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Expert Review ajog.org
Umbilical cord prolapse: revisiting its definition
and management
Lo Wong, MRCOG; Angel Hoi Wan Kwan, MRCOG; So Ling Lau, MRCOG; Wing To Angela Sin, MRCOG;
Tak Yeung Leung, MD, FRCOG
Umbilical cord prolapse is an unpredictable obstetrical emergency with an incidence
ranging from 1 to 6 per 1000 pregnancies. It is associated with high perinatal mortality,
ranging from 23% to 27% in low-income countries to 6% to 10% in high-income
countries. In this review, we specifically addressed 3 issues. First, its definition is not
consistent in the current literature, and “occult cord prolapse” is a misnomer because the
cord is still above the cervix. We proposed that cord prolapse, cord presentation, and
compound cord presentation should be classified according to the positional relationship
among the cord, the fetal presenting part, and the cervix. All of them may occur with
either ruptured or intact membranes. The fetal risk is highest in cord prolapse, followed
by cord presentation, and lastly by compound cord presentation, which replaces the
misnomer “occult cord prolapse.” Second, the mainstay of treatment of cord prolapse is
urgent delivery, which means cesarean delivery in most cases, unless vaginal delivery is
imminent. The urgency depends on the fetal heart rate pattern, which can be brady-
cardia, recurrent decelerations, or normal. It is most urgent in cases with bradycardia,
because a recent study showed that cord arterial pH declines significantly with the
bradycardia-to-delivery interval at a rate of 0.009 per minute (95% confident interval,
0.0003e0.0180), and this may indicate an irreversible pathology such as vasospasm or
persistent cord compression. However, cord arterial pH does not correlate with either
deceleration-to-delivery interval or decision-to-delivery interval, indicating that inter-
mittent cord compression causing decelerations is reversible and less risk. Third, while
cesarean delivery is being arranged, different maneuvers should be adopted to relieve
cord compression by elevating the fetal presenting part and to prevent further cord
prolapse beyond the vagina. A recent study showed that the knee-chest position provides
the greatest elevation effect, followed by filling of the maternal urinary bladder with 500
mL of fluid, and then the Trendelenburg position (15�) and other maneuvers. However,
each maneuver has its own advantages and limitations; thus, they should be applied
wisely and with great caution, depending on the actual clinical situation. Therefore, we
have proposed an algorithm to guide this acute management.
Key words: angle of progression, bradycardia-to-delivery interval, cesarean delivery,
Introduction
Umbilical cord prolapse is an unpre-
dictable obstetrical emergency with an
incidence ranging from 1 to 6 per 1000
pregnancies.1e5 Although some litera-
ture suggests that the incidence has been
similar over the past decades,6e9 a report
from Ireland showed a decline from 6.4
per 1000 in the 1940s to 1.7 per 1000 in
the 2000s and attributed it to a reduction
in grand multiparity and the increased
use of cesarean delivery.1 Other well-
known risk factors for cord prolapse
include fetal malpresentation, abnormal
lie, nonengaged fetal presenting part,
preterm labor, polyhydramnios, and
some obstetrical procedures such as
external cephalic version, amniotomy,
and induction of labor using large
balloon catheter.3e7,9e15 Cord compres-
sion and vasospasm leading to fetal
hypoxia account for most adverse peri-
natal outcomes in cord prolapse.6,7,9,13 It
can have catastrophic consequences for
the fetus and remains an important cause
of perinatal mortality. In some low-
income countries in Africa, the reported
perinatal mortality rate is approximately
23% to 27%,11,12 whereas it is approxi-
mately 6% to 10% in high-income
countries.1,13e15 The increased use of
From the Department of Obstetrics and
Gynaecology, Faculty of Medicine, Prince of
Wales Hospital, The Chinese University of Hong
Kong, Shatin, Hong Kong, China.
Received Feb. 19, 2021; revised June 15, 2021;
accepted June 16, 2021.
The authors report no conflict of interest.
The authors report no financial support for this
study.
Corresponding author: Tak Yeung Leung, MD,
FRCOG. tyleung@cuhk.edu.hk
0002-9378/$36.00
ª 2021 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2021.06.077
cord presentation, decision-to-delivery interval, fetal distress, knee-chest position,
tocolysis, transperineal sonography, Trendelenburg position, umbilical cord prolapse
cesarean delivery, simulation training,
and improved neonatal resuscitation has
lowered fetal mortality substantially over
the years.1,6,9,16
Owing to the uncommon nature of
the condition, many questions remain
unanswered for this important obstet-
rical emergency. First, there are varia-
tions in its definition and classification in
the literature.6,13 Second, there is a lack
of consensus on the degree of urgency in
delivery for this condition. Many previ-
ous studies have shown a poor
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correlation between the decision-to-
delivery interval and perinatal out-
comes.13 Third, different maneuvers
have been proposed to relieve cord
compression before delivery, yet their
efficacy has not been objectively
compared.13 Therefore, we aimed to
address these 3 issues in our review.
Definition of Cord Prolapse and Cord
Presentation
Although cord prolapse and presentation
are well-known obstetrical complications,
American Journal of Obstetrics & Gynecology 1
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https://doi.org/10.1016/j.ajog.2021.06.077
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Expert Review ajog.org
their definitions are not consistent in the
literature. Cord prolapse has been tradi-
tionally classified into overt and occult
types.6,7,13 Overt cord prolapse is
commonly defined as the descent of the
cord through the cervix, passing the pre-
senting part, and in the presence of
ruptured membranes.6,7,13 Although this
definition highlights a dangerous condi-
tion that requires immediate intervention,
it does not cover cases where the cord has
passed the cervix but remains contained in
an intact herniated amniotic sac extending
into the vagina (Figures 1 and 2, Video).
The latter condition is more common in
preterm gestation or cervical incompe-
tence but may not be easily diagnosed
because vaginal visualization or palpa-
tion of the content inside the herniated
membranes may be obscured. Hence,
sonographic examination is important
to rule out any prolapsed cord in the
herniated amniotic sac (Figure 2).
Although the membranes are intact,
compression between the cervix and
the fetal part may still occur during
uterine contractions. Upon rupture of
the membranes, the cord becomes un-
protected in the vagina or may even be
flushed out of the vagina. In such cases,
the fetal risk is higher than cases
currently classified as “occult” cord
prolapse or cord presentation.17
Therefore, we propose to include the
descent of the umbilical cord below
the cervix, with both ruptured and
intact membranes, in the classification
of cord prolapse (Figure 1).
The definition of “occult” cord pro-
lapse is more variable. Although most
authors described it as the cord being
alongside but not in advance of the fetal
presenting part, in the presence of
rupture of membranes,6,7,9 some other
authors also included cases with intact
membranes.18 Nonetheless, “cord
alongside the fetal presenting part”
essentially means “compound cord
presentation.” In such cases, the cord
has not yet prolapsed outside the cer-
vix, and therefore, “prolapse” is a
misnomer for this condition. The
definition drawn by the Royal College
of Obstetricians and Gynaecologists is
even more confusing—“the descent of
the umbilical cord ‘through the cervix’
2 American Journal of Obstetrics & Gynecology M
and ‘alongside the presenting part’ in
the presence of ruptured mem-
branes.”13 It is an improperdescription,
because, in real clinical situation, it is
rather impossible for the umbilical
cord to pass through the cervix while
still being alongside the presenting
part, which has not yet passed through
the cervix (Figure 1). Lin et al6
described “occult” as the cord being
only palpable alongside the presenting
part when passing the examining finger
into the cervical canal, whereas Hol-
brook et al7 stated that the cord is not
visible or palpable in “occult cord
prolapse.” In terms of denotation, both
meant that the cord remains inside the
cervix (ie, not yet prolapsed) and thus is
not revealed or palpable unless some-
one puts their fingers inside the cervix.
In such cases, there is a chance of cord
compression between the presenting
part and the uterine wall, resulting in
fetal distress.9,19 The risk of subsequent
cord prolapse also exists, but because
the fetal presenting part displaces the
cord from the cervical os, the chance is
lower than that of cord presentation or
a loop of cord in a herniated amniotic
sac (Figure 1).13 As such, the misnomer
“occult prolapse” is misleading with an
underestimation of the risk to fetal
outcome for the latter 2 conditions.
Therefore, we propose to replace
“occult cord prolapse” by a more ac-
curate term “compound cord presen-
tation,” which may occur with either
ruptured or intact membranes.
Cord presentation is defined as the
presence of the cord between the fetal
presenting part and the cervical os, but it
is worth pointing out that some authors
included cases with both intact and
ruptured membranes,13,20 whereas some
only consider cases with intact mem-
branes,6,21 probably based on the argu-
ment that a presenting cord would
prolapse when the cervix is open and the
membranes are ruptured. However, a
presenting cord may remain above the
cervical os if the cervix is minimally
dilated, and such condition can nowa-
days be diagnosed with sonography.
Hence, it is appropriate to include cord
presentation with ruptured membranes
too.
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Because the fetal risk is highest in cord
prolapse, followed by cord presentation
and then compound cord presentation
(known as “occult cord prolapse”), we
propose the following modification of
their definitions, according to the posi-
tional relationship between the umbilical
cord, the cervix, and the presenting part
and the status of the membranes
(Figure 1):
1) Cord prolapse: the cord is below the
cervix
� with ruptured membranes or
intact membranes;
� the extent of cord prolapse can
further be graded to inside or
outside the vagina.
2) Cord presentation: the cord is above
the cervix but below the presenting
part
� with ruptured membranes or
intact membranes.
3) Compound cord presentation: the
cord is above the cervix and along-
side the presenting part
� with ruptured membranes or
intact membranes.
Urgency in Delivery and Fetal
Outcome
At present, the mainstay of treatment for
umbilical cord prolapse with a viable
fetus is emergency delivery. Delaying
delivery for extremely premature cases
with rupture of membranes has been
reported with a good outcome but it is
exceptional.22 In arranging an emergent
cesarean delivery, maternal risk has to be
balanced with the fetal risk of hypox-
ia.23,24 There is no consensus on the
optimal decision-to-delivery interval,13
because many previous studies have
shown poor correlation between
decision-to-delivery interval and um-
bilical cord arterial blood gas or perinatal
outcomes.25e28 One of the major rea-
sons is that many of these studies are of a
small scale, with fewer than 50
patients.25e28 The largest cohort of 438
cases came from Uganda, and it
demonstrated a higher perinatal mor-
tality rate of 53.5% (53 in 99 cases) when
the decision-to-delivery interval was
beyond 60 minutes than 12.1% (27 in
224 cases) when it was within 30
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FIGURE 1
Classification of cord prolapse and presentation
Cord prolapse is defined as the cord below the cervix with (A) ruptured and (B) intact membranes;
cord presentation is defined as the cord above the cervix and below the fetal presenting part with (C)
ruptured and (D) intact membranes; compound cord presentation is defined as the cord above the
cervix and alongside with the fetal presenting part, with (E) ruptured (previously named as “occult”
cord prolapse) and (F) intact membranes.
Wong. Umbilical cord prolapse: a revisit. Am J Obstet Gynecol 2021.
ajog.org Expert Review
minutes.11 Another large cohort of 246
cases from Turkey also demonstrated a
higher incidence of poorer Apgar score
at 5 minute (<7) when the decision-to-
delivery interval was beyond 60 mi-
nutes than situations when it was within
(58.3% vs 3.2%) 60 minutes.29 However,
decision-to-delivery interval is often
long in low-income countries for trans-
porting patients to hospitals for de-
livery8,11,18; hence, their results may not
apply to high-income countries, wherein
the concern is whether the perinatal
outcome could be improved with a
decision-to-delivery interval shorter
than 30 minutes.1,14,16 Huang et al30
reviewed 40 term pregnancies with um-
bilical cord prolapse and reported that
the median decision-to-delivery interval
was longer for those neonates with a 5-
minute Apgar score of <7 compared
with those at or above 7 (16.8�7.9 mi-
nutes vs 5.2�3.3minutes). Murphy et al2
also reported that prolonged decision-
to-delivery interval of more than 30
minutes was associated with a low 5-
minute Apgar score of less than 7, but
not with a low cord pH (<7), which is
commonly a criterion used in defining a
correlation between intrapartum fetal
distress and cerebral palsy.31e35 Kaymak
et al36 reviewed 98 cases of umbilical
cord prolapse and reported that a de-
livery interval of greater than 10 minutes
predicted adverse neonatal outcome
independently. In contrast, Faiz et al37
reported a contradictory result of
improved Apgar scores at 5 minutes with
decision-to-delivery interval longer than
20 minutes.
In addition to the small sample size in
most studies,25e28,36 the lack of a
consistent correlation between decision-
to-delivery interval and perinatal out-
comes can also be explained by several
reasons. First, fetal condition as reflected
by the fetal heart rate pattern at the time
of cord prolapse varies across cases.38,39
The presence of any other unfavorable
fetal factors, the location at which cord
prolapse occurs (ie, inside or outside
clinical setting), the degree of cord pro-
lapse, and the different maneuvers used
to relieve cord compression may all
affect perinatal outcomes.28 Unfortu-
nately, these factors have not been
analyzed in the current literature.
Moreover, although decision-to-delivery
interval has been employed in most
studies, it is not a direct reflection of the
actual duration of fetal compromise or
hypoxia. The time of cord prolapse and
the onset of fetal hypoxia may have
occurred well before the diagnosis or the
time at which a decision for delivery is
made. Therefore, decision-to-delivery
interval is not an accurate predictor of
perinatal outcomes.38,39
In a recent retrospective review of 114
umbilical cord prolapse cases, it was
found that the fetal heart rate may pre-
sent with the following 3 patterns: (1)
persistent bradycardia, (2) recurrent
decelerations, or (3) normal.39 The fetal
outcomes were analyzed according to the
different fetal heart rate patterns and the
duration of fetal heart rate abnormalities
(starting from the bradycardia or decel-
eration to delivery) and decision-to-
delivery interval. It was found that cord
arterial pH deteriorated significantly
with bradycardia-to-delivery interval in
cases presented with fetal bradycardia, at
a rate of 0.009 per minute (95% confi-
dent interval, 0.0003e0.0180).39 The
risk of severe acidosis (pH,<7) was 80%
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(1 in 5 cases) when bradycardia-to-
delivery interval was >20 minutes, but
only 17.2% (5 in 29 cases) when the in-
terval was <20 minutes. In contrast,
there was no correlation between cord
arterial pH and deceleration-to-delivery
intervalor decision-to-delivery interval.
These results are consistent with our
belief that intermittent cord compres-
sion causes recurrent fetal heart rate
decelerations, which are potentially
reversible with less risk of fetal hypoxia.
In contrast, fetal bradycardia is likely to
be irreversible and may be caused by
persistent cord compression or vaso-
constriction secondary to the exposure
of the prolapsed cord to a lower tem-
perature inside or outside the
vagina.6,7,17,18,30 This has great implica-
tion on the management of umbilical
cord prolapse, in terms of the urgency of
delivery.
Although prompt delivery is desirable
in all cases of umbilical cord prolapse, it
has to be weighed against the maternal
risk of an urgent cesarean delivery and
general anesthesia, such as intubation
failure and aspiration pneumonia.23,40e42
In cases with normal fetal heart rate
pattern or decelerations without
American Journal of Obstetrics & Gynecology 3
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FIGURE 2
Cord prolapse with intact membranes herniated to the vagina
A, The patient is in supine position (before turning the patient to Trendelenburg position). The fetus is in transverse lie with its back close to the cervix.
B, After turning the patient to the Trendelenburg position (15�), the fetal back is away from the internal os. C,While the patient is still in the Trendelenburg
position, the maternal urinary bladder is filled with normal saline up to 300 mL. There is no additional elevation effect. The patient is then sent to the
operation theater.
Wong. Umbilical cord prolapse: a revisit. Am J Obstet Gynecol 2021.
Expert Review ajog.org
bradycardia, the risk of fetal hypoxia is
considerably lower than those cases
where bradycardia has occurred. In such
cases, spinal anesthesia can be an option
instead of general anesthesia. A decision-
to-delivery interval within 30 minutes is
acceptable, provided that the fetal heart
rate is continuously monitored to ensure
there would be no subsequent deteriora-
tion. In contrast, delivery in a short in-
terval is critical in cases with persistent
bradycardia to prevent adverse perinatal
outcome because the cord arterial pH
drops at the rate of 0.009 per minute and
a bradycardia-to-delivery interval of less
than 20 minutes should be achieved to
minimize the chance of severe fetal
acidosis.38,39,43e46
Maneuvers to Manage Cord Prolapse
Unless vaginal delivery is imminent,
most cases of cord prolapse require a
cesarean delivery.6,7,9,13 Because the
preparation for cesarean delivery and
anesthesia require some time, immediate
relief or prevention of cord compression
while delivery is being arranged is
equally important, to reduce the risk of
hypoxic brain injury and subsequent
cerebral palsy and mortality.13,43 Hence,
a number of maneuvers have been sug-
gested to relieve cord compression, such
as elevation or disengagement of the fetal
presenting part. Such maneuvers can be
4 American Journal of Obstetrics & Gynecology M
classified into the following 2 ap-
proaches: (1) “pushing” up by manual
elevation (usually transvaginal)
(Figure 3, A) or by filling of the maternal
urinary bladder (Figure 3, B) or (2)
“pulling” by gravitational force after
elevating the maternal pelvis, which can
be achieved in the knee-chest position
(Figure 3, C) and Trendelenburg posi-
tion (Figure 3, D) and by wedging the
maternal pelvis (Figure 3, E and F).
Intuitively, “pulling” by gravitational
force has 2 potential advantages over
“pushing” from below. First, after
elevating the maternal pelvis, the gravi-
tational force may also reduce the risk of
further prolapse from inside to outside
the vagina, Second, the effect of “push-
ing” up methods depends on the initial
station of the fetal presenting part. The
higher the station is, the lesser is the
effectiveness of the pushing. Although
some small case series reported on the
success of individual maneuvers,47,48 it is
not possible to conduct a randomized
controlled trial to objectively compare
their efficacy in this uncommon but
acute clinical condition.
Therefore, a recent observational
study was conducted to objectively
evaluate the degree of elevation effect by
various maneuvers in a group of 20
women carrying a cephalic-presenting
singleton fetus at term.49 Different
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maneuvers, including the Trendelenburg
position (15�), the knee-chest position,
wedging of their buttocks, and filling
their urinary bladder with 100 mL, 300
mL, and 500 mL of fluid, were applied to
them just before their elective cesarean
delivery. During each maneuver, trans-
perineal sonographic measurement of
the parasagittal angle of progression,
which is between the longitudinal axis of
the pubic bone and the lowest convexity
of the fetal skull, was made as an indi-
cator of the fetal head station (Figure 4, A
and B).50e56 The study reported that the
knee-chest position resulted in the
greatest elevation effect of the fetal head,
with a reduction of the parasagittal angle
of progression by 23� (approximately 3
stations up) (Figure 4, C).57 Further-
more, the elevation effect was indepen-
dent of the initial fetal head station.49 It
was followed by filling the maternal
bladder with 500 mL (a reduction of the
angle by 14 degrees; approximately 2
stations up) (Figure 4, D) and then 300
mL of normal saline (9�). In contrast,
elevation using bladder filling alone was
station dependent. A greater degree of
fetal head elevation by bladder filling was
achieved when the initial fetal head sta-
tion is lower. Hence, there seems to have
no advantage in elevation if the initial
fetal presenting part is high. In addition,
bladder filling with 100 mL of normal
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FIGURE 3
Different maneuvers for relieving cord compression
A, Transvaginal manual elevation. B, Filling of maternal urinary bladder. C, The knee-chest position. D, The Trendelenburg position. E and F,Wedging the
maternal pelvis in supine and lateral position, respectively.
Wong. Umbilical cord prolapse: a revisit. Am J Obstet Gynecol 2021.
ajog.org Expert Review
saline, Trendelenburg position at 15 de-
grees, and elevation of the maternal
buttocks with a wedge or pillow gave a
modest elevation effect (approximately
5� to 7�).49 Upon further review on the
pros and cons of each maneuver (Table),
we have drawn an algorithm in man-
aging cord prolapse.
Manual elevation of the presenting
part
Manual elevation of the presenting part
to reduce cord compression can be per-
formed immediately during the vaginal
examination while the diagnosis of um-
bilical cord prolapse is made. It is the
most direct and quickest method,
compared with other maneuvers,
because it does not require any instru-
mentation.12,58 However, such trans-
vaginal approach is unpleasant for the
patient and laborious for the doctor,
especially during the transportation of
the patient.59 It is also technically diffi-
cult to push the fetal presenting part up
when its station is high or when the fetus
is in transverse lie. Another potential
drawback is that it may create more
room for further prolapse of the
umbilical cord. There is also a potential
risk of cord compression by the exam-
ining fingers in the vagina, especially
when a loop of cord is already outside of
the vagina.6 Alternatively, a suprapubic
approach to elevate the fetal presenting
part may be tried if it is not deeply
engaged in the maternal pelvis.60
Although transvaginal manual elevation
can be one of the first maneuvers in
relieving cord compression immediately
after the diagnosis of cord prolapse, it
can be taken over by other more suitable
maneuvers if possible.
Trendelenburg position or elevation of
the patient’s buttocks
In the Trendelenburg position, the
woman is placed in a head-down posi-
tion with the maternal pelvis tilted above
the maternal head, so that the fetus is
“pulled” up by gravitational force and
away from the cervix. The position can
be performed swiftly if the patient is
already on an adjustable bed. Greater
tilting of the bed may be more effective
in disengagingthe fetal presenting part
but is limited by maternal discomfort. A
15-degree tilt is a practical angle of
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inclination.49 However, an adjustable
bed may not always be available. In such
circumstances, elevation of the maternal
buttocks can be achieved by placing a
thick pillow or wedge under the woman’s
buttocks. These methods have a modest
elevation effect,49 but the angle of tilt
may be increased further if necessary, at
the expense of more maternal discom-
fort. In addition, elevation of the
maternal buttocks can also reduce the
risk of further cord prolapse outside
the vagina, making it more preferable
than manual elevation.
Filling of the maternal urinary bladder
Maternal urinary bladder filling is
another “pushing”method to elevate the
fetal presenting part.47,48,61,62 It was
originally described by Vago,47 who
proposed to instill the urinary bladder
with 500 to 750 mL of fluid. Caspi et al61
used the same method and volume,
which successfully prevented perinatal
mortality in their 88 cord prolapse cases.
Chetty et al62 filled the bladder with 400
to 500 mL of fluid and reported no
perinatal mortality in their 24 cases with
an average diagnosis-to-delivery interval
American Journal of Obstetrics & Gynecology 5
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FIGURE 4
Transperineal sonographic measurement of the parasagittal angle of
progression
A, Graphic illustration of the measurement. B, At supine position: 113.6�. C, At the knee-chest
position: 82.2�. D, After filling the urinary bladder with 500 mL of saline: 86.4�.
Wong. Umbilical cord prolapse: a revisit. Am J Obstet Gynecol 2021.
Expert Review ajog.org
of 65 minutes. The infused volume in
these studies concurred with that of
Kwan et al,49 which showed that 500 mL
could elevate the fetal presenting part by
2 stations. It is effective in terms of
elevating the fetal head, especially when a
delay in delivery is expected or trans-
portation of the patient for a longer
distance is needed. It has the advantage
over manual elevation, because it does
not require continuous assistance of
skilled personnel once bladder filling is
complete. However, because the direc-
tion of elevation by the distended
bladder is from below the level of the
fetal presenting part, it is less effective
when the fetal head is at a higher sta-
tion.49 In addition, other disadvantages
include the need for equipment and time
to complete the procedure. In practice, it
may take at least 2 minutes from
obtaining the equipment to completion
of catheterization under aseptic tech-
nique and a further 2 to 4 minutes to fill
the bladder up to 300 to 500 mL.49 This
6 American Journal of Obstetrics & Gynecology M
delay, in comparisonwith the immediate
effect of manual elevation, can impact on
perinatal mortality. Further delaymay be
experienced at the time of cesarean de-
livery when emptying of the bladder is
required. On balance, in units where
delivery can be effectively expedited, the
role of urinary bladder filling may be
limited and may even cause further delay
in management.
Knee-chest position
The knee-chest position has been re-
ported as one of the most effective
methods, and its elevation effect is not
affected by the initial fetal station.49 It
can be executed quickly without
requiring any equipment by the patient
independently. The position can be
maintained by the patient independently
without assistance from professional
personnel, who can have other critical
roles in the emergency. Hence, the knee-
chest position, whenever feasible, should
be the preferred maneuver. The
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drawback is that the position can be
exhausting and difficult tomaintain for a
pregnant woman; therefore, it is less
preferred if long-distance transportation
is anticipated. Furthermore,maintaining
the knee-chest position is difficult and
may be risky for patients who are under
regional anesthetic agents or who are not
cooperative in an emergency. When the
umbilical cord is already out of the va-
gina, extra precaution is required to
avoid trauma to the cord or stimulating
further vasospasm when turning the
mother from supine to knee-chest
position.
Immediate tocolysis
The use of short-acting tocolytic agents
in umbilical cord prolapse is debatable.
Given its uterine hypotonic effect, which
may lead to postpartum hemorrhage,
some authors and guidelines do not
recommend tocolytic agents as a pri-
mary management tool, but only when
fetal heart rate abnormalities persist after
attempts to prevent cord compression
mechanically.7,13,63,64 However, short-
acting tocolysis may be a useful adjunct
in patients who are in labor with regular
uterine contractions, even if fetal heart
rate abnormality has not yet occurred.
First, when performing manual eleva-
tion, the operator’s fingers are acting
against the uterine force—which may
result in fetal injury such as skull frac-
ture.65 Tocolysis reduces the counter-
acting force and therefore reduces the
force required to elevate the head
manually, potentially reducing the risk of
fetal injury. Second, persistent uterine
contractions may further push the pro-
lapsed cord out of the vagina, and
tocolysis may reduce such risk. In cases
of umbilical cord prolapse with intact
membranes, relaxing the uterus may also
reduce the subsequent risk of rupture of
membranes. Short-acting tocolytic
agents such as terbutaline (250e500 mg
intravenously or subcutaneously) or
nifedipine (10 mg capsule sublingually)
can be quickly administered. Their hy-
potonic effect is short acting and
reversible with effective uterotonic
agents. Therefore, we support the use of
tocolytic agents as an adjunct, unless the
risk of postpartum hemorrhage is high
http://www.AJOG.org
TABLE
Summary of the advantages and disadvantages of different maneuvers for relieving cord compression during
umbilical cord prolapse
Maneuvers Advantages Disadvantages
“Pushing” approach
Transvaginal manual
elevation
� Quick and simple
� No instrumentation required
� Unpleasant for the patient
� Manpower is required
� Elevation effect is modest.
� Difficult when the fetal station is high or in trans-
verse lie
� Potential of creating more room for further prolapse
of the cord
Filling of maternal urinary
bladder
� Elevation effect is good after filling of 500 mL
� Manpower is not required once bladder filling is
complete
� Suitable during long-distance transportation or
when a delay in delivery is expected
� Need instrumentation
� Time is required to complete the filling of urinary
bladder
� Emptying of the urinary bladder is needed before
cesarean delivery
� Less effective when the fetal head is at higher
station
“Pulling” approach (by gravitational force)
Trendelenburg position or
wedging
the maternal buttocks
� Can be quickly performed if the patient is on an
adjustable bed or a wedge or a pillow is available
� Elevation effect is not affected by the initial fetal
station
� Can prevent further prolapse out of the vagina
� Manpower is not required
� Need adjustable bed
� Tilting angle may be limited by maternal discomfort
� Elevation effect is modest
Knee-chest position � Greatest elevation effect
� Elevation effect is not affected by the initial fetal
station
� No instrumentation required
� Can prevent further prolapse out of the vagina
� Manpower is not required
� Can be exhausting and difficult for a pregnant
woman especially during long-distance
transportation
� Difficult in patients under regional anesthesia
� Need the patient’s cooperation
� Potential of causing further trauma or stimulation
during positioning if the cord is outside the vagina
Wong. Umbilical cord prolapse: a revisit. Am J Obstet Gynecol 2021.
ajog.org Expert Review
and uterotonic agents are unavailable. If
a longer duration of uterine relaxation is
desired, for example, during long-
distance transportation to a hospital, a
repeated regimen of nifedipine (10 mg
capsule sublingually every 15 minutes
for a total of 4 doses) can be used.
Alternatively, atosiban can also be
administered with intravenous bolus
loadingdose of 6.75 mg over 1 minute
followed by a loading infusion at a rate of
18mg/h, although it is expensive and not
readily available in low-income
countries.
Funic reduction
Cord reduction, or replacing the pro-
lapsed cord into the uterine cavity, was
practiced in the early decades of the last
century, when cesarean delivery was still a
high-risk procedure.21,60 Although it
might help to avoid cesarean delivery, it
did not improve perinatal outcome in
those days.21Hence, it is rarely performed
or recommended nowadays.13 The last
publication on cord reductionwas a small
series of 5 cases with successful reduction
of the prolapsed cords followed by vaginal
delivery 20 years ago.60 Fetal heart rate
abnormalities were common (3 in 5
cases) during and after the reduction, but
all of them had a cord pH between 7.13
and 7.40 upon delivery. There are several
challenges in performing cord reduction.
First, it is difficult to reduce a long loop of
cord through a mildly dilated cervix.
Second, manipulation of the cord may
cause cord compression or vasoconstric-
tion. Third, the successfully reduced cord
may prolapse again or become com-
pound cord presentation. Hence, it is not
recommended unless other maneuvers
MONTH 2021
have failed or urgent cesarean delivery is
not feasible. It should only be limited to
cases with a short segment of prolapsed
cord, with at least 4 cm cervical dilation,
and with the presenting fetal part at or
above �1 station. Moreover, the attempt
should not last longer than 2 minutes.60
To facilitate funic reduction, simulta-
neous elevation of the presenting part via
suprapubic approach, the Trendelenburg
position, or immediate tocolysis may be
attempted.60
Algorithm in the Acute Management
of Umbilical Cord Prolapse and Cord
Presentation with Ruptured
Membranes
Based on the different maneuvers
reviewed and the urgency of delivery in
different situations, we propose an al-
gorithm in the acute management of
American Journal of Obstetrics & Gynecology 7
http://www.AJOG.org
FIGURE 5
Algorithm in acute management of cord prolapse with ruptured
membranes
Wong. Umbilical cord prolapse: a revisit. Am J Obstet Gynecol 2021.
Expert Review ajog.org
umbilical cord prolapse in cases with a
viable fetus (Figure 5). Cesarean de-
livery is required unless the labor has
progressed to the second stage and
vaginal delivery is imminent. In such
cases, operative vaginal delivery can be
performed to expedite delivery. While
preparing for cesarean delivery, the
fetal heart rate should be assessed to
decide the urgency of delivery, and it
should be continuously monitored
during the preparation for delivery.
Simple and fast maneuvers should be
immediately performed to elevate the
fetal presenting part to relieve cord
compression. Manual elevation of the
presenting part should be done during
vaginal examination when the diag-
nosis is made. The patient can then be
put into a Trendelenburg position of at
least 15� if she is on an adjustable bed;
otherwise, elevation of the maternal
8 American Journal of Obstetrics & Gynecology M
buttocks can be achieved by placing a
thick pillow or wedge under the pa-
tient’s buttocks. The Trendelenburg
position or wedging the maternal
buttocks replaces manual elevation,
freeing the medical personnel for other
more critical roles, such as prepara-
tions for the delivery. Immediate
short-acting tocolysis should be given
in the presence of uterine contractions
to decrease the compression on um-
bilical cord and prevent further pro-
trusion of the cord. If the umbilical
cord is outside of the vagina, warm and
moist wrapping should be used to
protect the cord from trauma and to
reduce vasospasm owing to the cold
external environment.6
If cesarean delivery is not yet ready
but fetal distress persists despite the
above first-line treatments, additional
maneuvers should be considered while
ONTH 2021
delivery is being arranged. The choice of
the second line maneuver depends on
whether the patient is cooperative and
mobile, the availability of suitable in-
struments, and whether the cord is
outside the vagina. The knee-chest po-
sition is preferred if she is cooperative
and mobile, because it has been shown
to have the greatest elevation effect of
the fetal presenting part.49 If postural
change is difficult because of inability to
cooperate or anesthetic effect or the
cord is outside the vagina, urinary
bladder filling with 500 mL of normal
saline should be performed while
awaiting cesarean delivery. If a urinary
catheter is not available, a steeper
Trendelenburg position (30�) would be
the alternative. Knee-chest position can
still be adopted when the cord is outside
the vagina, but extra care should be
taken to avoid traumatizing the pro-
lapsed umbilical cord outside of the
vagina.
Algorithm in the Acute Management
of Umbilical Cord Prolapse and Cord
Presentation with Intact Membranes
With the cord still being protected by the
membranes, fetal heart rate is usually
normal, or only with intermittent vari-
able decelerations owing to cord
compression. It is of the utmost impor-
tance to avoid rupture of membranes
while operative delivery is being ar-
ranged. Hence, immediate tocolysis to
reduce intrauterine pressure and in-
structions to mothers to refrain from
pushing are essential. Lifting the
maternal buttocks by the Trendelenburg
position or wedging is also important, so
that the chance of the umbilical cord
flushing out in case of sudden rupture of
membranes is reduced. In cases of
extreme prematurity with painless cer-
vical dilatation as in cervical incompe-
tence, a conservative approach aiming at
prolonging the pregnancy can be
attempted.
Conclusion
Umbilical cord prolapse is an obstetrical
emergency that may lead to poor fetal
outcomes if left untreated. In this re-
view, we specifically addressed 3 issues.
First, cord prolapse, cord presentation,
http://www.AJOG.org
ajog.org Expert Review
and compound cord presentation
should be defined according to the po-
sitional relationship among the cord,
the fetal presenting part, and the cervix.
All of them may occur with either
ruptured or intact membranes. The
fetal risk is highest in cord prolapse,
followed by cord presentation, and
lastly, by compound cord presentation,
which replaces the misnomer “occult
cord prolapse.” Second, the mainstay of
treatment of cord prolapse is urgent
delivery, which means cesarean delivery
in most cases, unless vaginal delivery is
imminent. The urgency depends on the
fetal heart rate pattern, which can be
bradycardia, recurrent decelerations, or
normal. It is most urgent in cases with
bradycardia, because a recent study
showed that cord arterial pH declines
significantly with the bradycardia-to-
delivery interval at a rate of 0.009 per
minute. However, cord arterial pH does
not correlate with either deceleration-
to-delivery interval or decision-to-
delivery interval. Third, while cesarean
delivery is being arranged, different
maneuvers should be adopted to relieve
cord compression by elevating the fetal
presenting part and to prevent further
cord prolapse beyond the vagina. A
recent study showed that the knee-chest
position provides the greatest elevation
effect, followed by filling the maternal
urinary bladder with 500 mL of fluid,
the Trendelenburg position (15�), and
other maneuvers. However, each ma-
neuver has its own advantages and
limitations. They should be applied
wisely and with great caution depend-
ing on the actual clinical situation.
Therefore, we have proposed an algo-
rithm to guide this acute
management. -
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http://www.AJOG.org
	Umbilical cord prolapse: revisiting its definition and management
	Outline placeholder
	Introduction
	Definition of Cord Prolapse and Cord Presentation
	Urgency in Delivery and Fetal Outcome
	Maneuvers to Manage Cord Prolapse
	Manual elevation of the presenting part
	Trendelenburg position or elevation of the patient’s buttocks
	Filling of the maternal urinary bladder
	Knee-chest position
	Immediate tocolysis
	Funic reduction
	Algorithm in the Acute Management of Umbilical Cord Prolapse and Cord Presentation with Ruptured Membranes
	Algorithm in the Acute Management of Umbilical Cord Prolapse and Cord Presentation with Intact Membranes
	Conclusion
	References