Umbilical Cord Prolapse Management (RCOG 2014)

Algorithm Steps

1. ▶

   Start

   CORD PROLAPSE Identified

   Cord palpated below/beside presenting part with ruptured membranes

   1. ⚠

      Warning

      IMMEDIATE ACTIONS - Call Emergency

      This is an obstetric emergency - every second counts

      • CALL FOR HELP - Emergency cesarean team
      • Do NOT handle cord more than necessary (prevent vasospasm)
      • Continuous fetal heart rate monitoring
      • Note the TIME - clock starts now
      1. ●

         Action

         Relieve Cord Compression

         Elevate presenting part manually and position patient

         • Insert hand into vagina
         • Push presenting part UP and AWAY from cord
         • Keep hand in place until delivery
         • Positioning options (see next steps)
         1. ●

            Action

            Patient Positioning

            Reduce pressure on cord while preparing for delivery

            • KNEE-CHEST position (head down, buttocks up)
            • OR Left lateral with pillow under hip
            • OR Steep Trendelenburg
            • Exaggerated Sims position acceptable
            • Goal: Use gravity to move presenting part away from cord
            1. ●

               Action

               Cord Care

               Minimize handling, keep warm and moist

               • Handle cord as little as possible
               • If outside vulva: cover with warm saline-soaked gauze
               • Do NOT attempt to replace cord into vagina
               • Keep cord warm to prevent vasospasm
               1. ◆

                  Decision

                  Assess Cervical Dilation & Fetal Status

                  Determines delivery route

                  1. ●

                     Action

                     Fully Dilated - Consider Vaginal Delivery

                     If delivery is imminent, may proceed vaginally

                     • If head on perineum: assisted vaginal delivery
                     • Forceps or vacuum if appropriate
                     • Only if faster than cesarean
                     • Continue elevating presenting part until delivery
                     • Breech: assisted breech if expertise available
                     1. ◆

                        Decision

                        Fetal Heart Rate Status

                        Monitor throughout - guides urgency

                        • If FHR present and acceptable: continue current plan
                        • If prolonged bradycardia: expedite delivery
                        • If FHR absent: confirm and discuss with parents
                        1. ✓

                           Outcome

                           Delivery Achieved

                           Neonatal team for immediate assessment

                           • Immediate neonatal resuscitation as needed
                           • Cord blood gases
                           • Document times and interventions
                           • Debrief with team and family
                  2. ⚠

                     Warning

                     EMERGENCY CESAREAN SECTION

                     Category 1 (immediate) cesarean required

                     • Decision-to-delivery interval: aim <30 minutes
                     • Continue manual elevation of presenting part during transfer
                     • Patient to OR in position that relieves compression
                     • General anesthesia may be fastest
                     • Maintain fetal heart rate monitoring if possible
                     • Prepare for neonatal resuscitation
                     1. ●

                        Action

                        Consider Tocolysis

                        May help if contractions worsening cord compression

                        • Terbutaline 0.25mg SC
                        • May reduce contractions and cord compression
                        • Use while preparing for cesarean
                        • NOT a substitute for urgent delivery
                  3. ●

                     Action

                     Consider Bladder Filling

                     Can elevate presenting part if manual elevation difficult

                     • Fill bladder with 500-700mL saline via Foley
                     • Lifts presenting part away from cord
                     • Useful during transport or if delay in cesarean
                     • Empty bladder prior to cesarean
   2. ●

      Action

      Risk Factors (Prevention)

      Be vigilant in high-risk situations

      • Malpresentation (breech, transverse)
      • Polyhydramnios
      • Preterm labor
      • Multiple gestation
      • Amniotomy with high presenting part
      • Artificial rupture of membranes