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Umbilical Cord Prolapse Management (RCOG 2014)

Umbilical Cord Prolapse Management (RCOG 2014): Cord prolapse: cord below or beside the presenting part → Call for help now: obstetric emergency → Eleva...

Pathway Overview

17 steps

Algorithm Steps

17 total

  1. 01Start

    Cord prolapse: cord below or beside the presenting part

    Membranes ruptured. Suspect it when the FHR becomes abnormal soon after membrane rupture. Confirm by speculum and/or digital vaginal examination. Cord felt below the presenting part with intact membranes (cord presentation): do not rupture the membranes; senior review; caesarean is usually indicated in established labour.

  2. 02Warning

    Call for help now: obstetric emergency

    In hospital: emergency call for obstetrician, midwife, anaesthetist, neonatal team and theatre. Below the local limit of viability (for example under 23 weeks): no emergency call; notify the obstetric team. Out of hospital: call 000. Note the time. IV access and bloods (FBC, group and hold).

    • Stop the oxytocin infusion now if one is running
    • Auscultate the FHR now, then continuous FHR monitoring
    • No cord pulsation or no FHR heard: ultrasound now to confirm the fetal heart
  3. 03Action

    Elevate the presenting part off the cord

    Two gloved fingers in the vagina push the presenting part upwards. Keep it elevated until birth, or until the bladder is filled.

    • Avoid excessive upward displacement: more cord can prolapse
    • Option once above the pelvic brim: hand out of the vagina, continuous upward suprapubic pressure
    • These measures must not delay birth
  4. 04Action

    Position: knee-chest (face down) or left lateral, head down

    Left lateral: head-down tilt and a pillow under the left hip. In an ambulance use the exaggerated Sims position (left lateral, pillow under the hip); knee-chest is unsafe in a moving vehicle.

    • Waiting at home for the ambulance: knee-chest, face down
  5. 05Action

    Handle the cord as little as possible

    Handling, cold and drying can cause cord vasospasm. Do not try to push the cord back above the presenting part.

    • Keep loops outside the vagina warm and moist (warm saline swab); benefit unproven
  6. 06Action

    Out of hospital: transfer now to the nearest unit with caesarean section

    Call 000 and tell the receiving hospital. Keep the presenting part elevated during transfer, by hand or by bladder filling. Stay only if a skilled clinician finds that spontaneous vaginal birth is imminent.

    • A midwife goes in the ambulance if possible
    • Community midwives carry a Foley catheter and a fluid giving set for bladder filling
    • Bladder filling: Foley catheter, 500-750 mL sodium chloride 0.9% with a giving set, then clamp; empty it just before birth
  7. 07Decision

    Fetal heart present (auscultation or ultrasound)?

    Absent cord pulsation alone does not confirm fetal death. Confirm with ultrasound.

  8. If Yes
    1. Fetal heart present
    2. 08Decision

      Gestation under 25 weeks (pre-viable or periviable)?

      Periviable: about 22+0 to 24+6 weeks (RCOG 23+0 to 24+6). Pre-viable: below the local limit of viability (KEMH: under 23 weeks). Use the local periviability guideline.

    3. If Yes
      1. Under 25 weeks
      2. 09Warning

        Under 25 weeks: senior decision before any birth for fetal reasons

        Pre-viable (below the local limit of viability): no emergency caesarean or assisted birth for fetal reasons. Periviable: obstetric consultant and neonatologist counsel the parents briefly on expectant management, active care or ending the pregnancy. Go to the next steps only if active care is chosen.

        • Counselling must not delay birth once active care is agreed
        • No evidence supports putting the cord back into the uterus
        • No active care: senior obstetrician plans ongoing care with the woman
      3. 10Decision

        Vaginal birth imminent (fully dilated, quick and safe)?

        Decide with a senior obstetrician. Caesarean section is the mode of birth when vaginal birth is not imminent.

      4. If Yes
        1. Imminent vaginal birth
        2. 11Action

          Imminent vaginal birth: expedite (usually assisted)

          Fully dilated and birth can be quick and safe: forceps or ventouse by an experienced operator. Avoid compressing the cord. If birth is not quick, go to caesarean section.

          • Keep relieving cord compression until the operator is ready
          • Empty the bladder first if it was filled
          • Breech extraction only in selected cases, for example a second twin after internal podalic version
        3. 12Outcome

          Birth: newborn resuscitation team present

          A practitioner competent in newborn resuscitation attends every birth after cord prolapse.

          • Paired cord blood samples for pH and base excess
          • Document times: diagnosis, call for help, decision, birth
          • Explain events to the woman and her partner; debrief the staff
        If No
        1. Not imminent
        2. 13Action

          Not imminent: emergency caesarean section

          Category 1 (aim for birth within 30 min) if the FHR pattern is suspicious or pathological. Category 2 if the FHR is normal, with continuous CTG; change to Category 1 at once if the CTG becomes abnormal.

          • Keep the presenting part elevated during transfer to theatre and until birth
          • Anaesthetist decides the anaesthetic; regional is preferred if it causes no delay; avoid repeated regional attempts
          • Verbal consent is enough for Category 1
          • Maternal safety comes before the time target
        3. 14Action

          Delay to birth expected: fill the bladder

          Use it when transfer to theatre or hospital will take time. It keeps the presenting part elevated and replaces manual elevation.

          • Foley catheter; instil 500-750 mL sodium chloride 0.9% with a giving set, then clamp
          • Empty the bladder just before any attempt at birth, vaginal or caesarean
          • Then a dry pad to help keep the cord inside the vagina
        4. 15Action

          Persistent FHR abnormality or contractions: consider tocolysis

          Adult: terbutaline 250 micrograms (0.25 mg) subcut, while preparing for caesarean. It must not delay birth. Caution in maternal heart disease, arrhythmia or uncontrolled hyperthyroidism.

          • Terbutaline injection 500 micrograms/mL: 250 micrograms = 0.5 mL subcut
          • Tell the anaesthetist: beta-2 agonists raise arrhythmia risk with halogenated anaesthetics
          • Off-label use in Australia (PI indication: bronchospasm)
        5. Path rejoins step 12Shared downstream outcome
      If No
      1. 25 weeks or more
      2. Path rejoins step 10Shared downstream outcome
    If No
    1. No fetal heart
    2. 16Action

      No fetal heart on ultrasound: fetal death

      Stop the emergency measures for the fetus. A senior obstetrician plans the birth with the woman: caesarean only for maternal or obstetric reasons (for example transverse lie).

      • Give the woman and her partner a clear explanation and support
      • Document times and findings; debrief the staff
  9. 17Action

    Prevention: risk factors for cord prolapse

    Multiparity, birthweight under 2.5 kg, preterm labour, fetal anomaly, breech, transverse, oblique or unstable lie, second twin, polyhydramnios, unengaged presenting part, low-lying placenta.

    • Procedures: amniotomy with a high presenting part, vaginal manipulation of the fetus after membrane rupture, ECV, internal podalic version, balloon induction, intrauterine pressure catheter
    • Avoid amniotomy with a high or mobile presenting part; if essential, do it with immediate caesarean available
    • After membrane rupture or vaginal examination, auscultate the FHR; exclude cord prolapse at every vaginal examination if risk factors are present

Guideline Source

RCOG Green-top Guideline No. 50: Umbilical Cord Prolapse (2014; reviewed Dec 2024 and extended)

View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Measures to relieve cord compression must not delay birth; aim for birth within 30 min when the FHR is abnormal.
  • Periviable gestation or no fetal heart changes the plan; confirm the fetal heart by ultrasound and involve senior staff.
  • Terbutaline for tocolysis is off-label in Australia; follow local medication orders.
  • Out of hospital: transfer to the nearest unit with caesarean section unless spontaneous vaginal birth is imminent.

Applicable Regions

AUUKEUUSGlobal

AU: Consistent with the WA KEMH Cord Prolapse guideline (2025): stop oxytocin, terbutaline 250 micrograms subcut, bladder filling 500-750 mL, call 000 out of hospital, periviable gestation per local guideline.

UK: RCOG Green-top Guideline No. 50 (2014), reviewed Dec 2024 and extended for 2 years.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Umbilical Cord Prolapse Management (RCOG 2014)?

The Umbilical Cord Prolapse Management (RCOG 2014) is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on RCOG Green-top Guideline No. 50: Umbilical Cord Prolapse (2014; reviewed Dec 2024 and extended).

What guideline is the Umbilical Cord Prolapse Management (RCOG 2014) based on?

This algorithm is based on RCOG Green-top Guideline No. 50: Umbilical Cord Prolapse (2014; reviewed Dec 2024 and extended).

What are the limitations of the Umbilical Cord Prolapse Management (RCOG 2014)?

Known limitations include: Measures to relieve cord compression must not delay birth; aim for birth within 30 min when the FHR is abnormal.; Periviable gestation or no fetal heart changes the plan; confirm the fetal heart by ultrasound and involve senior staff.; Terbutaline for tocolysis is off-label in Australia; follow local medication orders.; Out of hospital: transfer to the nearest unit with caesarean section unless spontaneous vaginal birth is imminent.. Individual patient factors may require deviation from these recommendations.

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