Umbilical Cord Prolapse (UCP)

This is a crash cesarean - Definitive management is expedient delivery, almost always by cesarean. Studies suggest the interval to funic decompression matters even more than the interval to delivery, so the clock is already running when you get the call.

How it gets diagnosed - Fetal bradycardia or recurrent severe variable decelerations, especially immediately after membrane rupture, plus palpation of a pulsatile mass in the vaginal vault. There is no lab or imaging confirmation, and fetal heart rate changes are present in only about two-thirds of cases, so a normal tracing does not rule it out.

Know who is at risk before it happens - Malpresentation, multiple gestation (higher in the second twin), polyhydramnios, preterm rupture of membranes, intrauterine growth restriction, and preterm delivery. Nearly half are iatrogenic: amniotomy without an engaged presenting part, external cephalic version with ruptured membranes, amnioinfusion, fetal scalp electrode or intrauterine pressure catheter placement, and cervical ripening balloons.

Someone's hand stays in the vagina - Manual elevation of the presenting part off the cord continues from the room, through transport, onto the OR table, and through prep. Plan your positioning and your induction around that — don't ask them to let go.

Positioning - Steep Trendelenburg or knee-chest aids cord decompression, so expect to induce on a tilted table. Keep left uterine displacement on during transport and prep.

General anesthesia when there is no time - Induce only after the surgical field is prepped and drapes are up. Propofol plus succinylcholine RSI is the standard; ketamine 2.5 mg/kg is the better induction agent if she is hemodynamically unstable. Treat every parturient as a full stomach.

Airway edema - The natural edema of pregnancy makes intubation harder than in the same patient nonpregnant. Have the standard GETA setup laid out at the head of the bed before induction, not in the hallway.

Tocolytic as a bridge - If decelerations persist and delivery is not immediate, a tocolytic can relieve pressure on the umbilical vessels and improve placental perfusion.

Keep the cord warm and moist - If the cord is protruding from the introitus, ambient temperature is far colder than the uterus and triggers umbilical artery vasospasm that worsens fetal hypoxia. Warm saline-soaked gauze, and no additional pressure on the cord.

Bladder filling for a long transfer - Saline infusion into the bladder aids funic decompression and removes the need for continuous manual elevation when the interval to delivery will be long.

After delivery - Oxytocin in step with delivery of the placenta, uterine massage before you think about emergence, and an awake extubation. Have the neonatal resuscitation team present — survivors can develop neonatal encephalopathy and cerebral palsy from asphyxia, and preterm and low-birth-weight infants carry twice the mortality.

Drill it - Simulation team training shortens the diagnosis-to-delivery interval and improves fetal outcomes. This is a case worth rehearsing with your OB team before you live it.

Umbilical cord prolapse (UCP) is the cord exiting the cervical os ahead of the fetal presenting part. Overt prolapse puts the cord in front of the presenting part, where it is palpable as a pulsating structure in the vaginal vault; occult prolapse brings it down alongside the presenting part, where it is neither visible nor palpable. Either way the descending fetus compresses the cord, and exposure to ambient air causes umbilical artery vasospasm, producing fetal hypoxia, bradycardia, and — without rapid relief — fetal death or permanent disability.

Incidence is 1.4 to 6.2 per 1000. Roughly 57% occur within five minutes of membrane rupture and 67% within an hour, and nearly half of all cases are iatrogenic.