Cord Prolapse

Question 1

Define cord prolapse and cord presentation.

Answer 1

Cord presentation: Cord below the presenting part with intact membranes

Cord prolapse: Cord below the presenting part with ruptured membranes (cord palpable in vagina or visible at introitus)

Occult cord prolapse: Cord alongside presenting part (not below it) — harder to detect; suspected on CTG abnormalities

Question 2

What are the risk factors for cord prolapse?

Answer 2

Malpresentation (breech — especially footling, transverse, oblique)
Unengaged presenting part (high head)
Polyhydramnios (gush of fluid at ROM displaces cord)
Multiparity
Preterm labour (small presenting part doesn’t fill pelvis)
Multiple pregnancy (especially second twin)
Artificial rupture of membranes (ARM) — especially with high head
Low-lying placenta
Long umbilical cord
ECV
Cervical cerclage removal

Question 3

What is the emergency management of cord prolapse?

Answer 3

Call for help — category 1 CS (unless vaginal delivery imminent)
Do NOT handle the cord excessively (causes vasospasm)
Keep cord warm and moist — wrap in warm saline-soaked gauze if outside vagina. Do NOT attempt to replace it.
Manually elevate presenting part — gloved hand in vagina, push presenting part upward off the cord. Keep hand in place until delivery.
Maternal positioning:
Knee-chest (all fours, head down) OR
Left lateral with Trendelenburg/head down tilt OR
Exaggerated Sims position
Fill bladder with 500-700mL warm saline via catheter → clamp catheter (bladder filling elevates presenting part and inhibits contractions)
Consider tocolysis — terbutaline 0.25mg SC (reduces contractions, improves placental blood flow)
Continuous CTG monitoring
Category 1 CS — aim decision-to-delivery <30 minutes (ideally <15)
If fully dilated with cephalic presentation and delivery imminent → may proceed to assisted vaginal delivery