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Umbilical cord prolapse — MRCEM SBA MCQ

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HardObstetric and gynaecological emergenciesUmbilical cord prolapseMRCEM SBA

A woman at 39+1 weeks’ gestation presents to an emergency department with an on-site consultant-led maternity unit. Immediately after spontaneous rupture of membranes, the fetal heart rate falls to 75/min and remains there for four minutes. Her pulse is 96/min. A midwife finds the cervix 7 cm dilated, the fetal head high and a pulsating loop of umbilical cord at the vaginal opening. The obstetric, anaesthetic and neonatal teams have been called, and an operating theatre is available. What is the most appropriate immediate management and delivery plan?

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Reveal the answer and explanation

Correct answer: D — Elevate the presenting part manually and prepare for category 1 caesarean birth.

The cord visible after membrane rupture establishes overt umbilical cord prolapse. The persistent fetal bradycardia indicates compromise, while a cervix dilated to 7 cm and a high head make prompt vaginal birth unlikely. The immediate priority is to relieve cord compression by manually elevating the presenting part while arranging category 1 caesarean birth. The neonatal team has appropriately been called for the birth. ([rcog.org.uk](https://www.rcog.org.uk/media/3wykswng/gtg-50-umbilicalcordprolapse-2014.pdf)) A provides decompression but selects an unsuitable route: operative vaginal birth is an option at full dilatation when it can be accomplished quickly and safely. B selects the appropriate route but insufficient urgency; category 2 caesarean birth may be considered when the fetal heart-rate pattern is normal, not with persistent bradycardia. C has the right delivery urgency, and knee–chest positioning can reduce compression, but positioning is an adjunct rather than the best substitute for immediate manual elevation when a clinician can perform it. E likewise recognises the urgency, but tocolysis does not replace mechanical decompression. It may be considered if heart-rate abnormalities persist after attempts to relieve compression, particularly when birth is likely to be delayed. Temporising measures must not delay delivery. ([rcog.org.uk](https://www.rcog.org.uk/media/3wykswng/gtg-50-umbilicalcordprolapse-2014.pdf))

Reference: RCOG Green-top Guideline No. 50: Umbilical Cord Prolapse, sections 4.5–4.6 (2014) — https://www.rcog.org.uk/media/3wykswng/gtg-50-umbilicalcordprolapse-2014.pdf RCOG: Umbilical Cord Prolapse (Green-top Guideline No. 50) (Reviewed December 2024) — https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/umbilical-cord-prolapse-green-top-guideline-no-50/