Umbilical Cord Prolapse – GCC Nurse Clinical Guide

Overview

Emergency Management

Risk Factors

GCC Context

MCQ Practice

🚨 Cord Prolapse — Overview

Umbilical cord prolapse occurs when the umbilical cord descends through the cervix alongside or ahead of the presenting foetal part after membrane rupture. The presenting part compresses the cord against the maternal pelvis, causing acute foetal hypoxia.

CORD PROLAPSE = OBSTETRIC EMERGENCY. Every minute of cord compression increases foetal hypoxia and perinatal mortality risk. Decision-to-delivery interval should be <30 minutes (Category 1 caesarean section).

Types of Cord Presentation

Cord Prolapse (Overt)

Membranes ruptured
Cord descends BELOW presenting part
Cord may be visible at introitus or palpable on vaginal examination
Immediate emergency — foetal compromise occurs rapidly

Cord Presentation (Occult)

Membranes INTACT
Cord felt through forewaters on VE
Less urgent but requires monitoring and often elective CS
If membranes rupture → becomes frank prolapse

Incidence

~0.1–0.6% of deliveries
Perinatal mortality: ~90/1000 if outside hospital; ~30/1000 in hospital with rapid response

Diagnosis

Sudden severe foetal bradycardia or prolonged deceleration on CTG — ESPECIALLY following membrane rupture or vaginal examination
Cord visible at vaginal introitus
Cord palpable on digital vaginal examination
Any sudden CTG deterioration after membrane rupture = exclude cord prolapse with immediate VE

🏃 Emergency Management of Cord Prolapse

THE PRIORITY: Relieve cord compression while preparing for immediate delivery.

Immediate Actions (Simultaneous)

CALL FOR HELP: Emergency call — senior obstetrician, anaesthetist, midwives, theatre team, neonatal team. State: "CORD PROLAPSE — Category 1 caesarean section needed."
RELIEVE CORD COMPRESSION: Insert fingers into vagina and MANUALLY ELEVATE the presenting part off the cord. Maintain upward pressure throughout — DO NOT remove hand until delivery.
POSITION THE MOTHER:
- Knee-chest (all-fours) position: Mother kneels on all fours, chest lowered to bed — gravity lifts presenting part away from cord. PREFERRED if cord not yet prolapsed through introitus
- Trendelenburg position (steep head-down): Alternative — gravity shifts presenting part cephalad
- Left lateral (Sims') position: Acceptable alternative
HANDLE CORD GENTLY: Wrap exposed cord in warm wet gauze — prevents vasospasm from cold/drying. Do NOT attempt to replace cord into uterus (futile and harmful).
OXYGEN: High-flow O₂ to mother — improves foetal oxygenation while preparing for delivery.
IV ACCESS + BLOODS: FBC, group and save, coagulation — in preparation for caesarean.
BLADDER FILLING: Rapidly fill urinary bladder with 500–750 mL saline via urinary catheter — acts to lift presenting part mechanically and reduce cord compression. Useful as temporary measure during transfer to theatre.
URGENT DELIVERY: Category 1 caesarean section if not fully dilated. If fully dilated: assisted vaginal delivery (ventouse/forceps) may be faster — obstetrician decision.

Bladder filling technique: Insert urinary catheter → fill bladder with 500–750 mL sterile saline via giving set rapidly → clamp catheter → this hydrostatically elevates the presenting part off the cord. Empty bladder immediately before incision in theatre.

Tocolysis

Consider IV or sublingual terbutaline (tocolytic) to reduce uterine contractions temporarily — reduces intermittent cord compression during contractions while awaiting delivery
Terbutaline 0.25 mg SC/IV — useful temporising measure

Key Principles

The one action that saves babies: Manual elevation of the presenting part immediately upon diagnosis, maintained continuously until delivery. This single intervention prevents most foetal mortality from cord prolapse.

📊 Risk Factors for Cord Prolapse

Foetal Risk Factors

Malpresentation (breech, shoulder, transverse lie) — highest risk
Prematurity (<37 weeks) — poorly fitting presenting part
Multiple pregnancy (second twin particularly)
Small for gestational age
Long umbilical cord

Maternal/Obstetric Risk Factors

Polyhydramnios — cord washed down on membrane rupture
Multiparity (poorly engaged presenting part)
Artificial rupture of membranes (ARM) — greatest iatrogenic risk
External cephalic version (ECV)
Internal podalic version
Amnioinfusion

ARM (Artificial Rupture of Membranes) — highest iatrogenic risk: Before performing ARM, always ensure the presenting part is well-engaged (2/5 or less palpable abdominally). ARM with a poorly-engaged presenting part (3/5 or more) dramatically increases cord prolapse risk. Palpate cord position beforehand.

Prevention

CTG monitoring after membrane rupture (spontaneous or artificial)
VE immediately after membrane rupture to exclude cord prolapse
ARM only when presenting part well-engaged
Elective caesarean for known malpresentations (breech, transverse lie) with polyhydramnios

🌍 GCC-Specific Context

SCFHS / DHA / QCHP Exam Focus ▼

Cord prolapse = cord descends through cervix after membrane rupture → cord compressed by presenting part → foetal hypoxia
Diagnosis: sudden foetal bradycardia after rupture of membranes; cord visible/palpable on VE
FIRST action: manually elevate presenting part off cord AND call for help simultaneously
Positions: knee-chest (preferred) or Trendelenburg or Sims' left lateral
Bladder filling (500–750 mL saline) — hydrostatic elevation of presenting part
Handle exposed cord with warm wet gauze — prevents vasospasm
Do NOT attempt to replace cord into uterus
Category 1 caesarean section — decision-to-delivery <30 minutes
ARM with unengaged presenting part = highest iatrogenic risk for cord prolapse
Breech, transverse lie, polyhydramnios = highest risk conditions

GCC Obstetric Emergency Training ▼

Cord prolapse simulation training conducted in all GCC tertiary maternity units as part of mandatory obstetric emergency training
Multi-professional team training (midwives + obstetricians + anaesthetists + neonatologists) improves cord-to-delivery intervals
All maternity units in GCC should have clear Category 1 caesarean section protocols with 30-minute decision-to-delivery target
Post-incident review of all cord prolapse cases for quality improvement

📝 MCQ Practice

1. A midwife performs a vaginal examination on a labouring patient after spontaneous rupture of membranes. She feels a pulsating loop of cord alongside the foetal head. The CTG shows severe foetal bradycardia. What is the MOST important FIRST action?

✅ B — Manual elevation of the presenting part to relieve cord compression is the most critical immediate action. It must be maintained continuously. Simultaneously call for help. Do NOT remove the hand from the vagina until delivery. Do NOT attempt to replace the cord — this is futile and damages cord vasculature.

2. Which position is MOST appropriate for a patient with cord prolapse while preparing for emergency caesarean section?

✅ B — Knee-chest (all-fours, chest down) is the preferred position — gravity lifts the presenting part cephalad and reduces cord compression. Trendelenburg (steep head-down) is an alternative. These positions work with manual elevation to reduce cord compression during transfer to theatre.

3. How much saline is instilled into the bladder as a temporising measure in cord prolapse during transfer to theatre?

✅ C — Bladder filling with 500–750 mL sterile saline hydrostatically elevates the presenting part, reducing cord compression as a bridge to delivery. The catheter is clamped after filling and drained immediately before uterine incision in theatre. This is an adjunct to — not replacement for — manual elevation.

4. An exposed loop of cord is visible at the introitus. How should the cord be handled?

✅ C — Exposed cord should be wrapped in warm moistened gauze/swabs to prevent temperature-related vasospasm. Do NOT attempt to replace the cord — this is ineffective and causes cord trauma. Cold causes vasospasm and worsens foetal hypoxia. Ice is absolutely contraindicated.