1. Definition
The term ‘cord prolapse’ refers to the descent of the
umbilical cord, following rupture of the membranes,
through the cervix so that it lies either alongside the fetal
presenting part or descends beyond it (Murphy &
MacKenzie 1995, Lin 2006, Siassakos et al 2008) (Fig 1).
Where the forewaters are still intact, this is defined as a
‘cord presentation’ (Tiran 2006, Siassakos et al 2008).
In normal circumstances, the well flexed fetal head moves
down into the maternal pelvis during the latter weeks of
pregnancy or in early labour, which prevents the descent of
the umbilical cord.
There are two types of cord prolapse:
G Overt prolapse - there is protrusion of the
umbilical cord beyond the fetal presenting part.
The membranes are invariably ruptured and
the cord is either visible or palpable on
vaginal examination.
G Occult prolapse – the cord descends alongside,
but not beyond the presenting part in the
presence of intact or ruptured membranes.
Definitive diagnosis is difficult, but clinical
features of fetal compromise may be
indicative of cord prolapse (Siassakos
et al 2008).
Cord prolapse is usually diagnosed at vaginal
examination; however, it may also be suspected in
pregnancies considered at increased risk of cord
prolapse, and/or where there are abnormal changes in
the fetal heart rate pattern, eg variable fetal heart rate
decelerations or fetal bradycardia (Koonings et al 1990).
It is a life-threatening obstetric emergency because
blood flow through the umbilical vessels is often
compromised by the compression of the umbilical cord
against the fetal presenting part, the cervix and uterus,
and the female bony pelvis, which can lead to
intrapartum hypoxia, long term morbidity and death
(Siassakos et al 2008).
Incidence
Cord prolapse is not common and the incidence is
considered to range from 0.1% to 0.6% of births (Lin 2006,
Siassakos et al 2008). However, where cord prolapse occurs
in the presence of a breech presentation, this rate increases
further to just over 1% of births (Panter & Hannah 1996).
Background
Cord prolapse is a true obstetric emergency associated with
maternal morbidity and perinatal morbidity and mortality.
The perinatal mortality rate associated with cord prolapse
remains high at around 9%, although the rate has fallen in
past decades (Murphy & MacKenzie 1995). This is believed
to be due to modern obstetric practices which may have
influenced the natural history of cord prolapse (Boyle &
Katz 2005). These include the more rapid and frequent use
Obstetric emergencies
Umbilical Cord Prolapse
Obstetric emergencies / Umbilical Cord Prolapse 01
Fig. 1
Prolapsed umbilical cord
Fetus
Uterus
Umbilical
cord
Cervix

2. of operative births (caesarean sections) and a more
proactive approach to the intrapartum management of
preterm births (Panter & Hannah 1996). In unfortunate
cases where infant death does occur, this is now more
likely to be associated with complications relating to the
prematurity of the fetus or its low birth weight, rather than
as a result of intrapartum asphyxia (Murphy and MacKenzie
1995, Siassakos et al 2008).
The research evidence indicates that the time interval
between the diagnosis of cord prolapse and the delivery
of the infant is significantly related to fetal outcome and
the incidence of stillbirth and neonatal death. Therefore,
where a cord prolapse occurs within the community setting,
delay in transfer to hospital appears to be a significant
factor in fetal prognosis (Murphy & MacKenzie 1995).
The anticipation of cord prolapse, its early diagnosis and
the effective monitoring of fetal well-being are therefore all
crucial aspects of intrapartum care (Koonings et al 1990,
Draycott et al 2008).
Risk factors linked with cord prolapse
The possibility of a cord prolapse occurring should be
anticipated where the membranes (forewaters) rupture in
any situation and the presenting part is either not fully
engaged, or not well applied to the cervix/lower uterine
segment. Therefore, the presence of any of the following
factors could predispose to cord prolapse:
General
Related to engagement of the presenting part
G Unengaged or poorly applied presenting part
G Multiparity – the presenting part may not
be engaged
G Malpresentation - eg shoulder/compound
presentation
G High parity/unstable lie – where weakened
muscles allow unrestricted movement and the
long axis of the fetus is constantly changing
eg oblique/transverse lie
G Breech presentation – particularly with a footling
or complete breech
Related to uterine/pelvic factors
G Polyhydramnios (also referred to as hydramnios)
– an excessive amount of amniotic fluid in
pregnancy, means the cord can easily slip down
in the ‘gush’ following spontaneous rupture of
the membranes (SRM)
G Unusually long umbilical cord
G Low lying placenta (placenta praevia) or other
abnormal implantation of the placenta
G Malformation/contracture of the pelvis
Related to fetal factors
G Prematurity - where the gestation is < 37
completed weeks of pregnancy ie the smaller
size of the fetus is significant in relation to the
size of the maternal pelvis and malpresentation
is more common
G Low birth weight/small for gestational age
where the birth weight is <2.5 kg (as before)
G Second twin – where malpresentation is
more commonplace
G Fetal congenital malformation
Related to clinical procedures
It is suggested that around 50% of cord prolapses are preceded
by obstetric intervention/manipulation (Usta et al 1999).
G Planned artificial rupture of the membranes in
the presence of a high presenting part
G External cephalic version (ECV)
G Manual rotation of the fetus (eg internal
rotation of occipito-posterior (OP) position)
G Stabilising induction of labour
G Application of fetal scalp electrode (FSE)
G Internal podalic version of the second twin
G Rotational instrumental delivery (Draycott et al
2008, Siassakos et al 2008)
Obstetric emergencies / Umbilical Cord Prolapse 02
Obstetric emergencies Umbilical Cord Prolapse

3. Obstetric emergencies Umbilical Cord Prolapse
Obstetric emergencies / Umbilical Cord Prolapse 03
First line management
In hospital
Where cord prolapse is suspected, the practitioner should
perform a vaginal examination without delay and where it
is diagnosed, immediately instigate the following measures:
G The practitioner needs to remain calm, so that
the woman and her partner do not panic/
become distressed. Always endeavour to give
explanations of your findings and the emergency
measures that might be required. While it can be
more difficult in true emergency situations to
keep the woman and her partner informed of all
events, it is important to gain their informed
consent/cooperation for any interventions/
procedures needed.
G Use the emergency call bell to summon urgent
assistance. The delivery suite coordinator will
need to summon the obstetric registrar,
anaesthetist, theatre team (for caesarean section)
and neonatal paediatrician.
G If an intravenous infusion of oxytocin is in
progress, this should be discontinued
immediately.
G Maternal oxygen via non-rebreathing facemask
at a rate of 15 litres/min may be given to help
increase Po2 levels in the hypoxic fetus.
G The practitioner who has diagnosed the cord
prolapse should make every effort to try and
keep the umbilical cord from being compressed
between the presenting part and the woman’s
bony pelvis. With their consent, the woman
should be assisted into the knee chest position
(ie the baby gravitates away from the lower
uterine segment) (Fig 2), or helped to lie down in
the left lateral with a pillow or make-shift wedge
positioned under her left hip (exaggerated Sims
position) (Fig 3). The head of the bed may also
be lowered (ie Trendelenburg position) to help
relieve cord compression.
G The practitioner should perform a vaginal
examination and, keeping their fingers/gloved
hand in the woman’s vagina, make every effort
to manually elevate the presenting part and
reduce any compression against the umbilical
cord. Where SRM occurs at the time of vaginal
examination, elevation of the presenting part
should be instigated and maintained. This is
particularly important during uterine contractions
and elevation should continue until delivery
(Vago 1970).
G Excessive handling of the umbilical cord should
be avoided, as this can induce the vessels in the
cord to go into spasm. Any handling of the
umbilical cord must therefore be kept to an
absolute minimum.
G Where the cord is presenting outside the
woman’s vagina, there is a risk that it can
become cooled and dehydrated, and spasm of
the cord vessels (vasoconstriction) is more likely
to arise. Where possible, the cord should be
gently replaced into the woman’s vagina;
alternatively it can be kept moistened by gently
applying sterile gauze that has been soaked in
warmed saline solution (Goswami 2007),
although there is little evidence to support this
practice (Draycott et al 2008).
Fig. 2
Fig. 3

4. Obstetric emergencies Umbilical Cord Prolapse
G Where the woman is continuing to have uterine
contractions, this may effect the obstetric plan of
care and subsequent management.
G Where immediate delivery is not possible
(eg during transfer in from the community),
insertion of a self-retaining Foley catheter into
the bladder and the instillation of 500-750mls
of sterile normal saline can help to enlarge the
bladder sufficiently, so that it pushes the
presenting part above the ischial spines and
relieves any compression against the cord (Katz
et al 1988, Houghton 2006). NB. The holes
at the end of a Foley catheter are small, so
attaching an intravenous bag of normal saline
to a blood giving set and squeezing the bag of
saline, can help to expedite this process. Fetal
well-being should be continuously monitored
throughout this procedure to help gauge the
effectiveness of the intervention. The woman’s
bladder will need to be drained immediately
before delivery whether this is in theatre prior
to caesarean section, or at assisted vaginal birth.
G The obstetrician may elect to give a tocolytic
to reduce contractions and help alleviate
bradycardia where there is a foreseeable delay
before delivery. The administration of Terbutaline
0.25mg subcutaneously is suggested (NCCWCH
2007, Draycott et al 2008).
G Fetal well-being should be continuously assessed
by auscultation of the fetal heart rate using CTG
or ultrasound scan.
G With maternal consent, two wide bore cannulae
(one in each arm) should be inserted and blood
obtained for full blood count (FBC), Group &
Save (G&S) and cross-match (X match) – if a
Jehovah’s Witness, practitioners may need to
consider the use of cell saver.
G The obstetric registrar will determine the urgency
of delivery and the most appropriate mode
of delivery:
(i) If the cervix is fully dilated and it is
considered delivery can be accomplished safely
and quickly, then assisted vaginal delivery may
be attempted.
(ii) Where the baby’s condition is not giving any
cause for concern and there is no umbilical cord
compression, it may be possible to achieve a
regional (spinal) anaesthesia prior to a Category
2 caesarean section.
(iii) Where the cord is compressed and/or the
fetal heart rate pattern is abnormal, the baby
needs to be delivered urgently. In this situation
the woman would be advised to undergo a
Category 1 caesarean section, with the aim of
delivering within 30 minutes. Applying the
aforementioned temporary measures to reduce
cord compression can enable the use of regional
anaesthesia, which is preferable to general
anaesthesia (GA) (Afolabi et al 2006). However,
the elected method of anaesthesia will
ultimately depend on the baby’s condition.
(iv) In the event of fetal death, it is usual
practice to cease intervention and allow labour
to continue to the birth of the baby.
G A practitioner who is competent in neonatal
resuscitation should attend the delivery, as the
need for resuscitation is known to be high
(Murphy & MacKenzie 1995). A neonatalogist
should be present.
G Once the baby has been delivered, paired
(arterial and venous) cord bloods should be
obtained for blood gas analysis, pH and base
excess measurement (NCCWCH 2007, Draycott
et al 2008).
In the community
G Where cord prolapse occurs in the community
and the woman is alone, she should be advised
over the phone to adopt the knee-chest position
while awaiting paramedic assistance.
G Where the midwife diagnoses cord prolapse in
the woman’s home, they should call 999 for
immediate paramedic assistance and prepare
the woman for urgent transfer by ambulance
into the nearest consultant led maternity unit.
G Women being transferred into hospital by
ambulance will need to lie in the left lateral
position as they will need to be strapped into
the ambulance stretcher.
G Elevation of the presenting part (whether
manually or by bladder filling) should be
maintained during transfer. It is recommended
that community-based midwives carry a Foley
catheter and a giving set for this purpose
(Siassakos et al 2008).
Obstetric emergencies / Umbilical Cord Prolapse 04

5. Obstetric emergencies Umbilical Cord Prolapse
Obstetric emergencies / Umbilical Cord Prolapse 05
G Handling of umbilical cord presenting outside
the woman’s vagina should be kept to an
absolute minimum.
Implications for practice
G In the presence of known risk factors,
practitioners should always anticipate the
potential for cord prolapse occurring.
G Practitioners need to be aware of the maternal
morbidity and perinatal morbidity and mortality
associated with cord prolapse.
G The practitioner diagnosing a cord prolapse
should summon emergency assistance
immediately. Where this is in hospital, the
obstetric registrar and delivery suite coordinator
should be in attendance. If the cervix is not fully
dilated, arrangements should be made for urgent
delivery by caesarean section.
G If a fetal heart rate is not present and the
umbilical cord is not pulsating (non pulsatile),
prompt ultrasound assessment for viability
should be undertaken.
G Following delivery, umbilical arterial and venous
cord blood should be obtained for blood gas
analysis, pH and base excess measurement
(NCCWCH 2007, Siassakos et al 2008).
G Contemporaneous and accurate documentation
of events, including the relevant times, names of
practitioners present and their designation,
care/interventions/obstetric manipulations
undertaken, clinical decisions made and
outcomes should be completed in accordance
with Nursing and Midwifery Council (NMC) best
practice guidance for record keeping
(NMC 2009).
G A clinical incident AIMS (Accident and Incident
Management System) form should be completed
for the attention of the Maternity Risk Manager.
G Practitioners should be aware that because cord
prolapse requires a rapid, often operative birth,
the woman and her partner can sustain
psychological trauma that might affect their
ability to bond with their baby, cause postnatal
depression (PND) or leave them with a fear of
childbirth. Debriefing and support from a
practitioner competent in counselling should
always be offered (Mapp 2005, Mapp &
Hudson 2005).
G Debriefing can also be helpful for the maternity
staff involved.
G The safe management of cord prolapse demands
a high level of clinical and interpersonal skills
from all practitioners involved.
G On-site, annual multiprofessional (practical)
obstetric emergency training has been found to
enhance skills and knowledge retention, clinical
performance, team communication and improve
perinatal outcomes (Draycott et al 2006, Crofts
et al 2007, Siassakos et al 2009a, Siassakos
et al 2009b).
G Cord prolapse guidelines are mandated by the
Clinical Negligence Scheme for Trusts (CNST)
Maternity Risk Management Standards (NHSLA
2009), Welsh Risk Pool (Welsh Risk Pool 2005),
and Clinical Negligence and Other Risks Scheme
(CNORIS 2009).
References
Afolabi BB, Lesi FE, Mera NA (2006). Regional versus general anaesthesia for caesarean
section. Cochrane Database of Systematic Reviews, issue 4.
Boyle JJ, Katz VL (2005). Umbilical cord prolapse in current obstetric practice. Journal
of Reproductive Medicine 50(5):303-6.
Clinical Negligence and Other Risks Scheme (CNORIS 2009). http://www.cnoris.com
[Accessed 26 March 2010].
Crofts JF, Ellis D, Draycott TJ et al (2007). Change in knowledge of midwives and
obstetricians following obstetric emergency training: a randomised controlled trial of
local hospital, simulation centre and teamwork training. BJOG: An International Journal
of Obstetrics and Gynaecology 114 (12):1534-41.
Draycott T, Winter C, Crofts J, et al, eds (2008). Module 8. Cord prolapse in: PROMPT:
Practical Obstetric MultiProfessional Training Course Manual. London: RCOG Press:117-24.
Goswami K (2007). Umbilical cord prolapse. In: Grady K, Howell C, Cox C eds.
Managing Obstetric Emergencies and Trauma. The MOET course manual 2nd
ed.
London: RCOG Press: 233-7.
Houghton G (2006). Bladder filling: an effective technique for managing cord prolapse.
British Journal of Midwifery 14(2):88-9.
Katz Z, Shoham Z, Lancet M et al (1988). Management of labor with umbilical cord
prolapse: a 5-year study. Obstetrics and Gynecology 72(2):278-81.
Koonings PP, Paul RH, Campbell K (1990). Umbilical cord prolapse. A contemporary
look. Journal of Reproductive Medicine 35(7):690-2.
Lin MG (2006). Umbilical cord prolapse. Obstetrical and Gynecological Survey
61(4):269-77.
Mapp T (2005). Feelings and fears post obstetric emergencies-2. British Journal of
Midwifery 13(1):36-40.
Mapp T, Hudson K (2005). Feelings and fears during obstetric emergencies-1. British
Journal of Midwifery 13(1):30-5.
Murphy DJ, MacKenzie IZ (1995). The mortality and morbidity associated with umbili-
cal cord prolapse. British Journal of Obstetrics and Gynaecology. 102(10):826-30.
National Collaborating Centre for Women’s and Children’s Health (2007). Intrapartum
care: care of healthy women and their babies during childbirth. London: RCOG Press.

6. Obstetric emergencies Umbilical Cord Prolapse
Obstetric emergencies / Umbilical Cord Prolapse 06
NHS Litigation Authority (2009). Clinical Negligence Scheme for Trusts maternity
clinical risk management standards. Version 2. 2009/10. London: NHS Ligitation
Authority.
Nursing and Midwifery Council (2009). Record keeping: guidance for nurses and
midwives. London: NMC
Panter KR, Hannah ME (1996). Umbilical cord prolapse: so far so good? Lancet
347(8994):74.
Siassakos D, Fox R, Draycott TJ (2008). Umbilical Cord Prolapse [Green-top Guideline
No. 50]. London: RCOG Press.
Siassakos D, Crofts JF, Winter C et al (2009a). The active components of effective
training in obstetric emergencies. BJOG: An International Journal of Obstetrics and
Gynaecology 116 (8):1028-32.
Siassakos D, Hasafa Z, Sibanda T et al (2009b). Retrospective cohort study of
diagnosis-delivery interval with umbilical cord prolapse: the effect of team training.
BJOG: An International Journal of Obstetrics and Gynaecology 116 (8):1089-96.
Tiran D (2006). Baillière’s Midwives’ Dictionary. 10th
ed. London: Baillière Tindall: 264.
Usta IM, Mercer BM, Sibai BM et al (1999). Current obstetrical practice and umbilical
cord prolapse. American Journal of Perinatology 16 (9):479-84.
Vago T (1970). Prolapse of the umbilical cord. A method of management. American
Journal of Obstetrics and Gynecology 107:967-9.
Welsh Risk Pool (2005). Standard 15: Maternity, Version 3.
Suggested additional reading
Fraser DM, Cooper MA eds (2009). Myles textbook for midwives. 15th
ed. Edinburgh:
Churchill Livingstone: 627-9.
Kinsella SM, Scrutton MJL (2009). Assessment of a modified four-category classification
of urgency of caesarean section. Journal of Obstetrics and Gynaecology 29(2):110-13.
McGeown P (2001). Practice recommendations for obstetric emergencies. British
Journal of Midwifery 9 (2):71-3.
Patterson C (2005). Managing cord prolapse at a home birth. Practising Midwife
8(9):34-5.
Rogers C, Schiavone N (2008). Cord prolapse audit: recognition, management and
outcome. British Journal of Midwifery 16(5):315-18.
Thurlow JA, Kinsella SM (2002). Intrauterine resuscitation: active management of fetal
distress. International Journal of Obstetric Anesthesia 11(2):105-16.
Weston R (2001). When birth goes wrong. Practising Midwife 4(8):10-12.
Useful resources
Practical Obstetric Multiprofessional Training (PROMPT) and associated resources,
includes a downloadable cord prolapse proforma:
http://www.prompt-course.org/home.htm