Umbilical cord prolapse is when the

umbilical cord In placental mammals, the umbilical cord (also called the navel string, birth cord or ''funiculus umbilicalis'') is a conduit between the developing embryo or fetus and the placenta. During prenatal development, the umbilical cord is physiologi ...

comes out of the uterus with or before the presenting part of the

baby An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used to ...

. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It usually occurs during

labor Labour or labor may refer to: * Childbirth, the delivery of a baby * Labour (human activity), or work ** Manual labour, physical work ** Wage labour, a socioeconomic relationship between a worker and an employer ** Organized labour and the labour ...

but can occur anytime after the rupture of membranes. The greatest risk factors are an abnormal position of the baby within the uterus and a

premature Premature may refer to: * ''Premature'' (2014 film), an American comedy film * ''Premature'' (2019 film), an American romantic drama film * '' PREMature'', a 2015 British television drama miniseries See also * Premature aging, of an organism * ...

or small baby. Other risk factors include a

multiple pregnancy A multiple birth is the culmination of one multiple pregnancy, wherein the mother gives birth to two or more babies. A term most applicable to vertebrate species, multiple births occur in most kinds of mammals, with varying frequencies. Such bir ...

, more than one previous delivery, and too much amniotic fluid. Whether medical rupture of the amniotic sac is a risk is controversial. The diagnosis should be suspected if there is a sudden decrease in the baby's heart rate during labor. Seeing or feeling the cord confirms the diagnosis. Management focuses on quick delivery, usually by

cesarean section Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen, often performed because vaginal delivery would put the baby or m ...

. Filling the bladder or pushing up the baby by hand is recommended until this can take place. Sometimes women will be placed in a knee-chest position or the

Trendelenburg position In the Trendelenburg position, the body is lain supine, or flat on the back on a 15–30 degree incline with the feet elevated above the head. The reverse Trendelenburg position, similarly, places the body supine on an incline but with the head ...

in order to help prevent further cord compression. With appropriate management, the majority of cases have good outcomes. Umbilical cord prolapse occurs in about 1 in 500 pregnancies. The risk of death of the baby is about 10%. However, much of this risk is due to

congenital anomalies A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can r ...

or prematurity. It is considered an emergency.

Signs and symptoms

The first sign of umbilical cord prolapse is usually a sudden and severe decrease in fetal heart rate that does not immediately resolve. On fetal heart tracing (a linear recording of the fetal heart rate) this would usually look like moderate to severe

variable decelerations Cardiotocography (CTG) is a technique used to monitor the fetal heartbeat and the uterine contractions during pregnancy and labour. The machine used to perform the monitoring is called a cardiotocograph. Fetal heart sounds was described as ea ...

. In overt cord prolapse, the cord can be seen or felt on the

vulva The vulva (plural: vulvas or vulvae; derived from Latin for wrapper or covering) consists of the external female sex organs. The vulva includes the mons pubis (or mons veneris), labia majora, labia minora, clitoris, vestibular bulbs, vulval ...

or vagina. A majority of umbilical cord prolapse cases happen during the

second stage of labor Childbirth, also known as labour and delivery, is the ending of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million births globally ...

Risk factors

Risk factors that are associated with umbilical cord prolapse tend to make it difficult for the baby from appropriately engaging and filling the maternal pelvis or are related to abnormalities of the umbilical cord. The two major categories of risk factors are spontaneous and iatrogenic (those that result from medical intervention). * spontaneous factors: ** fetal malpresentation: abnormal fetal lie tends to result in space below the baby in the maternal pelvis, which can then be occupied by the cord. **

polyhydramnios Polyhydramnios is a medical condition describing an excess of amniotic fluid in the amniotic sac. It is seen in about 1% of pregnancies. It is typically diagnosed when the amniotic fluid index (AFI) is greater than 24 cm. There are two clini ...

, or an abnormally high amount of amniotic fluid ** prematurity: likely related to increased chance of malpresentation and relative polyhydramnios. **

low birth weight Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an infant of or less, regardless of gestational age. Infants born with LBW have added health risks which require close management, often in a neonatal int ...

: usually described as <2500g at birth, though some studies will use <1500g. Cause is likely similar to those for prematurity. ** multiple gestation, or being pregnant with more than one baby at a given time: more likely to occur in the baby that is not born first. ** spontaneous rupture of membranes: about half of prolapses occur within 5 minutes of membrane rupture, two-thirds within 1 hour, 95% within 24 hours. * treatment associated factors: **

artificial rupture of membranes Artificial rupture of membranes (AROM), also known as an amniotomy, is performed by a midwife or obstetrician and was once thought to be an effective means to induce or accelerate labor. The membranes can be ruptured using a specialized tool, suc ...

** placement of internal monitors (for example, internal scalp electrode or

intrauterine pressure catheter An intrauterine pressure catheter (IUPC) is a catheter used during management of labor to measure uterine contractions by taking into account intrauterine pressure and contraction frequency, duration, and strength. This is mainly of use for an obs ...

) ** manual rotation of fetal head

Diagnosis

Umbilical cord prolapse should always be considered a possibility when there is a sudden decrease in fetal heart rate or variable decelerations, particularly after the rupture of membranes. With overt prolapses, the diagnosis can be confirmed if the cord can be felt on vaginal examination. Without overt prolapse, the diagnosis can only be confirmed after a

, though even then it will not always be evident at time of procedure.

Classification

There are three types of umbilical prolapse that can occur: * overt umbilical cord prolapse: descent of the umbilical cord past the presenting fetal part. In this case, the cord is through the

cervix The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long (~1 inch) and roughly cylindrical in shape, which changes during ...

and into or beyond the vagina. Overt umbilical cord prolapse requires rupture of membranes. This is the most common type of cord prolapse. * occult umbilical prolapse: descent of the umbilical cord alongside the presenting fetal part, but has not advanced past the presenting fetal part. Occult umbilical prolapse can occur with both intact or ruptured membranes. * funic (cord) presentation: presence of the umbilical cord between the presenting fetal part and fetal membranes. In this case, the cord has not passed the opening of the cervix. In funic presentation, the membranes are not yet ruptured.

Management

The typical treatment of umbilical cord prolapse in the setting of a viable pregnancy involves immediate delivery by the quickest and safest route possible. This usually requires cesarean section, especially if the woman is in early labor. Occasionally, vaginal delivery will be attempted if clinical judgment determines that is a safer or quicker method. Other interventions during management of cord prolapse are typically used to decrease the chance of complications while preparations for delivery are being made. These interventions are focused on reducing pressure on the cord to prevent fetal complications from cord compression. The following maneuvers are among those used in clinical practice: * Manual elevation of the presenting fetal part. * Repositioning of the mother to be in the knee-chest position or

(head down with feet elevated), lying on left side is usually preferred. * Filling of the

bladder The urinary bladder, or simply bladder, is a hollow organ in humans and other vertebrates that stores urine from the kidneys before disposal by urination. In humans the bladder is a distensible organ that sits on the pelvic floor. Urine en ...

using a foley catheter can help elevate the presenting fetal part and lift it off the cord. * Use of

tocolytic Tocolytics (also called anti-contraction medications or labor suppressants) are medications used to suppress premature labor (from Greek τόκος ''tókos'', "childbirth", and λύσις ''lúsis'', "loosening"). Preterm birth accounts for 70% ...

s (medications to suppress labor) have been proposed, usually done in addition to bladder filling rather than as a stand-alone intervention. If the mother is far from delivery, funic reduction (manually placing the cord back into the uterine cavity) has been attempted, with successful cases reported. However, this is not currently recommended by the Royal College of Obstetricians and Gynaecologists (RCOG), as there is insufficient evidence to support this maneuver.

Outcomes

The primary concern with umbilical cord prolapse is inadequate blood supply, and thus oxygen, to the baby if the cord becomes compressed. The cord can become compressed either due to mechanical pressure (usually from the presenting fetal part) or from sudden contraction of the vessels due to decreased temperatures in the vagina in comparison to the uterus. This can lead to death of the baby or other complications. Historically, the rate of fetal death in the setting of cord prolapse has been as high 40%. However, these estimates occurred in the context of home or births outside of the hospital. When considering cord prolapses that have occurred in inpatient labor and delivery settings, the rate drops to as low as 0-3%, though the mortality rate remains higher than for babies without cord prolapse. The reduction in mortality for hospital births is likely due to the ready availability of immediate cesarean section. Many other fetal outcomes have been studied, including

Apgar score The Apgar score is a quick way for doctors to evaluate the health of all newborns at 1 and 5 minutes after birth and in response to resuscitation. It was originally developed in 1952 by an anesthesiologist at Columbia University, Virginia Apgar, ...

(a quick assessment of a newborn's health status) at 5 minutes and length of hospitalization after delivery. While both measures are worse for newborns delivered after cord prolapse, it is unclear what effect this has in the long-term. Relatively large studies that have tried to quantify long-term effects of cord prolapse on children found that less than 1% (1 in 120 studied) had a major neurologic disability, and less than 1% (110 in 16,675) had diagnosed cerebral palsy.

Epidemiology

Rates of umbilical cord prolapse ranges from 0.1 to 0.6% of all pregnancies. This rate has remained stable over time. A recent study estimates 77% of cord prolapses occur in singleton pregnancies (where there is only one baby). In twin pregnancies, cord prolapses occur more frequently in the second twin to be delivered, with 9% in the first twin and 14% in the second twin.

References

External links

{{DEFAULTSORT:Umbilical Cord Prolapse Medical emergencies Complications of labour and delivery Wikipedia medicine articles ready to translate