Prolapsed Umbilical Cord

When the umbilical cord slips ahead of the presenting part, every second of compression steals oxygen from the fetus. Your hands — literally — buy time until delivery.

A prolapsed umbilical cord occurs when the cord descends through the cervix ahead of or alongside the fetal presenting part. Once the presenting part compresses the cord against the pelvis, fetal blood flow and oxygen delivery drop rapidly. Risk factors include rupture of membranes with a high presenting part, breech or transverse lie, polyhydramnios, multiparity, and a long cord. The hallmark finding is sudden, severe variable decelerations or prolonged bradycardia immediately after membrane rupture — but the definitive sign is feeling or seeing the cord in the vagina. The nurse's immediate action is to insert a gloved hand into the vagina and manually elevate the presenting part off the cord. Do not attempt to push the cord back in. Place the patient in Trendelenburg or knee-chest position to use gravity to relieve compression. If the cord is protruding from the vagina, cover it with saline-soaked sterile gauze to prevent vasospasm from drying and cold. Administer oxygen at 10 L/min by nonrebreather mask to maximize maternal-fetal oxygen delivery. Prepare for emergency cesarean delivery — this is the definitive treatment. Continuous fetal monitoring is maintained throughout. Tocolytics (e.g., terbutaline) may be ordered to reduce contractions and further cord compression while the OR is prepared.

Key Distinctions

Don't confuse prolapsed cord (cord visible or palpable in the vagina, requires manual elevation) with cord compression causing variable decelerations (managed with repositioning and amnioinfusion — covered in the variable decels atom). Students mistakenly think they should push the cord back into the uterus; the correct action is lifting the presenting part OFF the cord. Knee-chest position relieves pressure; lithotomy does not — it increases compression.

Clinical Pearl

Hand up, head up, OR now. Gloved hand lifts the presenting part, Trendelenburg or knee-chest lifts gravity off the cord, and the team races to the operating room.