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Umbilical cord prolapse

Umbilical cord prolapse
Literature review current through: Jan 2024.
This topic last updated: Mar 03, 2022.

INTRODUCTION — Umbilical cord prolapse can be overt or nonovert (occult). In overt prolapse, the cord slips ahead of the fetal presenting part and prolapses into the cervical canal, vagina, or beyond. It is an obstetric emergency because the prolapsed cord is vulnerable to complete occlusion (compression of all three vessels), partial occlusion (compression of the umbilical vein), or vasospasm of either umbilical artery. In nonovert prolapse, the cord slips alongside, but not ahead of, the presenting part but is also vulnerable to compression and its sequelae. Any of these scenarios can compromise fetal oxygenation to varying degrees.

Of note, an alternative nomenclature has been proposed whereby classification is based on the positional relationship among the cord, the fetal presenting part, and the cervix [1]. In this system, "cord prolapse" refers to an umbilical cord that has prolapsed past the fetal presenting part and beyond the internal cervical os, "cord presentation" refers to an umbilical cord ahead of the fetal presenting part but above the internal cervical os, and "compound cord presentation" refers to both the cord and fetus presenting above the internal cervical os. Any of the three clinical scenarios can occur with either intact or ruptured membranes.

This topic will discuss the frequency, pathogenesis, risk factors, clinical findings, diagnosis, management, potential prevention, and outcome of umbilical cord prolapse.

PREVALENCE — Umbilical cord prolapse occurred in 0.16 to 0.18 percent of live born births in three large series [2-4], but the prevalence may be slowly declining with the increased use of ultrasound in the third trimester, which can lead to preemptive diagnosis [4]. (See 'Anticipation and prevention of cord prolapse' below.)

PATHOGENESIS — The pathogenesis of umbilical cord prolapse is not always clear. One obvious mechanism is rupture of membranes resulting in high outward flow of amniotic fluid that carries the umbilical cord past an unengaged fetal presenting part. Another probable mechanism is disengagement of the presenting part during obstetric procedures, allowing the cord to prolapse.

RISK FACTORS

Overview — Umbilical cord prolapse primarily occurs in two settings: (1) when the presenting part does not adequately fill the pelvis because of maternal or fetal characteristics, and (2) when obstetric interventions are performed that dislodge the presenting part. Although observational studies suggest that obstetric interventions increase the risk of cord prolapse, it is often difficult to determine whether prolapse would have occurred spontaneously if the intervention had not been performed [5].

Fetal and maternal factors that have been associated with cord prolapse include:

Malpresentation (breech, transverse, oblique, or unstable lie)

Preterm gestational age

Low birth weight

Second twin

Low lying placentation

Pelvic deformities

Uterine malformations/tumors

External fetal anomalies

Multiparity

Polyhydramnios

Long umbilical cord

Unengaged presenting part

Prolonged labor

Atypical placental cord insertions (velamentous and marginal)

Obstetric interventions account for approximately 50 percent of cases of cord prolapse [6]. Iatrogenic factors that have been associated with cord prolapse include:

Iatrogenic rupture of membranes [7], especially with an unengaged presenting part

Cervical ripening with a balloon catheter [8]

Induction of labor [9]

Application of an internal scalp electrode

Insertion of an intrauterine pressure catheter

Manual rotation of the fetal head

Amnioinfusion

External cephalic version

Internal podalic version

Application of forceps or vacuum

Specific risk factors

Nonvertex fetal presentation is consistently associated with a high risk of cord prolapse [10-13]. In one review, the overall frequency in vertex, breech, and transverse lies was 0.24, 3.5, and 9.6 percent, respectively [11]. Footling breech presentation carries a higher risk than other types of breech presentation. Nevertheless, most cord prolapses occur with vertex presentations because of the relatively low incidence of noncephalic presentations.

Preterm births have a higher rate of cord prolapse, probably due to the smaller size of the fetus relative to the amniotic fluid volume and the increased frequency of malpresentation among preterm fetuses [10,12,14].

Multiple gestation – The excess risk of cord prolapse in twin gestations is limited to the nonpresenting twin, in whom malpresentation is more common, and, for that reason, in whom obstetrical manipulation is more common [10,14-16]. In a series of 455 twin pairs, the risk of cord prolapse of the second twin was 1.8 percent (8 out of 455) and velamentous and marginal umbilical insertions were the only independently associated risk factors on multivariate analysis [17].

Multiparity – Cord prolapse in parous patients may be related to the increased likelihood of membrane rupture prior to engagement of the presenting part since engagement in these patients often occurs after labor has begun and later than in nulliparas [13]. In one report of 30 patients with cord prolapse, two-thirds were para six or more, and one experienced cord prolapse in two successive deliveries [18].

Polyhydramnios is often associated with an unstable lie or unengaged presenting part, as well as copious flow of amniotic fluid after membrane rupture [19]; all of these factors increase the risk of cord prolapse.

In the general obstetric population, routine amniotomy for labor augmentation did not significantly increase the risk of cord prolapse compared with no amniotomy in a meta-analysis of randomized trials (relative risk 1.00, 95% CI 0.14-7.10; two trials, 1615 participants); however, the wide confidence interval suggests that the possibility of an effect cannot be excluded [20].

CLINICAL PRESENTATION AND FINDINGS — In the hospital setting, cord prolapse usually presents with the abrupt onset of severe, prolonged fetal bradycardia or moderate to severe variable decelerations or late decelerations in a patient with a previously normal tracing [6,10]. The fetal heart rate changes typically occur soon after membrane rupture or an obstetric intervention that dislodges the presenting part. Less commonly, the care provider may palpate a pulsating cord incidentally on a vaginal examination performed to assess labor progress with a normal fetal heart tracing. Another less common scenario is a patient who spontaneously ruptures membranes at home or on the antepartum unit and reports seeing or feeling an overt cord prolapse at the time of rupture.

In one series, mean cervical dilation at the time of cord prolapse was 5.8 cm and mean station was -1.6 [5].

DIAGNOSIS

Intrapartum – Intrapartum cord prolapse should be suspected in patients with abrupt onset of severe, prolonged fetal bradycardia or moderate to severe variable decelerations after a previously normal tracing. The presence of risk factors for prolapse (see 'Risk factors' above) increase diagnostic suspicion. The diagnosis of overt umbilical cord prolapse is based on visualization or palpation of the umbilical cord ahead of the presenting part. Nonovert prolapse may or may not be confirmed at cesarean birth.

Antepartum – Antepartum ultrasound examination may show the umbilical cord interposed between the presenting part of the fetus and the internal cervical os. Color flow Doppler studies can clarify cord position if there is uncertainty on real-time sonographic examination (image 1A-C) [21]. Transvaginal imaging may be necessary if visualization is limited transabdominally. (See 'Pregnancies with funic (cord) presentation' below.)

Differential diagnosis — Fetal heart rate changes suggestive of cord prolapse can also be caused by a fall in maternal blood pressure, tachysystole, placental abruption, uterine rupture, and vasa previa. The clinical setting helps to distinguish these disorders from prolapse.

Fetal bradycardia following injection of a neuraxial anesthetic suggests a fall in maternal blood pressure as the cause. This diagnosis is supported by normalization of the fetal heart rate in response to maternal intravenous fluid infusion and phenylephrine or ephedrine administration.

Placental abruption, uterine rupture, and vasa previa are usually accompanied by vaginal bleeding, and abruption and rupture are often painful in the absence of labor anesthesia, which distinguishes these disorders from nonovert (occult) prolapse, which is painless. (See "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences" and "Uterine rupture: After previous cesarean birth" and "Uterine rupture: Unscarred uterus" and "Velamentous umbilical cord insertion and vasa previa".)

Tachysystole is defined by the presence of more than 5 contractions in 10 minutes averaged over a 30-minute window and typically occurs in patients receiving uterotonic drugs.

MANAGEMENT OF INTRAPARTUM CORD PROLAPSE

Our approach — The optimal obstetric management of acute cord prolapse is prompt delivery to avoid fetal compromise or death from compression of the cord between the presenting fetal part and the birth canal. There are no data from prospective studies or randomized trials on which to base management recommendations because of the infrequent and urgent nature of this problem. When an acute overt cord prolapse is detected or nonovert prolapse is suspected, a clinically practical approach includes the following:

Call for assistance and prepare for emergency delivery – Nursing, anesthesia, obstetric, operating room, and pediatric providers.

Initiate maneuvers for intrauterine resuscitation – These maneuvers are primarily targeted to moving the fetus off of the cord. (See 'Intrauterine resuscitation' below.)

Monitor the fetal heart rate to determine whether resuscitative interventions are effective, which impacts the urgency of delivery.

If the prolapse is overt:

Minimize manipulating an overtly prolapsed cord and avoid exposing it to the cold environment, which may exacerbate poor perfusion by inducing spasm of the umbilical artery/arteries. Gently replace an overtly prolapsed cord in the vagina and keep it moist with wet gauze.

Perform emergency delivery by the most rapid and safe route, which is typically cesarean – Assisted vaginal delivery may be considered in select situations when, in the clinician's judgment, the fetus can be delivered safely and as quickly, or more quickly, than by cesarean. Some examples include prolapse at full dilation with breech presentation or prolapse after birth of the first twin. In a population-based analysis of birth certificate data from over 16,000 deliveries complicated by cord prolapse and over 10 million controls, cesarean birth was associated with a higher risk of fetal injury than vaginal birth (18.5 versus 8.7 percent; adjusted odds ratio 2.6, 95% CI 2.3-2.9) [4]. However, these findings should be interpreted with caution. Analysis of information in birth certificates is limited because of missing, incomplete, and inaccurate information. Furthermore, it was not possible to determine what factors lead to the decision to attempt vaginal delivery versus immediate cesarean delivery.

-Anesthesia – The type of anesthesia (neuraxial versus general) depends on whether a neuraxial catheter is already in place and will provide an adequate anesthetic level for delivery anesthesia and the urgency of delivery (ie, whether category III tracing persists or improves with intrauterine resuscitation maneuvers and the maneuvers being utilized to prevent cord compression).

-Fetal heart rate monitoring – The fetal heart rate should be monitored continuously while preparations for delivery are being made to gauge the effectiveness of maneuvers being utilized to reduce cord compression and the urgency, but not need, for delivery. We perform an emergency cesarean regardless of the findings and attempt neonatal resuscitation, if required.

-Simulation drills – Management of cord prolapse is an excellent area for simulation drills to educate providers, facilitate communication techniques, and identify unit-specific barriers to emergency delivery. Team training can significantly lower the time from diagnosis to delivery [22].

If the prolapse is not overt:

Resuscitative maneuvers may lead to a category I or II tracing due to resolution of the nonovert prolapse or because an alternative diagnosis was responsible for the category III tracing. We base the decision to proceed with an urgent delivery on the fetal heart rate tracing: If resuscitation ameliorates the concerning characteristics, then expectant management is reasonable, in contrast to cases of overt prolapse.

Intrauterine resuscitation — The following maneuvers can be helpful for reducing pressure on the cord before delivery. In the absence of randomized trials or large comparative studies, there is no strong evidence that one maneuver is better than another or that combinations of maneuvers are more successful. It is reasonable to attempt any or all of the maneuvers until the fetal heart rate pattern improves to category I or II, or until delivery can be effectuated.

Elevate the presenting part:

Manually — Manual elevation of the presenting part is the most common intervention for managing cord prolapse, and the maneuver we prefer because it is fast, does not require special equipment, and has been effective in large series [14,23]. While preparations for an emergency cesarean birth are made, the clinician places their hand in the vagina and gently elevates the fetal head until it is not compressing the cord. Although effective, a prolonged period of manual elevation can be difficult for the clinician and the patient.

Using Trendelenburg or knee-chest position — Placing the patient in steep Trendelenburg (15 to 30 degrees) or the knee-chest position may change the relationship between the fetus and umbilical cord such that gravity pulls the fetus and cord away from and above the internal cervical os, thereby alleviating cord compression.

By retrofilling the bladder — Retrofilling the bladder rapidly with 500 to 700 milliliters of saline via a bladder catheter distends the bladder, which may gently elevate the presenting part [24]. Bladder filling may be particularly useful as a temporizing measure when cesarean birth cannot be performed urgently. A review of 187 cases of cord prolapse managed by retrofilling the bladder with or without adjunctive tocolysis reported only one perinatal death [25].

One study assessed the degree of head elevation by these and other maneuvers using transperineal ultrasound measurement of the parasagittal angle of progression (psAOP) before 20 planned cesarean term births without cord prolapse or ruptured membranes [26]. The following maneuvers were evaluated: elevation of the maternal buttocks by a wedge; knee-chest position; Trendelenburg position with a 15 degree tilt; and filling the maternal bladder with 100mL, 300 mL, and 500mL of saline. Knee-chest position had the greatest effect in elevating the fetal head above baseline (approximately three stations), followed by filling the maternal bladder with 500 mL of saline (approximately two stations). The elevating effect of the other maneuvers assessed, including 300 mL and 100 mL of saline in the maternal bladder, was only modest. Whether these same results would be seen in patients with umbilical cord prolapse is unknown.

Administer a tocolytic — A rapidly acting tocolytic can be administered to reduce pressure on the cord from uterine contractions. In one report of 51 cases of cord prolapse, the use of both bladder filling and a tocolytic drug appeared to be beneficial: there were no fetal or neonatal deaths despite a mean interval from diagnosis to delivery of 35 minutes; the majority of infants had Apgar scores ≥7 at five minutes [27].

Consider manually replacing the prolapsed cord — After the fetal head is elevated with gentle suprapubic pressure or transvaginally or both, the cord is slipped over the widest part of the head and placed in the nuchal area. The head is then gently returned to its original position in the birth canal to decrease the chance of creating an oblique or transverse lie. Close attention to the fetal heart rate is required if attempting this maneuver, particularly if it is in the attempted vaginal delivery of a second twin.

Manual replacement of the cord (funic reduction) is a controversial resuscitative maneuver because the procedure appeared to be associated with an increase in intrapartum asphyxia and demise in the era before continuous fetal monitoring became available; however, one subsequent small case series reported five successful vaginal deliveries 14 to 512 minutes after funic reduction without anesthesia [28].

Special situations

Prolapse on an antepartum unit — Initial management (eg, call for assistance, check the fetal heart rate, initiate maneuvers for intrauterine resuscitation) is similar to that described above for intrapartum prolapse and the patient is transferred to the labor and delivery unit for urgent evaluation and emergency cesarean birth. However, if the diagnosis of cord prolapse is made when a routine Doppler check of the fetal heart rate in a patient with advanced cervical dilation and PPROM does not detect a heart rate, no fetal heart motion can be detected by ultrasound on the labor and delivery unit, and the fetal demise is suspected to have occurred remote from the time of transfer to the unit, then emergency cesarean delivery is unlikely to lead to successful neonatal resuscitation.

Pre-hospital cord prolapse — Umbilical cord prolapse may occur with prelabor rupture of membranes outside of the hospital or during planned home birth. Patients with an overt cord prolapse should call for help and be instructed to assume the knee-chest face-down position [29] or lie on the floor with pillows to elevate the hips above the heart while waiting for an ambulance for hospital transfer. While being transported in the motor vehicle, however, the knee-chest position is potentially unsafe for the mother, so a left lateral position is recommended, with pillows under the hip. If possible, the presenting part should be elevated manually or by bladder distension during the transfer, as described above. (See 'Intrauterine resuscitation' above.)

Previable gestational age — Only a few case reports have described conservative management of ruptured membranes and overt cord prolapse at a previable gestational age. All four mothers were placed in Trendelenburg position and, in one case, the cord was manually replaced in the vagina several times [25]. Delivery occurred 3.5 days to three weeks after cord prolapse, with one neonatal death and three liveborn infants who were ultimately discharged home. These cases were likely reported because of the rarity of conservative management and good outcomes in this setting. Conservative management places the mother at risk of serious infection, may not prevent perinatal death, and may result in the delivery of a child who is severely disabled. (See "Periviable birth (limit of viability)".)

OUTCOME

Short term

In hospital prolapse – Reported perinatal mortality associated with cord prolapse varies widely, from 0 to 3 percent for events occurring among patients monitored on a labor and delivery unit [13,25]. Asphyxia and complications related to preterm birth and congenital anomalies are the major causes of poor outcome [14].

Out of hospital prolapse – Cord prolapse occurring outside of the hospital setting generally has a poor prognosis; perinatal mortality rates range from 38 to 44 percent [13,25]. A report from The Netherlands of umbilical cord prolapse occurring in the home identified six cases [30,31]. Three cases involved a planned home birth with a midwife in attendance; the other three cases were self-diagnosed when the cord prolapsed outside the vagina after prelabor spontaneous rupture of membranes. The diagnosis-to-delivery interval ranged from 31 to 72 minutes. All of the infants were live born, but one subsequently died of asphyxia. This was a self-diagnosed case managed with manual elevation and bladder filling in the ambulance and diagnosis to cesarean delivery time of 47 minutes.

Compression of umbilical vessels interferes with fetal oxygenation; thus the degree of cord compression, the interval between cord prolapse and delivery, the duration of bradycardia, and successful use of intrauterine resuscitation maneuvers all impact the risk of asphyxia [16,32]. Intact outcomes have been reported with long diagnosis-to-delivery intervals, presumably because umbilical blood flow was sufficient despite prolapse [33], such as in cases of intermittent cord compression [32]. Another factor is that some cords (eg, non-coiled) may be more vulnerable to cord compression than others. (See "Gross examination of the placenta", section on 'Coiling'.)

In a study that evaluated the correlation between umbilical cord pH and the onset of bradycardia-to-delivery time, onset of decelerations-to-delivery time, and decision to perform cesarean-to-delivery time, a significant association was only noted for the bradycardia-to-delivery time [32]. The authors calculated that the umbilical cord arterial pH drops only 0.009 units for each minute of bradycardia before the infant is delivered, possibly obviating the need for emergency delivery. In a subsequent letter to the editor, however, their calculations were challenged [34]. The author of this letter opined that extracellular fluid base deficit is a better predictor of fetal metabolic acidosis and outcome and that for each minute of complete cord occlusion, the base deficit rises by 0.5 mmols/L, which is much more than would be predicted by the previous calculations and justifies expedited delivery.

Longterm — There are sparse data on the long-term outcome of children whose birth was complicated by cord prolapse. In a series of 132 cases, only 1 of 120 survivors had a long-term handicap [14]. A study of risk factors for cerebral palsy identified 110 children with cerebral palsy among 16,785 cases of cord prolapse or 1 case of cerebral palsy per 153 cord prolapses [35].

ANTICIPATION AND PREVENTION OF CORD PROLAPSE

Anticipating and managing risk

We do not routinely screen pregnant patients near delivery with ultrasound to assess umbilical cord position. The sensitivity and specificity of ultrasound examination for detecting cord prolapse are unclear and most cord prolapses occur in patients without antepartum sonographic evidence of funic presentation [36,37]. Ultrasound examination is reasonable when there is a clinical concern of funic presentation (eg, malpresentation) [21,36,38]. (See 'Diagnosis' above.)

Risk factors for cord prolapse are generally not modifiable, but awareness of patients at high risk may help facilitate prompt diagnosis and delivery when prolapse occurs. For example, in patients with risk factors for prolapse or with fetal heart rate decelerations, cord prolapse should be excluded by vaginal examination after spontaneous rupture of membranes. We admit all nonlaboring patients with prelabor rupture of membranes to the labor unit and continuously monitor the fetal heart rate to check for fetal heart rate decelerations. On the antepartum unit, we perform intermittent fetal heart rate monitoring to check for fetal heart rate decelerations in patients with prelabor rupture of membranes and counsel them about the signs and symptoms of cord prolapse.

We do not electively hospitalize most patients with malpresentation, but counsel them about the signs, symptoms, and management of cord prolapse and instruct them to call their provider upon spontaneous rupture of membranes or the onset of labor. The Royal College of Obstetricians and Gynaecologists suggests advising patients in the community with transverse, oblique, or unstable fetal lies to present to the hospital urgently when they begin labor or rupture membranes and suggests discussing planned hospital admission with patients after 37+0 weeks of gestation [29].

Pregnancies with funic (cord) presentation

Monitoring – When funic (also known as cord) presentation is identified as an incidental finding antepartum, we perform follow-up evaluation of cord location to help with labor and delivery planning. In a series of 13 patients identified as having funic presentation on a third-trimester ultrasound, six had uncomplicated vaginal births (five vertex and one breech), six had cord presentation and malpresentation (five breech and one transverse) at the time of birth and underwent cesarean (one had cord prolapse), and one had a cesarean birth for failure to progress [37].

Route of delivery – There are no high-quality data on which to base a strong recommendation for or against scheduled cesarean birth when funic (cord) presentation is noted in a nonlaboring patient with cephalic presentation at term. The authors attempt to deliver these patients vaginally, but scheduled cesarean birth is also a common practice in this setting.

Patients with a floating vertex, cervical dilation (>2 cm), and persistent funic (cord) presentation after 39 weeks of gestation are at high risk of cord prolapse upon membrane rupture; polyhydramnios augments this risk. These patients are unlikely to benefit from expectant management at this gestational age. The authors offer them induction of labor by "needling" the membranes in a controlled environment, with the anesthesia team ready for an emergency cesarean birth if a cord prolapse occurs.

For less high-risk patients with a funic (cord) presentation that has not resolved before labor at term, the authors advise coming to the labor and delivery unit as soon as labor begins so that the cord position can be evaluated, usually by physical examination. If physical examination is inconclusive, transvaginal ultrasound with color and/or power Doppler will clarify the diagnosis. If the funic (cord) presentation has resolved, the patient should continue to labor with a goal of vaginal birth, unless there are other indications for cesarean birth. If the funic (cord) presentation is confirmed, we monitor the patient/fetal heart rate continuously and perform a controlled amniotomy (see 'Minimizing risk from obstetric maneuvers' below), with the anesthesia team ready for an emergency cesarean birth in the event of cord prolapse. Cesarean birth without a trial of labor is also reasonable.

Minimizing risk from obstetric maneuvers — Identifying patients at risk for cord prolapse and avoiding unnecessary obstetric interventions in these patients may prevent some cases of prolapse. However, obstetric interventions are often indicated and cannot be avoided. Anticipation of prolapse and modification in standard techniques can reduce the risk of prolapse in these cases.

If possible, perform amniotomy only when the presenting part is well applied to the cervix. In one series of 37 patients with cord prolapse during delivery, iatrogenic rupture of membranes accounted for 23 (62 percent) cases [7].

When the presenting part is not well applied and amniotomy is necessary, "controlled amniotomy" with either a fetal scalp electrode, 22-gauge spinal needle, or small angiocatheter with the needle removed and simultaneous application of fundal pressure may decrease the risk of prolapse. In pregnancies with polyhydramnios or an unengaged presenting part, we use a small gauge needle to puncture fetal membranes in one or more places in the operating room. This "controlled amniotomy" minimizes the risk of gushing amniotic fluid and enables emergency cesarean birth in the event of cord prolapse.

Avoid disengaging the fetal presenting part when performing procedures such as application of a fetal internal scalp electrode, intrauterine pressure catheter insertion, fetal scalp sampling, amnioinfusion, forceps application, and manual rotation of the fetal head.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor".)

SUMMARY AND RECOMMENDATIONS

Prevalence – Umbilical cord prolapse is a rare event potentially associated with serious fetal/neonatal complications. (See 'Prevalence' above and 'Outcome' above.)

Risk factors – Risk factors for cord prolapse include (1) fetomaternal factors that lead to inadequate filling of the maternal pelvis by the fetus and (2) iatrogenic obstetric interventions, but many prolapses occur without antecedent risk factors. (See 'Risk factors' above.)

Clinical presentation – The first sign of cord prolapse is usually severe, prolonged fetal bradycardia or moderate to severe variable decelerations or late decelerations after a previously normal tracing. The prolapse may be overt or nonovert (occult). (See 'Clinical presentation and findings' above.)

Management – Standard obstetric management of cord prolapse is prompt cesarean birth to avoid fetal compromise or death from compression of the cord. However, vaginal birth may be a reasonable option in select cases when delivery is imminent and can be safely assisted. (See 'Our approach' above.)

Intrauterine resuscitation – Intrauterine resuscitation using maneuvers to elevate the presenting part (eg, manually, or placing the patient in a knee-chest position or deep Trendelenburg, or retrofilling the bladder with at least 500 mL of saline) and administering a tocolytic may reduce pressure on the cord while preparations are being made for delivery. (See 'Intrauterine resuscitation' above.)

Outcome – Reported perinatal mortality related to cord prolapse varies widely, from 0 to 3 percent for events occurring among patients monitored on a labor and delivery unit. Asphyxia and complications related to prematurity and congenital anomalies are the major causes of poor outcome. The degree of cord compression, the interval between cord prolapse and delivery, and successful use of intrauterine resuscitation maneuvers all impact the risk of asphyxia. (See 'Outcome' above.)

Ultrasound screening – We do not routinely perform ultrasound examinations to assess umbilical cord position near term, but would order an ultrasound examination to confirm cord position when there is a clinical suspicion of funic presentation. (See 'Anticipation and prevention of cord prolapse' above.)

Anticipation and risk reduction

Awareness of patients at high risk of prolapse may help facilitate prompt diagnosis and delivery when prolapse occurs. For example, cord prolapse should be excluded by vaginal examination after spontaneous membrane rupture in patients with risk factors for prolapse or with fetal heart rate decelerations. (See 'Anticipating and managing risk' above.)

Patients with transverse, oblique, or unstable lie should present to the hospital urgently when they begin labor or rupture membranes. (See 'Anticipating and managing risk' above.)

In high-risk patients, the risk of cord prolapse may be reduced by minimizing use of obstetric interventions that may disengage the presenting part and by performing controlled amniotomy. (See 'Anticipation and prevention of cord prolapse' above.)

For patients with a funic (cord) presentation that has not resolved before labor at term, management depends on the risk of cord prolapse. (See 'Pregnancies with funic (cord) presentation' above.)

-Patients with a floating vertex, cervical dilation >2 cm, and persistent funic presentation at ≥39 weeks are at very high risk of cord prolapse with rupture of membranes and unlikely to benefit from expectant management, especially if polyhydramnios is present. The authors offer these women induction of labor by "needling" the membranes in a controlled environment, with the anesthesia team ready for an emergency cesarean delivery in the event of cord prolapse.

-Patients in whom the vertex has descended, the cervix is not significantly dilated, and amniotic fluid volume is normal are at increased risk of cord prolapse, but not the highest risk group. The authors advise these patients to come to the labor and delivery unit as soon as labor begins so that the cord position can be evaluated. The patient can continue to labor with a goal of vaginal delivery if the funic (cord) presentation has resolved. If the funic (cord) presentation is confirmed, we monitor the patient/fetal heart rate continuously and perform a controlled amniotomy, with the anesthesia team ready for an emergency cesarean delivery in the event of cord prolapse. Cesarean delivery without a trial of labor is also reasonable.

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Topic 4461 Version 30.0

References

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