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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Overt cord prolapse: cord visible at introitus or palpable in vagina below presenting part
- Occult cord prolapse: cord alongside presenting part but not below it — suspected from CTG abnormalities
- Risk factors: malpresentation (transverse/oblique lie, breech), polyhydramnios, prematurity, multiparity, amniotomy with high head
- Emergency management: call for help, manually elevate presenting part (hand in vagina, push upward), avoid handling cord
- Fill maternal bladder with 500 mL warm saline (delays delivery and reduces cord compression)
- Category 1 caesarean section — deliver within 30 minutes. In theatre: maintain elevation until baby delivered
Overview
Cord prolapse occurs when the umbilical cord descends through the cervix alongside or ahead of the fetal presenting part after the membranes have ruptured. Compression of the cord between the presenting part and the pelvis can cause fetal hypoxia and death within minutes if not managed promptly. It is one of the most time-critical obstetric emergencies. Overt prolapse (cord visible or palpable below the presenting part) is easier to diagnose, while occult prolapse (cord alongside but not past the presenting part) may present only as unexplained CTG abnormalities after membrane rupture.
Epidemiology
Cord prolapse occurs in approximately 0.1–0.6% of deliveries. The incidence is higher in breech presentations (~1%), transverse lie (~10%), and in the second twin. Risk factors include malpresentation, polyhydramnios, prematurity (<37 weeks), multiparity (>4), long umbilical cord, artificial rupture of membranes (especially with a high presenting part), and male fetus. With prompt recognition and management, perinatal mortality has fallen to approximately 5–10%.
Clinical Features
Symptoms
Cord visible at the vulva — unmistakable diagnosis
Cord palpated on vaginal examination below or beside the presenting part
Sudden onset of severe CTG abnormalities (prolonged bradycardia, variable decelerations) immediately after membrane rupture
Signs
Palpable pulsating cord on vaginal examination
Fetal bradycardia or pathological CTG
Cord visible at introitus
Investigations
First-line
Clinical diagnosisDiagnosis is clinical — VE or visual inspection. Do NOT delay for investigations
CTGMay reveal bradycardia or pathological pattern — cord prolapse should be considered in any sudden CTG deterioration after membrane rupture
Second-line
Cord blood gasAfter delivery — assess degree of fetal acidosis
Specialist
Neonatal assessmentAfter delivery: assess for hypoxic ischaemic encephalopathy if significant delay
1
Immediate actions
- Call for help — emergency buzzer. Alert obstetric, anaesthetic, and neonatal teams
- Manually elevate the presenting part: insert hand into vagina and push presenting part upward — MAINTAIN CONTINUOUSLY until delivery
- Avoid handling the cord (may cause vasospasm). If cord is outside vulva, gently replace into vagina
- If cord is pulsating, fetus is alive — proceed with urgency
2
Reduce cord compression
- Maternal positioning: left lateral, knee-chest, or head-down (Trendelenburg) position
- Fill bladder with 500 mL warm normal saline via Foley catheter — elevates presenting part from cord
- Continue manual elevation of presenting part during transfer to theatre
3
Delivery
- Category 1 caesarean section — target delivery within 30 minutes
- If cervix fully dilated and delivery imminent: consider assisted vaginal delivery (ventouse/forceps) if quicker
- Empty filled bladder before CS incision
- Maintain manual elevation until baby is delivered
4
Post-delivery
- Cord blood gas analysis
- Neonatal assessment — Apgar, acidosis, signs of hypoxia
- Debrief mother and partner. Document detailed timeline
- Incident reporting and review
Complications
- Fetal hypoxia and death: From cord compression — the primary concern. Speed of delivery is crucial
- Hypoxic ischaemic encephalopathy (HIE): If prolonged hypoxia before delivery
- Perinatal mortality: ~5–10% with prompt management, higher if diagnosis delayed
UKMLA Exam Tips
- 1Cord prolapse = hand in vagina to elevate presenting part + category 1 CS. Do NOT remove hand until delivery
- 2Fill bladder with 500 mL saline — practical exam-testable management step
- 3Position: all-fours, knee-chest, or Trendelenburg — to reduce cord compression
- 4Risk factors: transverse lie, breech, polyhydramnios, amniotomy with high head — very commonly tested
- 5Never handle the cord unnecessarily — vasospasm worsens cord blood flow
- 6Sudden fetal bradycardia immediately after ARM (amniotomy) → think cord prolapse
practicetest your knowledge on cord prolapseApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — obstetrics and beyond.
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