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    Umbilical cord prolapse

    A plan for an ob emergency


    Risk factors

    Several factors increase the risk of cord prolapse. The main precipitating event is rupture of membranes (ROM), either spontaneous or performed artificially by a healthcare provider. Most risk factors for UCP can be separated into two categories: spontaneous and iatrogenic (Table 1).

    Spontaneous causes may be related to fetal factors, uterine distention, or pregnancy complications. Fetal risk factors include malpresentation, fetal anomalies, fetal growth restriction/small for gestational age, funic presentation, and cord abnormalities. Factors related to uterine distention include polyhydramnios, multiple gestation (although this may also be related to increased risk of malpresentation), and grand multiparity. Pregnancy complications that put the fetus at risk of UCP include preterm delivery and preterm premature rupture of membranes.1-3,5

    A number of iatrogenic causes also exist, some of which are related to routine procedures performed as part of normal labor management. These include artificial ROM (especially if the fetal head or presenting part is not engaged), placement of a fetal scalp electrode or an intrauterine pressure catheter, amnioinfusion, attempted rotation of the fetal head from occiput posterior to occiput anterior, and external cephalic version.1-3,5

    Approximately half the cases of UCP may be linked to iatrogenic causes, but iatrogenic cord prolapse does not appear to be clinically linked to poor outcomes.5,6 This is because the procedures in question are generally performed on Labor & Delivery units, where continuous fetal monitoring and any necessary interventions are available. Furthermore, iatrogenic UCP can occur in cases in which risk factors may have led to a spontaneous prolapse without intervention. Studies seem to support this finding, because different regional obstetric practice styles have no effect on the incidence of UCP.5


    Although a large percentage of UCP cases are attributed to iatrogenic causes, there is no evidence that knowledge of risk factors can reduce the incidence of UCP.5 At the same time, it is important to be aware of the risks when undertaking the interventions previously described. We recommend avoiding amniotomy unless the fetal head is well-engaged, or if necessary, “needling” the bag for a slower, more controlled release of fluid.7 If the vertex is not well applied to the cervix, mild fundal pressure during placement of a fetal scalp electrode or intrauterine pressure catheter may help to minimize elevation of the vertex out of pelvis. Providers should exercise caution with any of these procedures and perform them only in cases in which other methods are inadequate.

    UCP cannot be prevented, but subsequent fetal complications have been shown to often be preventable, with significant decreases in fetal morbidity and mortality when the condition is promptly and appropriately treated.5



    Sharon T. Phelan, MD
    Dr. Phelan is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.
    Bradley D. Holbrook, MD
    Dr. Holbrook is a senior resident in the Department of Obstetrics and Gynecology at the University of New Mexico School of Medicine, ...


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