Prolapsed cord — MSF Essential obstetric and newborn care

What this guideline says

GMJ summary

Umbilical cord prolapse occurs when the umbilical cord drops in front of the presenting part, usually when membranes rupture. Risk factors include low cord insertion or excessive length, transverse or breech presentation, sudden rupture of the amniotic sac, excess amniotic fluid, and twin pregnancy. Compression of the cord between maternal tissues and the foetus during contractions causes foetal distress and rapid foetal death.

Diagnosis is made after rupture of the amniotic sac when the cord can be felt between the fingers (with pulsations if the foetus is still alive) and foetal heart rate is slow and irregular. This is an obstetric emergency requiring immediate delivery. Management depends on foetal viability: if the foetus is dead or non-viable (extreme premature), vaginal delivery proceeds with no caesarean section. If the foetus is alive, emergency caesarean section is required whilst manually elevating the presenting part to relieve cord compression, or rapid vaginal extraction if the cervix is fully dilated and presenting part engaged.

The guideline emphasises that manual elevation of the presenting part must be maintained until foetal extraction by caesarean section. If manual elevation through the vagina is difficult, the bladder may be filled with 500 ml of 0.9% sterile sodium chloride to maintain upward displacement. Foetal heart tones should be checked immediately before the procedure; if no longer heard, vaginal delivery should proceed as the foetus is already dead.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Position the woman in knee-chest or Trendelenburg (dorsal decubitus, head down) position to relieve pressure on the prolapsed cord
2. Manually push the presenting part toward the uterine fundus to relieve cord compression and do not remove hand until foetal extraction by caesarean section
3. If manual elevation is difficult to maintain, fill the bladder with 500 ml of 0.9% sterile sodium chloride to maintain upward displacement
4. Perform emergency caesarean section for a viable foetus, maintaining manual elevation of the presenting part via the vagina until extraction
5. Check foetal heart tones immediately before the caesarean procedure; if no longer heard, proceed with vaginal delivery instead
6. If the presenting part is engaged and cervix fully dilated, perform rapid vaginal extraction (instrumental delivery or total breech extraction) rather than attempting to push the presenting part back
7. For a dead or non-viable (extreme premature) foetus, proceed with vaginal delivery without caesarean section
8. Diagnosis is made by palpating the cord between fingers after membrane rupture, with foetal distress indicated by slow and irregular foetal heart rate

From the guideline

Verbatim

“Do not remove hand until extraction of the foetus by caesarean section.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

Related on GMJ

Interconnected resources

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