Complications: Umbilical Cord Prolapse
A prolapsed umbilical cord occurs when the unborn baby’s umbilical cord drops through the cervix into the vagina before the baby’s head. This is an emergency situation due to the fact that the blood supply to baby may be cut off. How much of the blood supply is cut off depends upon how long the cord has been prolapsed, and how much pressure is on the cord.
An umbilical cord prolapse occurs after your membranes are ruptured bag of water. It may happen immediately after your water breaks, or at any time afterwards. In some situations, the umbilical cord can be seen hanging from the vagina. A prolapse may also occur when baby’s head is not positioned against the cervix. It may also happen when baby is not head-down, such as a breech presentation, or transverse position. Most umbilical cord prolapses happen when the mother is in labor. If her water breaks on its own (spontaneous rupture of membranes), a vaginal exam should be done right away to make sure that the umbilical cord cannot be felt.1
The two types of umbilical cord prolapse
When the cord comes through the cervical opening before the baby, it is called an overt prolapse. The umbilical cord may be seen hanging from the vagina, or the cord may be in the vagina. When the umbilical cord is exposed to the open air, it becomes cold, which causes the vessels inside of it to clamp down, which causes even less blood supply to reach the baby.1
When the umbilical cord comes through the cervical opening (cervical os) at the same time as the baby, it is called an occult prolapse. In an occult prolapse, the umbilical cord cannot be seen, or felt.1
Risk factors for cord prolapse
There are a number of reasons why an umbilical cord may prolapse. They include:
- Spontaneous rupture of membranes (the bag of water breaks)
- Baby is not in the vertex position when the membranes rupture
- Polyhydramnios (larger amount of amniotic fluid than normal)
- When the baby is premature
- A woman has delivered many babies (multiparity)
- The umbilical cord is very thin, or has little coiling may slip through the cervix
- Artificial rupture of membranes when the baby’s presenting part is not applied to the cervix
- During an external cephalic version (attempting to rotate a baby that is not in the head-down position)
- Placing an internal scalp electrode on baby’s head
- During an amnioinfusion
When a woman is in the labor and delivery unit and her baby is being monitored by an electronic fetal monitor, a prolapsed umbilical cord may cause baby’s heart rate to suddenly become very slow. The rapid drop in heart rate will alert the physician, midwife, or labor and delivery nurses that a problem has developed. A rapid drop in an unborn baby’s heart rate does not always mean that an umbilical cord prolapse has occurred. A vaginal exam should be performed immediately to see of the cord has prolapsed. A baby’s heart rate may suddenly drop if the mother’s blood pressure drops too low, which sometimes happens after she receives an epidural, or spinal anesthesia.1
When a cord prolapse happens, the baby may suddenly begin to move inside of the uterus. If the mother is in a labor and delivery unit when the cord prolapses, and her baby’s fetal heart rate pattern is being monitored, it may show a very sudden drop in the heart rate that does not return to the previous rate (fetal bradycardia) if most, or all, of the blood supply to baby has been cut off.
If the umbilical cord is positioned between baby’s body and another surface (one of Mom’s bones, or tissue inside of her pelvis) the blood flow through the cord may only be affected when the she has a contraction. In this case, the fetal heart rate pattern will show a sharp drop in the heart rate during a contraction, then return to its normal rate after the contraction is over (variable deceleration). If this rapid drop in baby’s heart rate continues with each contraction, or if the heart rate suddenly drops to a dangerous level, the baby will develop hypoxia unless the pressure on the cord is relieved.2
In situations where the blood flow through the umbilical cord is completely cut off for no more than five minutes, the baby may completely recover. In situations where the blood flow through the umbilical cord is completely cut off for longer than five minutes, or the baby’s heart rate continues to drop during contractions for too long a period of time, the baby may not fully recover, or may not survive.
What happens to the mother depends on the kind of prolapse
When an overt prolapse of the cord occurs, it is an emergency situation. The most important immediate action is to relieve the pressure on the cord until the baby is delivered. While preparing for an emergency cesarean section, the mother will be assisted into the knee-chest position. A physician, midwife, or labor and delivery nurse, will place fingers, or a hand, inside of the vagina to lift the present part of baby’s body away from the cord. An oxygen mask should be placed on the mother’s face. A Foley catheter may also be placed in the mother’s bladder and filled with enough sterile fluid to help left the part of baby’s body away from the cord. When the mother is taken to the operating room, she will receive general anesthesia so that her baby can be delivered as quickly as possible.2
When an occult prolapse of the cord occurs, the baby’s heart rate may only drop when the mother has a contraction. In an occult prolapse, the umbilical cord cannot be felt when a vaginal exam is performed. In this case, the mother’s position will be changed so that she is either lying completely on her left side, or she will be placed on her back and the bed will be adjusted so that her head is lower than her body. An oxygen mask should be placed on her face. If the baby’s heart no longer drops suddenly (variable decelerations), she may be able to continue with her labor. Her physician or midwife may start an amnioinfusion to add extra fluid around inside of her uterus, which may take the pressure of the umbilical cord when she has a contraction. If baby’s heart continues to drop quickly when a contraction occurs, an emergency cesarean section should be performed.
Reducing the risks of a cord prolapse in the labor and delivery unit
To reduce the possibility of baby’s umbilical cord coming through the cervical opening, the physician, or midwife, should perform a vaginal exam before performing an amniotomy (breaking the bag of water). The position of the baby’s presenting part should be checked to make sure that baby is in the vertex position (head down), and that the head is applied against the cervix. If the head is still high, the membranes should be ruptured by the physician or midwife using a needle (instead of an amnihook), which would cause a slow leak of amniotic fluid instead of a gush of fluid. If possible, the membranes should be ruptured at a later time, when the head is lower.2
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- Holbrook, B., & Phelan, S. (2013). Umbilical cord prolapse. Obstetrics and Gynecology Clinics, 40(1), 1-14. doi: 10.1016/j.ogc.2012.11.002
- Kish, K. (2013). Chapter 19. Malpresentation & Cord Prolapse. In DeCherney, A., Nathan, L., Laufer, N., & Roman, A (Eds), CURRENT diagnosis & treatment: Obstetrics & Gynecology. New York, NY: McGraw-Hill