PassFinals
Obstetrics

Umbilical Cord Prolapse

Umbilical cord prolapse is descent of the cord past or alongside the presenting part after membrane rupture, so the presenting part and contractions compress it and fetal oxygenation fails.

In a nutshell

Cord prolapse is the cord descending past the presenting part after the membranes rupture, compressing it and causing acute fetal hypoxia. Lift the presenting part off the cord with a gloved hand and hold it there while the team prepares the fastest safe birth.

Classic presentation

Moments after membrane rupture with a high presenting part, the fetal heart rate falls into a prolonged bradycardia and a pulsating cord is felt in the vagina.

Key points

  • Overall incidence is 0.1% to 0.6% of births, rising to 1% with breech presentation. One large study reported a perinatal mortality rate of 91 per 1000.
  • Around 21% of babies have a low Apgar score at 1 minute and 7% at 5 minutes, which is why a resuscitation-competent practitioner attends every birth.
  • About half of cases follow an obstetric intervention: amniotomy with a high presenting part, vaginal manipulation of the fetus, podalic version or stabilising induction.
  • Discuss elective admission after 37+0 weeks for transverse, oblique or unstable lie. Unstable lie means the fetal long axis changing repeatedly after 37+0 weeks.
  • At the threshold of viability, 23+0 to 24+6 weeks, discuss expectant management; temporary measures have been recorded for periods up to 3 weeks.
  • Terbutaline is a betamimetic. NICE bars betamimetics for prolonging preterm pregnancy; here one subcutaneous dose buys minutes for fetal resuscitation. Different purpose, so no contradiction.

First-line investigation

Speculum or digital vaginal examination the moment the trace becomes abnormal after membrane rupture, with continuous cardiotocography (CTG) running.

Management

Declare and decompress

  • Say cord prolapse out loud, pull the buzzer, note the time and stop the oxytocin. Call obstetrics, anaesthetics, theatre and a newborn-resuscitation practitioner.1
  • Gloved hand into the vagina; lift the presenting part off the cord and hold it there until birth, including throughout any transfer.1
  • Position knee-chest, or left lateral with the head down and a pillow under the left hip. In a moving ambulance use the left lateral position.1

Buy time without causing delay

  • If birth will be delayed or she is being transferred, fill the bladder: Foley catheter with a blood giving set, clamped once 500 to 750 mL are in.1
  • Empty the bladder immediately before any attempt at birth, vaginal or caesarean. Adding bladder filling to a hand already elevating adds nothing.1
  • Handle loops outside the vagina minimally to prevent vasospasm. Warm saline swabs are of unproven benefit. Never replace the cord to continue labour.1
  • Trace still abnormal after mechanical measures and birth delayed: terbutaline 250 micrograms (0.25 mg) subcutaneously, single dose, while preparing theatre. A bridge, not treatment.1,4,3

Birth: route and category

  • Vaginal birth not imminent: caesarean. Category 1 (immediate threat to life), aiming for birth within 30 minutes or less if the trace is suspicious or pathological.1
  • Trace normal: category 2 (compromise, not immediately life-threatening), with continuous assessment and re-categorisation to category 1 if it deteriorates.1
  • Fully dilated and birth achievable quickly and safely: an experienced operator may do an assisted vaginal birth. Verbal consent suffices for a category 1 caesarean.1

At and just after birth

  • A practitioner competent in newborn resuscitation attends. Take paired arterial and venous cord samples for pH and base excess: recommended, not optional.1
  • Assess blood loss, uterine tone and trauma; use the postpartum haemorrhage pathway if loss reaches 500 mL. Document times, findings, measures and mode of birth.1,6
  • Debrief the family and arrange neonatal follow-up. Reassure that the chance of cord prolapse in a future pregnancy remains very low.5

Community, and the threshold of viability

  • At home: 999, knee-chest face-down until the ambulance arrives, do not touch the cord. Community midwives carry a Foley catheter and fluid infusion equipment.1,5
  • Transfer everyone to the nearest consultant-led unit unless immediate examination shows spontaneous vaginal birth is imminent, maintaining elevation throughout.1
  • 23+0 to 24+6 weeks: discuss expectant management and counsel on continuation or termination. Below 23+0 weeks the guideline does not apply.1

Exam traps

  • Do not push the cord back above the presenting part to let labour continue. The guideline does not recommend it, at any gestation.
  • Wrapping the cord in warm saline swabs is of unproven benefit. It is not forbidden, but it must never delay anything.
  • If a hand is already elevating the presenting part, filling the bladder as well adds nothing further to neonatal outcome.
  • Empty the filled bladder immediately before any attempt to assist birth, vaginal or caesarean. The catheter is clamped, so it will not drain by itself.
  • In a moving ambulance the knee-chest position is unsafe. Use the exaggerated Sims position: left lateral with a pillow under the hip.
  • Verbal consent is satisfactory for a category 1 caesarean. Do not delay theatre chasing a signature.
  • A normal trace after confirmed prolapse allows category 2, not observation. Re-categorise to category 1 the moment it becomes abnormal.

Key sources

  1. RCOG Green-top Guideline No. 50, Umbilical Cord Prolapse (guideline PDF) (Second edition, November 2014, 19 pages. Section 2, sections 4.1 to 4.9 and Table 1: incidence and mortality, risk factors, when to suspect, pressure relief and bladder filling, tocolysis, mode and category of birth, community care, threshold of viability and delayed cord clamping. Section numbers quoted in this chapter are the PDF's own)
  2. RCOG guidance page, Umbilical Cord Prolapse (Green-top Guideline No. 50) (Currency and scope. The page states this is the second edition, that it was reviewed in December 2024 and extended for 2 years with review commencing in 2026, and that the page was last reviewed 05 November 2014. Its summary excludes pregnancies before 22 completed weeks, whereas the guideline PDF says 23+0 weeks)
  3. NICE NG25, Preterm labour and birth (Cited only for the rule that betamimetics are not used for tocolysis in preterm labour, which is the point of contrast with GTG50's single subcutaneous dose. No recommendation number is printed: the NICE HTML chapter and the guidance PDF both returned empty bodies to automated retrieval on 2026-08-07, so the locator could not be confirmed on the page this reference links)
  4. BNF, Terbutaline sulfate (Monograph confirmed from a verbatim extract at reports/textbook-source-packs/batch04/terbutaline-sulfate.md, retrieved 2026-08-07. The BNF's licensed obstetric indication is uncomplicated premature labour by intravenous infusion; it carries no subcutaneous tocolytic dose, and it lists cord compression among the contra-indications for that indication. The subcutaneous regimen used in cord prolapse comes from GTG50, not the BNF)
  5. RCOG patient information, Umbilical cord prolapse in late pregnancy (Based on GTG50; the page states it was last reviewed 04 August 2025 and is due for review 04 August 2028. Community advice to call 999 and adopt the knee-chest position, the left lateral position with pillows under the hip for ambulance transfer, and the very low chance of recurrence in a future pregnancy)Updated 4 Aug 2025
  6. RCOG Green-top Guideline No. 52, Prevention and Management of Postpartum Haemorrhage (Cited only for the blood-loss definitions of primary postpartum haemorrhage. The RCOG page states this is the second edition with the third in development, and that the page was last reviewed 16 December 2016. Treatment of postpartum haemorrhage follows the PassFinals postpartum haemorrhage chapter, which leads with NICE NG235)Updated 16 Dec 2016

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.