Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. This occurs in 1/500 deliveries. Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.

Risk factors for cord prolapse include:

• prematurity
• multiparity
• polyhydramnios
• twin pregnancy
• cephalopelvic disproportion
• abnormal presentations e.g. Breech, transverse lie

Around 50% of cord prolapses occur at artificial rupture of the membranes. The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.

Management

cord prolapse is an obstetric emergency

• the presenting part of the fetus may be pushed back into the uterus to avoid compression
• if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
• the patient is asked to go on 'all fours' until preparations for an immediate caesarian section have been carried out
  • the left lateral position is an alternative
• retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
• tocolytics may be used to reduce uterine contractions (terbutaline)
• although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.