Umbilical Cord Prolapse: Symptoms, Types, Causes and Treatment

Umbilical cord prolapse is a rare yet critical obstetric emergency, posing immediate risks to fetal life. Though infrequent, its unpredictable nature means that every maternity provider must be ready to recognize, diagnose, and manage this complication without delay. In this article, we'll walk you through the symptoms, types, causes, and optimal treatments for umbilical cord prolapse, grounding our explanations in current scientific evidence.

Symptoms of Umbilical Cord Prolapse

Umbilical cord prolapse often strikes without warning, but some signs can alert healthcare providers and pregnant individuals to its presence. Rapid recognition is vital, as prompt action can make the difference between life and death for the fetus.

Symptom	Description	Detection Method	References
Visible/palpable cord	Cord seen or felt in or outside vagina	Physical exam	2 4 8 10
Fetal heart rate changes	Sudden bradycardia or decelerations	Electronic monitoring	2 8 10
Membrane rupture	Often occurs after spontaneous or artificial rupture	Patient history	3 6 8
No symptoms (rare)	Especially in occult or early cases	May be asymptomatic	1 2

Table 1: Key Symptoms

Recognizing the Symptoms

The most definitive sign of umbilical cord prolapse is the presence of the cord in the vagina or even outside the vulva after the membranes have ruptured. This is best detected through a physical examination, especially if there is suspicion due to changes in fetal heart rate or abnormal labor progress 2 4 8 10.

Fetal Heart Rate Abnormalities

A sudden drop in fetal heart rate, particularly bradycardia (less than 110 bpm) or recurrent variable decelerations, is a common presenting sign. These changes are typically the first alert for clinicians, especially when there are risk factors or after rupture of membranes 2 8 10. The degree and pattern of heart rate changes can indicate the severity and urgency of the situation.

The Role of Membrane Rupture

Most cases of umbilical cord prolapse occur following the rupture of membranes—either spontaneously or through medical intervention (amniotomy). After rupture, if the fetal presenting part is not well engaged, the cord can slip past and become compressed 3 6 8.

Occult or Subtle Cases

Occult cord prolapse—where the cord slips alongside but not past the presenting part—may not produce overt symptoms. In these instances, changes in fetal heart rate may be the only clue, and a high index of suspicion is essential 1 2.

Types of Umbilical Cord Prolapse

Umbilical cord prolapse is not a single entity but rather a spectrum of presentations, each with unique risks and management considerations. Understanding the different types helps tailor both diagnosis and intervention.

Type	Key Features	Membrane Status	References
Cord Prolapse	Cord drops below presenting part, into vagina	Ruptured or intact	1 2 8
Cord Presentation	Cord between presenting part and cervix	Usually intact	1 2
Compound Presentation	Cord prolapse with fetal part (e.g., hand)	Ruptured or intact	2
Occult Prolapse	Cord alongside presenting part, not palpable	Intact or ruptured	1 2

Table 2: Types of Umbilical Cord Prolapse

Classic Cord Prolapse

This is the most concerning type: after membrane rupture, the umbilical cord slips past the fetal presenting part and may be found in the vagina or even outside the vulva. This creates a high risk of cord compression and fetal compromise 1 2 8.

Cord Presentation

Seen when the cord lies between the fetus and the cervical opening but remains behind intact membranes. While immediate compression risk is lower, rupture of membranes can convert this to a true prolapse rapidly 1 2.

Compound Presentation

Here, the cord prolapses along with a fetal part, such as a hand or arm. The combined presence increases the likelihood of cord compression but may be less severe if the fetal part helps prevent tight compression 2.

Occult Prolapse

In this subtle form, the cord lies alongside the presenting part but does not descend into the vagina. Occult prolapse often escapes detection unless fetal monitoring reveals unexplained heart rate abnormalities 1 2.

Causes of Umbilical Cord Prolapse

While umbilical cord prolapse is largely unpredictable, research has highlighted certain risk factors and causes that increase its likelihood. Recognizing these can help anticipate and possibly reduce its occurrence.

Cause/Risk Factor	Description	Magnitude of Risk	References
Malpresentation	Breech, transverse, or unstable lie	Strongly increased	3 5 6 8 10
Multiparity	Multiple previous births	Increased	3 6 10
Low birth weight/Prematurity	Fetal weight <2,500g or early gestation	Increased	3 8 10
Polyhydramnios	Excess amniotic fluid	Strongly increased	3 6 8 10
Spontaneous ROM	Spontaneous rupture of membranes	Major immediate risk	3 6 8
Iatrogenic events	Amniotomy, cervical ripening, procedures	Significant (up to 50%)	3 10

Table 3: Causes and Risk Factors

Fetal Malpresentation

One of the strongest risk factors is abnormal fetal lie or presentation—particularly breech or transverse positions. These presentations prevent the fetal head from effectively blocking the pelvic inlet, allowing the cord to slip through 3 5 6 8 10.

Multiparity

Women who have had several previous births are at higher risk, possibly due to a more relaxed uterus and pelvic structures, which may not hold the fetus as firmly in place 3 6 10.

Low Birth Weight and Prematurity

Smaller or premature fetuses are less able to fill the birth canal, leaving more space for the cord to prolapse 3 8 10.

Polyhydramnios

An excess of amniotic fluid makes it easier for the cord to move around the fetus and potentially prolapse, especially when membranes rupture suddenly 3 6 8 10.

Spontaneous and Artificial Rupture of Membranes

The majority of cord prolapse cases occur after the spontaneous rupture of membranes (SROM), but artificial rupture (amniotomy) and other interventions can also be culprits, especially if the presenting part is not engaged 3 6 8 10.

Iatrogenic Causes

Medical interventions such as amniotomy, insertion of balloon catheters, or fetal blood sampling can unexpectedly trigger cord prolapse. In some series, up to half of the cases are linked to such procedures 3 10.

Treatment of Umbilical Cord Prolapse

Once umbilical cord prolapse is diagnosed, immediate action is vital to prevent fetal hypoxia and death. The treatment pathway depends on the situation's urgency, fetal status, and labor progress.

Treatment Step	Purpose	Mode of Action	References
Expedited Delivery	Prevent fetal hypoxia	Cesarean/vaginal	2 4 7 8 10
Relieve Cord Pressure	Maintain cord blood flow	Positioning/manual lift	2 7 9 10
Bladder Filling (Vago's Method)	Elevate presenting part, relieve pressure	Saline infusion	2 9 10
Funic Reduction	Attempt to reposition cord	Manual replacement	7
Conservative Management	Delay delivery in previable gestations	Monitor/supportive	4

Table 4: Key Treatment Strategies

Expedited Delivery

The cornerstone of management is rapid delivery, ideally within 30 minutes of diagnosis. Cesarean section is the preferred choice, especially if vaginal delivery is not imminent or feasible. In rare cases where the cervix is fully dilated and delivery is imminent, assisted vaginal delivery may be considered 2 4 7 8 10.

Relieving Cord Compression

While preparing for delivery, relieving pressure on the cord is crucial:

• Manual Elevation: Applying upward pressure on the presenting fetal part to free the cord 2 7 10.
• Maternal Positioning: Placing the mother in a knee-chest or steep Trendelenburg position helps gravity move the fetus away from the pelvis and reduce cord compression. The knee-chest position is especially effective 2.
• Bladder Filling (Vago’s Method): Instilling 400-500 mL of saline into the bladder can push the presenting part upward, relieving pressure from the cord and buying time until delivery 2 9 10.

Funic Reduction

In select cases, manual replacement of the prolapsed cord (funic reduction) may be attempted, especially if delivery is not immediately possible and the cord is not tightly compressed. However, this technique requires skilled hands and careful judgment 7.

Conservative Management

In rare cases, such as previable gestations, conservative or expectant management may be used, closely monitoring both mother and fetus. This approach is considered only when immediate delivery would not result in a viable infant 4.

Simulation and Team Training

Simulation training for maternity teams has been shown to improve recognition, teamwork, and documentation of cord prolapse events, leading to better neonatal outcomes 10.

Conclusion

Umbilical cord prolapse, though rare, is a true obstetric emergency requiring immediate recognition and action. Drawing from scientific literature, we've detailed the key aspects:

• Symptoms: Most often detected by visualizing or palpating the cord and by sudden fetal heart rate changes after membrane rupture.
• Types: Ranging from overt prolapse to occult and compound presentations, each with distinct diagnostic and risk profiles.
• Causes: Strongly linked to malpresentation, multiparity, low birth weight, polyhydramnios, and both spontaneous and iatrogenic rupture of membranes.
• Treatment: Hinges on expedited delivery and relieving cord compression through manual maneuvers and positioning, with cesarean section as the preferred delivery mode in most cases.

Main Points:

• Umbilical cord prolapse is unpredictable but potentially preventable by recognizing risk factors.
• Prompt diagnosis—often prompted by fetal heart rate changes—saves lives.
• Immediate steps to relieve cord pressure and expedite delivery are essential.
• Simulation and adherence to protocols can improve outcomes for both mother and baby.

Being prepared with knowledge and a clear action plan is the best defense against the dangers posed by umbilical cord prolapse.