Umbilical Cord Prolapse

PregnancyA prolapsed umbilical cord develops when the umbilical cord drops or prolapses, through the open cervix into the vagina in advance of the presenting part of the baby.

During an umbilical cord prolapse the cord is often compressed and the baby will receive an inadequate amount of blood and oxygen.

Umbilical cord prolapse is a thankfully infrequent obstetric emergency with an incidence of 0.14 to 0.62% of births. UCP has a significant perinatal morbidity and mortality (up to 50% of cases), usually as a result of birth asphyxia from the lack of oxygen to the child.

There is no question that an umbilical cord prolapse is an obstetrical emergency that mandates immediate delivery of the child.

What Happens in a Prolapse?

The umbilical cord is made of two arteries and one vein. The cord moves oxygenated blood from the placenta (attached to the mother) to the fetus. It also removes waste from the fetal bloodstream. Because of this, the fetus "breathes" through the umbilical cord.

In a cord prolapse, the umbilical cord that is normally floating around the baby, suddenly descends toward the cervix and the birth canal. This may not cause any problems for the fetus, as long as no pressure is placed on the cord. However, when labor begins, the life-giving cord can become a threat.

In labor, the fetal head moves down against the cervix. Occasionally, the part of the fetus that moves towards the cervix is the buttocks (breech presentation) or a foot (footling presentation). A breech or footling presentation is difficult to deliver vaginally, but when a prolapsed cord is present, it can become much worse.

During the birth process, the head or buttocks can press against the cord without symptoms at first. This pressure may not be obvious to the care provider if the bag of water (amniotic sac) is still intact. The doctor or nurse might only notice a sharp decrease in fetal heart rate. The lowest range of the fetal heart rate is 110 beats per minute, and this will be seen on the labor monitor. If the heart rate dips below this level, this the most important sign that a Cesarean Section may be needed.

When the mother is already in labor in the hospital, the doctor or midwife can deliberately "break the bag" or rupture the membranes. Often, this is a safe procedure to speed up the process of labor. However, if the fetal head is still too far away from the cervix, the cord can slip over the baby and become part of the flow of amniotic fluid as it leaves the body. The cord can then be seen by the nurse or the doctor. The fetal heart may or may not be affected, but the birth is compromised.

At Risk for Cord Prolapse

Two major risk factors for a cord prolapse are polyhydramnios and preterm delivery. In polyhydramnios, too much amniotic fluid is made within the uterus. This increases the chance the cord will fall out when the fluid leaves. In preterm delivery, the small fetus size means the cord can move faster around the baby, and slip out before the birth.

Risk factors for cord prolapse include: abnormal fetal presentation (e.g. footling, frank breech), polyhydramnios, high fetal presenting part, abnormally long umbilical cord, prematurity, and multiple gestation (e.g. twins).

Delivery With Cord Prolapse

When the health care provider has diagnosed a prolapsed cord, three options are available.

An amnioinfusion can be done. When the mother undergoes an amnioinfusion, a warmed saline solution is delivered into the uterus by a catheter. The purpose of the infusion is to remove the pressure on the umbilical cord by helping the fetus to "float" around it. While this is done, the fetal heart rate will be watched constantly.

If the birth is much closer, the doctor must take a different approach. When the baby's head is already pressed into the birth canal—or if the delivery is happening fast—he or she may ask the mother to get up on her knees and hands to deliver. Obviously, this can only be done if the mother can move. This is not possible if the mother has received a traditional epidural. If the mother needs to change position, the nurse or doula must be available to help her. Once on the hands and knees birthing position, the mother may help the baby to ease off the cord. The baby needs to be born quickly to prevent any further complications.

A Cesarean section will be done if the fetal heart rate is low. If the fetal heart rate does not return to normal, the doctor will place his or her fingers inside the vagina and hold the baby's head off the cord. This process can be done at any time the prolapsed cord is discovered, after the amniotic sac has broken. It can be done by either the doctor or the nurse. Once the care provider has gently pushed the baby's head off the cord, she will not remove her fingers.

This means that while the mother is transported to the operating room, the nurse or doctor might be on the stretcher with the mother, holding the baby off the umbilical cord. After the baby is removed from the uterus during surgery, the nurse will remove her hand from the vagina.

When Prolapse is at Home

If the mother feels her "water broke" and suddenly feels the cord coming out with it, she needs to act quickly. If anyone is with her, they need to call 911. If she is by herself, she needs to call the ambulance. What she must do is to relieve any possible pressure on the baby. If the ambulance can be called while she moves into a different position, this is best.

The goal is to not push. She may feel awkward on her hands and knees with her buttocks in the air, but this can keep the baby off the cord. Under no circumstances should she try to drive herself to the hospital. Sitting up or standing will push the baby's head further into the birth canal.

Also, when the baby's head moves into place for birth, the mother can feel like she needs to have a bowel movement. No matter what, she should never get up to go to the bathroom! Babies can be born quickly on the toilet by accident.

After the Birth

Baby's FeetAfter the delivery, a pediatrician will examine the baby. He or she will check the Apgar score and may order further lab testing. If the baby not responding, the health care team will need to perform CPR and administer oxygen. Even if the baby appears to be acting normally, he will need to be watched for longer than usual at the hospital. The pediatrician can give the parents more instructions based on the exam.

Because oxygen levels during birth might have been compromised, the baby needs to follow up with the pediatrician as scheduled. The doctor should address any concerns about the baby's health or development with the parents.