Umbilical cord prolapse and its effect on childbirth and how to deal with it

Umbilical cord prolapse is one of the most dangerous obstetric emergencies that can occur during childbirth, as it puts the baby’s life at immediate risk within just minutes. Simply put, the umbilical cord—responsible for delivering oxygen and nutrients to the fetus—slips down before or alongside the baby into the birth canal. This can lead to compression of the cord and a severe reduction or complete interruption of blood and oxygen flow.The main concern is that this condition often happens suddenly, especially after the amniotic fluid breaks or during labor. It requires extremely rapid medical intervention to save the baby before severe oxygen deprivation occurs, which could result in serious complications.In this Dalili Medical article, we will discuss umbilical cord prolapse, including its causes, warning signs, its impact on labor, and how it is managed quickly and effectively to save the baby’s life at the right time.

How common is umbilical cord prolapse?

Umbilical cord prolapse is a relatively uncommon condition in childbirth, occurring in حوالي 1 out of every 300 deliveries. رغم ندرته، إلا أنه يُعتبر من أخطر حالات الطوارئ التوليدية التي تتطلب تدخلًا فوريًا وسريعًا.

The risk of umbilical cord prolapse increases in certain pregnancy and labor situations, including:

• Excess amniotic fluid (polyhydramnios), which allows the cord to move more freely
• Breech presentation or any fetal position where the head does not adequately cover the cervix
• A small fetus for gestational age or preterm labor
• An unengaged fetal head before rupture of membranes
• Premature or early rupture of membranes (PROM), especially before the head is well applied
• Twin pregnancy, particularly during the delivery of the second twin

It may also occur near the end of pregnancy if the amniotic fluid suddenly breaks before the fetal head settles into the birth canal.

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Why is umbilical cord prolapse an emergency?

Umbilical cord prolapse is considered a medical emergency because it leads to compression of the cord, causing a rapid and severe reduction in oxygen and blood flow to the fetus within minutes. Without prompt intervention, this can result in serious complications.

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What is the first step when cord prolapse is suspected?

Immediate action is critical. Initial steps include:

• Calling for urgent medical assistance
• Elevating the presenting part of the fetus to relieve pressure on the cord
• Preparing for emergency delivery (most often an urgent cesarean section)

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Can cord prolapse occur with intact membranes?

❌ This is rare. However, if the cord lies in front of the fetus while the membranes are still intact, the condition is called:

Funic presentation

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What temporary positions can help before medical intervention?

Certain positions may temporarily reduce pressure on the cord until emergency care is provided, such as:

• Knee-chest position
• Trendelenburg position

???? The goal of these positions is to decrease pressure from the presenting fetal part on the umbilical cord, helping to temporarily improve blood and oxygen flow.

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Why is the fetal head lifted manually in emergencies?

A healthcare provider may manually elevate the fetal head داخل المهبل بهدف:

• Reducing direct pressure on the umbilical cord
• Temporarily improving blood and oxygen flow to the fetus
• Gaining time until emergency delivery can be performed

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What is the key CTG sign that raises suspicion?

Important signs on cardiotocography (CTG) include:

• Severe or recurrent variable decelerations
• Sudden fetal bradycardia

These findings are strong indicators of cord compression.

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Can the umbilical cord return to its normal position?

❌ No, the cord does not return to its normal position on its own once prolapse occurs.
This condition always requires urgent medical intervention and delivery.

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What is the relationship between membrane rupture and cord prolapse?

When the membranes rupture prematurely or suddenly before the fetal head is engaged, the rapid outflow of amniotic fluid can:

• Push the umbilical cord downward into the birth canal, leading to prolapse

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Which fetal positions are most associated with cord prolapse?

The condition is more likely to occur in:

• Breech presentation
• Transverse lie

This is because the fetal head does not effectively seal the cervical opening.

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Does cord prolapse affect the mother?

In most cases, umbilical cord prolapse does not directly harm the mother. However, it often requires:

• Emergency surgical intervention (usually cesarean section)
• Rapid anesthesia
• Significant psychological stress due to the emergency situation 

What is the difference between umbilical cord prolapse and cord compression?

• Umbilical cord prolapse: The cord descends in front of or beyond the presenting part of the fetus into the birth canal.
• Cord compression: The cord remains in its normal position but is compressed داخل الرحم، مما يؤثر على تدفق الدم فقط.

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What is umbilical cord prolapse?

Umbilical cord prolapse is an obstetric emergency that occurs during labor when the umbilical cord slips through the cervix into the birth canal before the baby is delivered.

It most commonly happens after rupture of membranes (when the water breaks), especially if the fetal head or presenting part is not well engaged in the pelvis.

The danger lies in the possibility of cord compression, which can reduce blood and oxygen flow to the fetus and lead to fetal distress.

Types of umbilical cord prolapse:

• Overt prolapse: The cord is visible داخل المهبل أو خارج الفتحة المهبلية
• Occult prolapse: The cord is not visible but is compressed between the fetus and the uterine wall or pelvis

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How does fetal hypoxia occur in cord prolapse?

Fetal hypoxia occurs due to sudden or repeated compression of the umbilical cord between the fetus and the uterine wall or pelvic bones, disrupting normal blood flow.

Mechanism step by step:

1. Cord descent
   The cord slips into the birth canal, often after rupture of membranes, making it vulnerable to الضغط.
2. Cord compression
   The fetal head or presenting part compresses the cord, especially during uterine contractions. This compression may be:
   • Intermittent
   • Continuous and severe
3. Effect on cord vessels
   The umbilical cord contains:
   • Two arteries (carry deoxygenated blood from the fetus)
   • One vein (carries oxygenated blood to the fetus)
     The umbilical vein is usually affected first because it is more easily compressed.
4. Reduced blood and oxygen flow
   Compression leads to:
   • Decreased oxygenated blood reaching the fetus
   • Disruption of fetal circulation
5. Progression to hypoxia and CO₂ buildup
   With استمرار الانضغاط:
   • Oxygen levels drop
   • Carbon dioxide levels rise
   • Metabolic acidosis develops
6. Effects on the fetus
   This results in:
   • Sudden fetal bradycardia (one of the earliest and most important signs)
     If untreated:
   • Fetal asphyxia
   • Severe complications or even fetal death

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Types (patterns) of umbilical cord prolapse

1. Overt (frank) prolapse
   • The cord descends into or outside the vagina
   • Usually occurs after membrane rupture
   • High risk due to direct compression
2. Occult prolapse
   • The cord is not visible
   • Compressed between the fetus and uterus
   • Often detected through CTG changes
   • Difficult to diagnose
3. Funic presentation
   • The cord lies in front of the presenting part
   • Membranes are still intact
   • Considered a warning stage before prolapse
4. Compound presentation with cord
   • A fetal part (e.g., hand) descends alongside the cord

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Signs of umbilical cord prolapse

1) Direct signs (on examination)

• Visible cord in the vagina or outside the vaginal opening
• Palpation of the cord during vaginal examination
• Cord felt before the fetal head

2) Indirect signs (fetal)

• Sudden fetal bradycardia (key warning sign)
• CTG abnormalities:
  • Variable decelerations
  • Sudden persistent drop in fetal heart rate
• Signs of hypoxia:
  • Abnormal heart rate patterns
  • Rapid deterioration if untreated

3) Contextual clues

• Sudden rupture of membranes before head engagement
• Sudden fetal distress after membrane rupture
• Maternal sensation of “something coming down” in the vagina

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Causes of umbilical cord prolapse

Umbilical cord prolapse occurs due to factors that allow the cord to descend before or alongside the presenting part.

1) Fetal-related causes

• Abnormal fetal positions:
  • Breech
  • Transverse lie
• Unengaged fetal head before membrane rupture
• Small fetus or prematurity (more فضای للحركة)

2) Amniotic fluid & membrane-related causes

• Premature rupture of membranes (PROM), especially before engagement
• Polyhydramnios (excess fluid)
• Sudden gush of amniotic fluid pushing the cord downward

3) Labor and medical intervention causes

• Artificial rupture of membranes (amniotomy) before head engagement
• Labor induction in unstable conditions
• Multiparity (repeated pregnancies leading to less uterine tone and fetal stability)

4) Pregnancy-related causes

• Twin or multiple pregnancy
• Disproportion between fetal size and pelvis
• Placenta previa (may be associated with abnormal fetal positioning)

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Risk factors for umbilical cord prolapse

1) Fetal factors

• Breech or transverse lie
• Prematurity or small fetal size

2) Amniotic fluid factors

• Polyhydramnios
• Sudden, heavy fluid release

3) Membrane and labor factors

• Premature rupture of membranes (PROM)
• Artificial rupture before engagement
• Multiparity (due to reduced uterine support and fetal stability) 

Fourth: Anatomical and pregnancy-related factors

• Multiple pregnancy (twins or more), which increases fetal instability
• A relatively small fetal head compared to the maternal pelvis
• Placenta previa in some cases, which may be associated with abnormal fetal positioning

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How is umbilical cord prolapse diagnosed?

Diagnosis is rapid and urgent, based mainly on clinical examination and fetal monitoring.

First: Clinical examination (most important and fastest)

1. Vaginal examination

• The cord may be felt inside the vagina
• It may be palpated as a pulsating structure beside the fetal head
• It may be seen protruding through the cervix in overt cases

2. Direct visualization

• In overt prolapse, the cord may be visible outside the vaginal opening

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Second: Fetal signs (CTG)

Even if the cord is not visible, suspicion arises when:

• Sudden fetal bradycardia
• Severe variable decelerations
• Sudden abnormal changes in the CTG tracing

These changes often appear immediately after rupture of membranes.

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Third: Speculum examination

• Used to visualize the vagina without applying pressure on the cord
• Helps confirm diagnosis, especially in non-visible cases

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Fourth: Ultrasound

• May show the cord in front of the fetal head (funic presentation)
• Not the primary diagnostic tool in emergencies

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What are the complications of umbilical cord prolapse?

Complications can develop rapidly due to cord compression and reduced oxygen supply.

First: Fetal complications

1. Fetal hypoxia

• Caused by cord compression
• Leads to decreased oxygen delivery

2. Fetal asphyxia

• A more severe stage of oxygen deprivation
• Causes major disruption of vital functions

3. Fetal acidosis

• Results from increased carbon dioxide and low oxygen
• Leads to rapid deterioration

4. Severe bradycardia or cardiac arrest

• Clearly seen on CTG
• May progress to intrauterine fetal death if not treated urgently

5. Long-term neurological complications (if the baby survives)

• Cerebral palsy
• Delayed neurological and motor development
  → Due to oxygen deprivation during birth

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Second: Maternal complications

Usually, there are no direct serious physical complications for the mother, but it may lead to:

• Increased stress and anxiety during labor
• Need for emergency cesarean section
• Rapid anesthesia and urgent surgical intervention

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Is there a medical (drug) treatment for cord prolapse?

⚠️ Medications are not definitive treatment. They are only temporary measures until delivery is achieved.

1) Tocolytics (to stop uterine contractions)

Goal: Reduce uterine contractions to decrease pressure on the cord and temporarily improve blood flow.

Common medications:

• Terbutaline (beta-2 agonist) → relaxes the uterus quickly
• Nitroglycerin (IV or sublingual) → rapid uterine relaxation in emergencies

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2) Stop labor-inducing medications

• Oxytocin must be stopped immediately
• Any drugs increasing contractions should be discontinued

→ Continued contractions worsen cord compression and hypoxia.

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3) Oxygen for the mother

• Given to improve maternal oxygen saturation
• Indirectly increases oxygen delivery to the fetus

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4) Intravenous fluids (IV fluids)

• Support maternal circulation
• Improve blood flow to the placenta and fetus

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5) Analgesics or sedatives (if needed)

• Used to reduce stress and pain during preparation
• Not a primary treatment

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Surgical management of umbilical cord prolapse

Surgery is the definitive and main treatment, aiming for rapid delivery to reduce cord compression time.

First: Emergency cesarean section

This is the most common and important treatment.

Indications:

• If the baby is not very close to vaginal delivery
• If vaginal delivery is not immediately possible

Steps:

• Rapid assessment of mother and fetus
• Immediate preparation of the operating room
• Rapid anesthesia (general or spinal depending on the situation)
• Urgent abdominal and uterine incision
• Immediate delivery of the baby

Goal:

• Minimize duration of cord compression
• Prevent brain hypoxia
• Save the baby’s life as quickly as possible

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Second: Operative vaginal delivery

Used only in selected cases.

Indications:

• Fetal head is very low in the pelvis
• Delivery is expected within minutes

Methods:

• Forceps
• Vacuum extraction

⚠️ Only used if delivery will occur very quickly, otherwise immediate cesarean is performed.

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Third: Supportive measures before surgery

• Manual elevation of the fetal head via vaginal examination
• Keeping the cord moist with warm saline to protect it

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Decision-making sequence in emergencies

• Diagnose cord prolapse
• Assess fetal head station
• If delivery is not imminent → emergency cesarean
• If the head is very low → assisted vaginal delivery

⚠️ Critical point:
⏱️ Time is the most important factor

Every minute of delay increases the risk of fetal hypoxia.
The goal is to complete delivery within minutes (ideally within 30 minutes or less).

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Can umbilical cord prolapse be prevented?

Yes, the risk can be significantly reduced, although complete prevention is not always possible.

First: Before and during labor

1. Ensure the fetal head is engaged before rupturing membranes
2. Avoid early artificial rupture of membranes, especially in:
   • Breech or transverse positions
   • High/unengaged fetal head
3. Use ultrasound before interventions to:
   • Confirm fetal position
   • Assess head engagement
   • Evaluate amniotic fluid

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Second: In high-risk cases

Consider changing the delivery plan, including cesarean section when necessary, such as in:

• Breech presentation
• Transverse lie
• Placenta previa
• Twin pregnancy

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Third: In polyhydramnios

• Manage cautiously
• Gradual and controlled drainage of amniotic fluid may be done under monitoring

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Fourth: After rupture of membranes

• Immediate monitoring
• Continuous fetal heart rate monitoring
• Ensure the fetal head remains stable in the pelvis

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Fifth: General preventive measures

• Avoid unnecessary vaginal examinations after membrane rupture
• Be prepared for emergencies in high-risk pregnancies
• Ensure availability of a trained medical team for rapid intervention