Umbilical cord prolapse is a rare but potentially dangerous complication that can occur in late pregnancy and labor and can end up with adverse perinatal outcomes.
This article looks at what cord prolapse is, how to prevent it, and also discusses management if an umbilical cord prolapse occurs.
Umbilical cord prolapse – definition and incidence
Let’s start with a couple of definitions related to umbilical cord prolapse so we know exactly what we are talking about.
Cord presentation is when the umbilical cord is in front of or at the side of the presenting part of the baby.
The presenting part of the baby is the part of the baby that presents against the cervix; it’s the lowest part of the baby.
A cord prolapse occurs when the umbilical cord descends through the cervix alongside or past the presenting part of the baby.
Determining whether it’s a cord presentation or a cord prolapse depends on whether or not the membranes have ruptured. In the case of a cord presentation, the bag of waters is complete; membrane rupture hasn’t happened yet. When the waters break and the cord is in front of the baby’s body that’s a cord prolapse.
Most cord prolapses occur when the waters break but not always. Rupture of membranes might occur, but the presenting part of the baby might be high in the pelvis. The umbilical cord doesn’t prolapse immediately but it does later, as labor progresses.
Your baby’s head is usually the presenting part during labor. This is called cephalic presentation. Your baby is head down with the chin tucked in and the crown of the head is first part of your baby’s body to be seen and also first to be born.
The head fits snugly against your cervix and it acts like a plug so nothing can get past it that shouldn’t – such as the umbilical cord.
Very rarely, though, the umbilical cord slips past the presenting part. This is called umbilical cord prolapse.
According to the latest research, umbilical cord prolapse has been decreasing in the last few decades. In the 1930s it was around 0.6%; in 2016 the rate was found to be 0.1%
The reduction in cord prolapse cases is believed to have been caused by improved care during pregnancy. A prolapsed umbilical cord tends to be much more common when the baby isn’t head first, as there’s usually room for the umbilical cord to slip through.
What’s it called when the cord is wrapped around the baby’s neck?
Umbilical cord prolapse is not the same thing as the cord being wrapped around the baby’s neck. This is called a nuchal cord and it hardly ever compromises the baby’s wellbeing.
Around 30% of babies have a nuchal cord during labor, which makes this event quite normal, and minor when compared with the seriousness of an umbilical cord prolapse.
You can read more about it in Nuchal Cord – 9 Facts About A Cord Around Baby’s Neck.
What does a cord prolapse feel like?
If you can’t listen to your baby’s heart rate, the only way you’ll know the cord has prolapsed is if you see, or feel, a short piece of the umbilical cord protruding from your vagina. This is only possible if your waters have broken.
Cord prolapse is very rare with your first baby, as first babies tend to engage from around 38 weeks of pregnancy. This means the head is well down in the pelvis and there’s hardly any room to let the umbilical cord pass.
Another sign of cord prolapse is a change in your baby’s fetal movements. When umbilical cord compression occurs there are severe changes to the baby’s heart rate and this can cause movements to slow or stop.
Although a change in your baby’s movements doesn’t always mean an abnormal fetal heart rate, you should seek immediate medical assistance if you notice any changes to your baby’s movements. Your baby might have stopped moving because he’s seriously compromised and is saving vital energy at this point.
Signs and symptoms of umbilical cord prolapse
The first sign of cord prolapse is usually a sudden and severe change in the fetal heart rate. This is because, when the cord prolapses, cord compression occurs. The compression of the cord interrupts the normal blood flow from the placenta to your baby.
If you’re in the hospital, your health care provider will immediately suggest a change in position to try to resolve the fetal heart rate changes.
If cord compression or cord presentation is suspected, a vaginal examination is done to feel for the presenting part. If the cord can be felt, it means cord prolapses are causing pressure on the cord.
Cord presentation management
Some health care providers choose to perform a controlled artificial rupture of the membranes, especially when cord presentation is suspected and indications from an ultrasound predict cord prolapse is likely.
They do this in an attempt to stop the cord from prolapsing. If it does, at least they are right next door to a fully prepared operating room.
There are many risks in this practice as interfering too early when it’s not necessary can trigger an unnecessary cascade of interventions.
Let me explain this a bit more clearly. When the umbilical cord is just presenting and the woman is moving freely it’s very likely that the cord moves away because it’s ‘swimming’ in the amniotic fluid.
Spontaneous rupture of membranes usually occurs when the cervix is almost fully dilated. Therefore, even if the cord prolapses at this stage, it’s quite likely the baby will be born soon after the rupture of membranes.
When an ultrasound shows a cord presentation, the woman should first make sure she’s received the right information about what to do if her waters break before labor starts, and then carry on with normal life.
Later, she should be allowed to birth as she wishes in a center with an operating room nearby, in case it’s needed. Attending staff should be informed when the woman is admitted in labor.
Cord prolapse management
A prolapsed umbilical cord is considered an obstetric emergency and its management will vary, depending on whether the woman in a hospital or at home.
Let’s look at the optimal management of prolapsed cord in both settings.
What to do if cord prolapses at home?
If you aren’t in hospital and you think your cord has prolapsed, call an ambulance immediately.
While you’re waiting:
- Move into a knee-chest position on the floor, with your bottom higher than your shoulders, to take the baby’s weight off your cervix. Stay in this position until the ambulance arrives
- If the cord is protruding out of your vagina, gently push it back in. This helps keep the cord warm and moist, which prevents the blood vessels from spasming
- It isn’t recommended that anyone uses fingers to keep the baby’s head off the cord, unless it is a health professional who knows how to deal with this emergency.
Prolapsed cord in a hospital
If the cord slips down through the cervix during labor and you’re in hospital, your care provider will place fingers inside your vagina and gently push the baby’s head away from the cord.
To reduce pressure, you will be moved into a position that elevates your bottom, such as on your hands and knees, with pelvis up and head down.
You’ll also be given oxygen. Your baby needs to be born very quickly to prevent lack of oxygen. If the baby is low enough, your care provider might use either forceps or a vacuum; otherwise, you will need a c-section.
Cord prolapse risk factors
There are certain pregnancy complications that increase the risk of prolapsed cord. Let’s look at these and other risk factors that can cause a cord prolapse:
- Polyhydramnios. Too much amniotic fluid can cause the baby to float above the cervical rim, allowing the cord to slip below the baby’s head
- Malpresentation of baby. The optimal fetal position for birth is head down, ensuring the baby’s head covers the cervix. Side lie (transverse) or breech presentation (head up and bottom down) can allow the cord to come through the cervix first
- Pre-labor rupture of waters. If the baby isn’t engaged and membranes rupture before labor, there is a chance the cord will prolapse with the gush of fluid from the birth canal
- Preterm birth. When labor starts prematurely, the baby might not be engaged in the pelvis yet and, if preterm premature rupture of membranes occurs, cord prolapse is likely to happen
- Twins or multiple gestation pregnancies. Due to the different position of each baby, there’s a risk one will have a low-lying cord
- Long umbilical cord. This can make it easier for the cord to be in front of the presenting part
- Induction when baby isn’t engaged. If the baby’s head is not well into the cervix, there’s a risk of a prolapsed umbilical cord.
What causes a cord prolapse?
Almost half the causes of umbilical cord prolapse are iatrogenic, meaning they happen as a consequence of interventions done during labor
The most common intervention is AROM, or artificial rupture of membranes. This procedure is risky for women who’ve had several babies previously, as the baby’s head is usually high
Rupturing the membranes artificially when the head is not snug against the cervix increases the risk of cord prolapse.
Types of cord prolapse
Doctors divide umbilical cord prolapse into three types:
- Overt cord prolapse. The unbilical cord goes through the cervix into the birth canal after the membranes have ruptured
- Funic presentation. A loop of the umbilical cord is between the fetal presenting part and the cervix
- Occult prolapse. The cord is alongside the presenting part but can’t be seen or felt by your health care provider; it can happen with intact or ruptured membranes.
What is the difference between cord prolapse and cord presentation?
Umbilical cord prolapse means the cord has passed through the cervix into the vagina before the presenting part of the baby.
Cord presentation is when the cord is ahead of the presenting part of the baby but hasn’t passed through the cervix. This is also known as funic presentation (see above).
Cord prolapse treatment
Cord prolapse is a medical emergency, and requires immediate action to prevent fetal distress, birth asphyxia, brain damage and cerebral palsy.
Immediate action is taken to monitor your baby’s heart rate while preparing you for emergency delivery of the baby.
Your health care provider will perform a vaginal exam, to asses cervical dilation.
If you’re fully dilated and your baby is about to be born, your health care provider might encourage you to push.
If you’re not fully dilated or the birth of the baby isn’t imminent, you will be prepared for an emergency c-section.
You will be given oxygen, via a face mask or nasal cannula, and encouraged to continue slow deep breathing, to prevent hypoxia.
Continuous fetal monitoring will be commenced to monitor uterine contractions and your baby’s well-being. An IV line will be started to administer intravenous fluid before and during surgery.
Complications of cord prolapse
The diagnosis of a prolapsed cord is an acute life-threatening obstetric emergency, as the umbilical cord can become compressed and cut off the flow of blood, and therefore oxygen, to the baby.
This causes changes in your baby’s heart rate and fetal distress. For most babies, there is no long-term harm if the cord prolapse is diagnosed early and action is taken immediately.
If the time between diagnosis and birth is too long, prolonged cord compression can result in birth asphyxia, brain damage and cerebral palsy. The mortality rate for untreated cord prolapse is high.
Outcomes of cord prolapse
How severely an umbilical cord prolapse will affect the baby will depend on how much pressure was on the cord and the length of time the cord was compressed.
If it was a partial cord compression it’s likely the baby will be born without any problems. Full compression reduces blood flow and oxygen to the baby and, if not detected in time, can lead to severe brain damage or death.
It’s a rare complication of birth and the incidence has decreased over the years. There have been significant advances in the management of umbilical cord prolapse, which has led to improved birth outcomes.
How to prevent a cord prolapse
It’s scary to think of the things that can go wrong in labor but it’s important to be aware and know what you can do to prevent this from happening.
There are certain things you can do to reduce the risk of the umbilical cord being compressed by your baby’s head:
- Avoid having your waters broken, especially if you’re not in labor and your baby’s head isn’t fully engaged. Babies can pop out of the pelvis even when they’re engaged, so it’s best to wait until nature determines when labor should begin
- Avoid cervical checks during pregnancy and labor, because of the risk of accidental rupture of membranes
- If your baby needs to be born early, discuss with your care provider the risks of cord prolapse associated with any induction methods suggested
- Be aware of optimal fetal positioning to ensure your baby is in a perfect position for birth. Spinning Babies is a fantastic resource for this
- Understand that certain conditions, such as excessive amniotic fluid, come with a higher risk of cord prolapse, and be prepared.