When caring for a prolapsed umbilical cord you should?

Umbilical cord prolapse is a complication that can occur during labor, either during delivery or just prior to delivery. The umbilical cord that has carried nutrients and oxygen to the baby throughout the pregnancy drops through the mother’s dilated cervix and into the vagina before the baby moves into the birth canal. The umbilical cord then becomes trapped between the infant and the cervix. That compresses the umbilical cord, which cuts off blood flow and oxygen to the baby as it is being born.

Umbilical cord prolapse can result in serious birth injury to a child who would otherwise have been born completely healthy. It does not take long for compression of the umbilical cord to result in serious, permanent damage. Fortunately, prolapse of the umbilical cord is not common; the Cleveland Clinic estimates that it takes place in roughly one out of 300 births. The bad news is that when it does happen, it is an emergency. If the doctor or medical professional overseeing the birth does not become aware of the prolapsed cord and act quickly, their inaction may constitute medical malpractice.

Risk Factors and Causes of Umbilical Cord Prolapse

Although umbilical cord prolapse does not occur in every delivery in which risk factors are present, certain conditions should put medical staff on alert that there is a danger of this complication arising. These risk factors include:

• Premature rupture of the membranes (water breaking), especially before 32 weeks of pregnancy
• Preterm labor
• Pregnancy with twins, triplets, or other multiples
• Excessive amniotic fluid (also called polyhydramnios)
• Breech presentation of fetus
• Abnormally long or thin umbilical cord
• Vacuum or forceps delivery

Umbilical cord prolapse can occur even when there are no risk factors, but it is much more likely when one or more of the factors above are present. A prolapsed cord cannot be prevented, but medical providers should be alert to the risk so that they can act quickly if needed.

Diagnosis of Umbilical Cord Prolapse

A fetal Doppler test or ultrasound imaging can show that the placement of the umbilical cord is problematic. A fetal heartbeat of less than 120 beats per minute (bradycardia) may also indicate that there is an issue with the cord. However, often diagnosis of umbilical cord prolapse requires little or no technology: the doctor may see or feel the prolapsed cord during a pelvic exam.

Once an obstetrician is aware that there is or could be a prolapsed cord, the medical team must spring into action. Time is of the essence: most research says that there should be no more than 12 minutes between the first sign of fetal distress and the delivery of the infant by emergency C-section.

Managing a Prolapsed Umbilical Cord

The standard of care for treating a prolapsed umbilical cord is immediate delivery of the baby. Given the risk of lack of oxygen and blood to the infant, attempting to continue with a vaginal delivery can be very dangerous. The doctor may, in some cases, be able to manually relieve compression of the cord until the baby can be delivered by C-section, but the birth must take place as quickly as possible

Complications of Umbilical Cord Prolapse

If a doctor fails to promptly diagnose or treat umbilical cord prolapse, the results can be devastating. Particularly with an overt umbilical cord prolapse, in which the cord presents before the baby, each contraction compresses the cord, decreasing blood and oxygen flow and increasing the risk of birth injury.

Some of the complications of a prolapsed umbilical cord include:

What is most heartbreaking about these serious and permanent conditions is that a few minutes’ inattention or delay on the part of a medical professional could have prevented them altogether. Instead, many families’ lives will be forever changed by loss or the need to provide lifelong care to a seriously injured child. Not only may the child need extensive, costly medical treatment and therapy, but one parent often needs to give up their career in order to care for their disabled child.

Is Failure to Diagnose Umbilical Cord Prolapse Medical Malpractice?

Because umbilical cord prolapse can and should be detected through simple monitoring and pelvic examinations, failure to diagnose and treat the condition in time may constitute medical malpractice. It may be that a doctor ignored risk factors that should have been noted in the patient’s chart. The doctor may also have failed to use a fetal heart rate monitor that would have alerted the medical team to signs of distress. Or, once umbilical cord prolapse was identified, the doctor may have failed to act to deliver the baby as soon as possible.

One thing is certain: if your baby suffered a serious birth injury as a result of an umbilical cord prolapse, you are probably facing a lifetime of economic consequences, not to mention your child’s loss of function and ability. If your baby’s injury was your doctor’s fault, you should not have to bear those consequences by yourself.

You may not know with certainty that your baby’s injury is due to medical malpractice, but if there is a chance that it was, you should explore the possibility. An experienced medical malpractice attorney can help you identify whether you have a claim, and help you pursue it if you do. Unfortunately, if you wait too long to file a medical malpractice claim, you will not be able to seek compensation from your doctor no matter how strong your claim would have otherwise been.

If you have questions about umbilical cord prolapse or OB/GYN malpractice, we invite you to contact Huegli Fraser to schedule a consultation.

Umbilical cord prolapse is when the umbilical cord exits the cervical os before the fetal presenting part. Compression of the cord results in vasoconstriction and resultant fetal hypoxia, which can lead to fetal death or disability if not rapidly diagnosed and managed. This activity reviews the diagnosis and management of patients with umbilical cord prolapse in the emergency department and highlights the role of early recognition and interprofessional involvement in improving patient outcomes.

Objectives:

• Describe the clinical presentation of umbilical cord prolapse.

• Outline the key steps in the acute management of umbilical cord prolapse.

• Review alternative management strategies that can be utilized after initial attempts at funic decompression have failed or in cases where obstetric care is not immediately available.

• Explain strategies to improve care coordination between the interprofessional teams caring for patients with umbilical cord prolapse to improve outcomes.

Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal morbidity and mortality. Resultant compression of the cord by the descending fetus during delivery leads to fetal hypoxia and bradycardia, which can result in fetal death or permanent disability. Early recognition and intervention are paramount to the reduction of adverse outcomes in the fetus.

Certain features of pregnancy increase the risk for the development of umbilical cord prolapse by preventing appropriate engagement of the presenting part with the pelvis. These include fetal malpresentation, multiple gestations, polyhydramnios, preterm rupture of membranes, intrauterine growth restriction, preterm delivery, and fetal and cord abnormalities.[1] Nearly half of the cases of umbilical cord prolapse can be attributable to iatrogenic causes.[2] Iatrogenic risk factors include amniotomy without an engaged fetal presenting part, attempted external cephalic version in the setting of ruptured membranes, amnioinfusion, placement of a fetal scalp electrode or intrauterine pressure catheter, or the use of a cervical ripening balloon.[1]

Estimates of the incidence of umbilical cord prolapse range from 1.4 to 6.2 per 1000.[3] The majority of cases of umbilical cord prolapse occur in single gestation pregnancies; in twin gestations, the incidence increases in the second twin.[2] Most prolapses occur shortly after rupture of membranes; one study estimates that 57% occur within five minutes of membrane rupture while 67% occur within one hour of rupture.[2] The incidence of umbilical cord prolapse is on a downward trend, which is thought to be secondary to the widespread use of cesarean sections for many of the risk factors of cord prolapse, such as fetal malpresentation.[4][5] Decreasing rates of grand multiparity worldwide are also thought to contribute to the reduced incidence.[5]

The occurrence of fetal bradycardia in the setting of ruptured membranes should prompt immediate evaluation for potential cord prolapse. There are two forms of umbilical cord prolapse.[1] The first, overt prolapse, occurs when the cord exits the cervix before the fetal presenting part; the second, occult prolapse, occurs when the cord exits the cervix with the fetal presenting part.[1] In overt prolapse, the cord is palpable as a pulsating structure in the vaginal vault. In occult prolapse, the cord is not visible or palpable ahead of the fetal presenting part. In overt prolapse, the diagnosis is clinical and made by palpation of a pulsating structure in the vaginal vault or visibly protruding from the vaginal introitus; this is typically accompanied by fetal bradycardia or severe variable decelerations, though fetal heart rate changes only present in approximately two-thirds of cases.[2][6] In occult prolapse, only fetal heart rate abnormalities may appear, as the cord will not be palpable or visible on examination. The diagnosis should be a consideration in cases of unexplained fetal heart rate changes in the setting of recent membrane rupture or other maneuvers that increase the risk of prolapse (for example, placement of a fetal scalp electrode).[1]

Umbilical cord prolapse is a clinical diagnosis and should be considered in the case of fetal bradycardia or recurrent variable decelerations, especially if they occur immediately after rupture of membranes. The diagnosis is confirmed by palpation of a pulsatile mass in the vaginal vault. No radiographic or laboratory confirmation is available, and funic decompression should be attempted as soon as the diagnosis is suspected. Antenatal ultrasound for cord presentation has been demonstrated to be a poor predictor of umbilical cord prolapse.[7]

The definitive management of umbilical cord prolapse is expedient delivery; this is usually by cesarean section. In rare cases, vaginal delivery or operative vaginal delivery may be faster and, thus, preferable, but this should only occur under the presence and guidance of an experienced obstetrician.[1]

Until delivery is possible, the cornerstone of management of umbilical cord prolapse is funic decompression, relieving the pressure on the cord by elevation of the fetal presenting part. Studies suggest that the interval to funic decompression may be more important to outcomes than interval to delivery.[8] Decompression should be done manually by the medical provider through the placement of their finger or hand in the vaginal vault and gentle elevation of the presenting part off the umbilical cord. The provider should be conscientious not to place any additional pressure on the cord, as this can cause vasospasm and worsen outcomes.[9] Placement of the mother in a steep Trendelenburg or knee-chest position can also aid in cord decompression. In cases of a potentially prolonged interval to delivery (i.e., the need for transfer to a hospital with obstetric capabilities), saline infusion into the bladder may aid in funic decompression and remove the need for continuous manual elevation by the provider.[10][11] If fetal decelerations persist and delivery is not imminent, the administration of a tocolytic can be attempted to relieve pressure on the umbilical vessels and to improve placental perfusion, thereby improving blood flow to the fetus.[12][13] Reduction of the cord into the os, which was common before the widespread availability of cesarean sections, has been associated with increased fetal mortality and is not routinely recommended except in cases of an expected long interval to delivery where other maneuvers have failed.[1]

If the cord is visibly protruding from the introitus, it should remain warm and moist because the ambient temperature is significantly colder than the temperature in the uterus and can result in vasospasm of the umbilical arteries, contributing to fetal hypoxia.[1] One method described as preventing this is the replacement of the cord into the vaginal vault followed by insertion of a moist tampon to keep it in place.[14]

In very rare cases of umbilical cord prolapse in peri-viable pregnancies, case studies demonstrate that conservative management may allow the continuation of the pregnancy until reaching a more desirable gestational age.[9][15] However, a frank discussion should take place with the patient regarding the experimental nature of this treatment and its potential risks. 

Pre-viable gestational age, lethal fetal abnormalities, or fetal demise are not indications for expedient delivery, and instead, a dilation and evacuation or labor induction should be the therapeutic choice, dependent on gestational age or maternal preference.[5]

Potential causes of a palpable mass in the vaginal vault include fetal malpresentation.[1] Possible causes of severe, prolonged fetal bradycardia include maternal hypotension, uterine rupture, vasa previa, and abruptio placentae.[1]

The rate of fetal mortality in umbilical cord prolapse is estimated to be less than 10%.[9][2][4] This reduction is a drastic decrease from earlier estimates of mortality, which ranged from 32 to 47%, which researchers hypothesize is due to the increased availability of cesarean sections and advances in neonatal resuscitation.[1][9] Gestational age and location of prolapse (inside versus outside the hospital) are the two significant determinants of outcome in umbilical cord prolapse.[5] Cord prolapse that occurs outside the hospital carries an 18-fold increased risk of mortality.[6] Premature infants and those with low birth weights have an increased risk of perinatal complications and twice the mortality.[9] Death in these infants appears to be attributable to their underlying conditions and the preterm delivery necessitated by the prolapse rather than complications of the prolapse itself. 

Outcomes for umbilical cord prolapse have drastically improved in recent years.[4] Still, a diagnosis of umbilical cord prolapse carries a risk of fetal mortality. Though rare, surviving infants may develop complications secondary to asphyxia, including neonatal encephalopathy and cerebral palsy.[16][17][18]

Emergent obstetric consultation is necessary for umbilical cord prolapse occurring in the emergency department. The attending clinicians should attempt maneuvers for funic decompression until definitive management is available. 

Many patients in resource-rich countries are opting for childbirth at home under the supervision of a non-physician attendant such as a midwife. Cases of umbilical cord prolapse that occur outside the hospital carry a nearly 20 times increased rate of mortality. As such, patients with increased risk of prolapses, such as those with fetal malpresentation or umbilical cord abnormalities, should be strongly discouraged from delivering outside of the hospital. Concentration on other portions of their birth plan, such as a silent birth or minimal pharmacologic intervention, may help these patients decide to deliver in the hospital. Since umbilical cord prolapse may happen in patients without risk factors, training for non-physician birth attendants in the early recognition and intervention in umbilical cord prolapse may lead to improved fetal outcomes in these cases. 

Patients themselves should also be counseled to recognize cord prolapse in the scenario of a gush of fluid followed by the feeling of vaginal pressure or something in the vagina. The patient should be instructed to call an ambulance and assume a knee-chest position while waiting for help to arrive.

Given the iatrogenic risk factors for umbilical cord prolapse, physician education also has a role to play in decreasing the frequency of this condition. The American College of Obstetricians and Gynecologists recommends against routine amniotomy in normally progressing labor unless needed for fetal monitoring.[19] If performing an amniotomy, engagement of the fetal head should be confirmed. In cases with risk of cord prolapse, for example, polyhydramnios or high fetal station, the amniotic sac may be ruptured with a needle rather than a hook to slow the flow of the amniotic fluid, though the efficacy of this technique has not been well-studied.[20]

Knowledge of the risk factors for umbilical cord prolapse does not decrease its occurrence [2], but such knowledge can help both healthcare providers, including midwives, labor and delivery nurses, and the patient prepare for potential umbilical cord prolapse. In patients with risk factors for developing umbilical cord prolapses, such as breech presentation with desired vaginal delivery, frank discussion with the patient and her partner regarding the risk should be undertaken, and the recommendation is to plan the delivery at a healthcare center where emergent cesarean delivery is available. Patient counseling by the clinician and nurse regarding the expected course of events in the case of umbilical cord prolapse in delivery may help the patient better understand the urgent nature of management before occurrence. Simulation team training exercises have been shown to decrease the time from diagnosis to delivery and improve fetal outcomes.[21][22][23]

Umbilical cord prolapse cases require an interprofessional team approach to care. This team includes physicians and specialists, as well as specialty-trained neonatal nursing staff. Through collaborative team communication, optimal care can be the result, with the best possible patient outcomes for both the mother and the neonate. [Level 5]

Review Questions

Umbilical Cord prolapse. Contributed by Wikimedia Commons, W. Smellie, 1792 (Public Domain)

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