delivered after cord prolapse,[8] it is unclear what effect this has in the long-term. Relatively large studies that have tried to quantify long-term effects of cord prolapse on children found that less than 1% (1 in 120 studied) had a major neurologic disability,[10] and less than 1% (110 in 16,675) had diagnosed cerebral palsy.[17]
Rates of umbilical cord prolapse ranges from 0.1 to 0.6% of all pregnancies.[12][16] This rate has remained stable over time. A recent study estimates 77% of cord prolapses occur in singleton pregnancies (where there is only one baby). In twin pregnancies, cord prolapses occur more frequently in the second twin to be delivered, with 9% in the first twin and 14% in the second twin.[10]
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