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The incidence of cord prolapse is reported to be 0.14 - 0.62% (1, 2), with a perinatal mortality between 8.6 - 49% (2,3) . There are several recognised risk factors:

Risk factors for cord prolapse: Low gestational age Low birth weight Abnormal presentation Multiple pregnancy High parity High head at presentation

A warning sign may be cardiotographic abnormalities, with a vaginal examination confirming diagnosis. It is important to prevent compression of the cord by the fetal head during contractions. Syntocinon must be turned off and tocolytics considered in the case of hyperstimulation. Manoeuvres available are the all fours or left lateral position, with an assistant's hand in the vagina to prevent the head compressing the cord. The cord should be kept moist or replaced if prolapsing out of the vagina. Oxygen is administered to the mother. Delivery is then advocated, either by expedient forceps or ventouse, or by caesarean section if the cervix is not fully dilated. Monitoring is crucial to prevent heroic procedures after fetal demise.

An alternative method of management is to fill the maternal bladder with 400-700mls of saline. This has a two-fold effect: 1. it elevates the head from the pelvic brim, reducing cord compression; 2. it has a tocolytic effect on the uterus. A caesarean section can then be performed with less haste. We found only two reports on this method, which describe a total of 75 cases with no perinatal deaths (4,5). These studies were however uncontrolled, and we do not know how many instances of cord prolapse occur overall, and how many of these result in perinatal death with conventional management. The apparent low number of deaths (n=13) associated with cord prolapse in the West Midlands over the last 5 years would suggest that conventional methods of management are also effective. However a protocol using bladder filling would seem particularly useful for longer delays, as when transferring from a home delivery to hospital.

References:

1. Koonings P. Umbilical cord prolapse. The Journal of Reproductive Medicine. 1990;35(7):690-2, Abstract
2. Murphy DJ, MacKenzie IZ. The mortality and morbidity associated with umbilical cord prolapse. Br J Obstet Gynaecol. 1995;102:826-30, Abstract
3. Mesleh R. Umbilical cord prolapse. Journal of Obstetrics and Gynaecology.1993;13:24-8.
4. Katz Z. Management of labor with umbilical cord prolapse: a 5 year study. Obstetrics & Gynaecology. 1988;72(2):278-81, Abstract
5. Chetty RM. Umbilical cord prolapse. South African Medical Journal. 1980;57(4):128-9, Abstract