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Lisa Fikac, RNC-NIC, MSN
Neonatal Outreach Coordinator Cape Fear Valley Health System PO Box 2000
Fayetteville, NC 28302

Office: (910)615-6933
Fax: (910)615-5472

 


 

When the umbilical cord falls, or prolapses, through the open cervix, below the presenting part, or is compressed between the presenting part and the pelvis or cervix, this is known as an umbilical cord prolapse.

The presenting fetal part does not fill the pelvic inlet, and this allows the cord to slip past the presenting part

Umbilical cord prolapse can occur prior to or during delivery of the fetus, but it often occurs when the membranes rupture (ROM)

 

Cord prolapse is estimated to occur in approximately 1:300 births

 

Umbilical cord prolapse is a life-threatening event for the fetus

Pressure on the cord causes oxygen deprivation to the fetus and can result in fetal death

 

Risk factors for umbilical cord prolapse include -

Preterm, low birthweight (LBW), or small for gestational age (SGA) fetuses

Fetal malposition - breech, transverse lie

Polyhydramnios

Multiple pregnancy

Long umbilical cord

Multiparity - usually due to a lack of engagement prior to the onset of labor

Placenta previa

Cephalopelvic disproportion (CPD) - usually due to a lack of engagement prior to the onset of labor

 

Interventions that may predispose the woman to developing an umbilical cord prolapse include -

Artificial rupture of membranes

Internal scalp electrode application

Intrauterine pressure catheter insertion

Manual rotation of the fetal head

Amnioinfusion or amnioreduction

External cephalic version with ruptured membranes

Application of forceps or vacuum


Clinical Presentation

The first sign of umbilical cord prolapse is usually -

A severe, prolonged, fetal bradycardia OR

A change from a normal fetal monitor tracing to severe variable decelerations

Overt prolapse occurs when the umbilical cord is protruding from the vagina or is palpated during a vaginal exam

The station of the presenting part may be 0 to -4 cm

Occult prolapse occurs when the cord is not visible or palpable, but it is located between the presenting part and the pelvis or cervix.....look for changes to an abnormal fetal heart rate tracing


Clinical Management - Prevention

Admission assessment includes -

Fetal presenting part and station

Cervical dilatation

Status of the membranes

Fetal heart rate, pattern, variability

History for presence of the above listed risk factors

Consider discontinuing ambulation if -

Risk factors are present

The membranes are ruptured

The presenting part is not engaged

At the time of ROM -

Initiate electronic fetal monitoring if not already in use

Perform a vaginal exam

 

Clinical Management - Prolapse Occurs

The provider who identifies the prolapse keeps his/her hand in the vagina to push the presenting part away from the cord until the infant is delivered

Continue to palpate for pulsation of the cord

If the cord has prolapsed out of the vagina, keep it moist

Change maternal position to relieve pressure on the cord and maintain until the infant is delivered. Positions include -

Knee-chest position

Trendelenburg position

Lateral position

Administer oxygen to the mother at 8 L/min

Continuously monitor the fetal heart rate

Immediate delivery -

Forcep vaginal delivery if the cervix is fully dilated

If the cervix is not fully dilated or the fetus in distress, the fetus is delivered by emergency Cesarean


Potential Complications

Maternal

Trauma to the birth canal from a rapid forceps delivery

Uterine atony with subsequent postpartum bleeding from general anesthesia

Blood loss

The usual concerns following any type of surgery (e.g., infection, ileus)

Fetus/Newborn

Fetal anoxia that results in long-term neurologic delays/deficits for the infant

Neonatal infection

Fetal/newborn death

The longer the cord prolapse persists, the greater the risk of mortality for the fetus/newborn

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