Obstetrics & Gynaecology
Cord Prolapse: Risk Factors, Relieving Compression & Delivery
Contents
Cord prolapse in one place: who is at risk, how to prevent it, how to take the pressure off the cord, and how to deliver. Based on the OLSS (Obstetric Life Saving Skills) lecture on cord prolapse at Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh.
Definition and classification
Cord prolapse is descent of the umbilical cord into the lower segment, where it lies below the presenting part, without intact membranes. It is uncommon overall, and more common in breech presentation (about 1%).
The lecture's classification (Wong 2021) goes by where the cord lies, and each type can occur with the membranes ruptured or intact:
- Cord prolapse: the cord is below the cervix.
- Cord presentation: the cord is above the cervix and below the presenting part.
- Compound cord presentation: the cord is above the cervix and alongside the presenting part. With ruptured membranes this was previously called "occult" cord prolapse.
Predisposing factors
| General | Procedure-related |
|---|---|
| Maternal: preterm labour, grand multiparity, rupture of membranes | Amniotomy |
| Fetal: prematurity, low birth weight (<2.5 kg), abnormal lie and presentation, fetal anomaly, multiple pregnancy | External cephalic version |
| Liquor and placenta: polyhydramnios, minor placenta praevia | Internal podalic version |
| Induction of labour | |
| Cervical ripening balloon catheter |
Prevention
- Discuss admission from 37 weeks with women whose lie is transverse, oblique or unstable.
- Advise early presentation to hospital if the membranes rupture.
- Inpatient management for PPROM with an abnormal presentation.
- Avoid ARM when the presenting part is high. If it must be done, arrange for an immediate caesarean section.
- Keep upward pressure on the presenting part during VE to a minimum.
Remark: PPROM = preterm prelabour rupture of membranes; ARM = artificial rupture of membranes; VE = vaginal examination.
Immediate measures
Call for help, then relieve cord compression:
- Maternal positioning: Trendelenburg or knee-chest position, to take pressure off the cord.
- Manual elevation of the presenting part, lifting it off the cord through the vagina.
- Bladder filling: instil 500-750 mL of saline into the bladder through a Foley catheter.
- Wedging the maternal pelvis, supine or lateral, is another option.
Acute management algorithm
For a live fetus with cord prolapse and ruptured membranes, when vaginal delivery is not imminent (Wong 2021):
- First line: Trendelenburg (15°), wedging, or digital elevation of the presenting part.
- Uterine contractions? Give acute tocolysis.
- Cord outside the vagina? Wrap it warm.
- Persistent fetal distress? Move to second-line measures:
- Knee-chest position: preferred, because it gives the best elevation without extra equipment. Less suitable if the cord is outside the vagina, she can't cooperate or is anaesthetised, or she needs long-distance transfer.
- Bladder filling (500 mL): if knee-chest isn't feasible and a urinary catheter is available.
- Steep Trendelenburg (30°): if neither knee-chest nor bladder filling is feasible.
- Caesarean delivery, whether or not the distress persists.
Definitive management
- Emergency caesarean section is the preferred and most effective intervention.
- Vaginal delivery may be considered when delivery is imminent, e.g. fully dilated with a low fetal station, or with an intrauterine fetal death.
Sources
- Obstetric Life Saving Skills (OLSS) lecture: Cord Prolapse. Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh, 2026.
- Wong. Umbilical cord prolapse: a revisit. Am J Obstet Gynecol. 2021 (classification, manoeuvres and management algorithm figures, as reproduced in the lecture).