Umbilical Cord Prolapse

Quick Answer

One-liner: Umbilical cord prolapse is descent of the umbilical cord past the fetal presenting part, requiring immediate manual elevation of the presenting part and emergency caesarean section within 30 minutes.

Cord prolapse is an obstetric emergency with perinatal mortality of 9-47% if untreated. It occurs in 0.14-0.62 per 1,000 deliveries, typically with malpresentation, polyhydramnios, multiparity, or artificial rupture of membranes with high presenting part. Immediate management: manual elevation of presenting part (vaginal examination fingers), knee-chest or Trendelenburg position, bladder filling 500-700mL saline to elevate fetal head, urgent obstetric consultation, and emergency Category 1 caesarean section. Avoid handling the cord (vasospasm), do not attempt reinsertion, and maintain continuous fetal heart rate monitoring.

---

ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Umbilical cord structures (2 arteries, 1 vein, Wharton's jelly), pelvic anatomy, relationship of cord to fetal presenting part
• Physiology: Fetal circulation, umbilical blood flow (240mL/min at term), mechanisms of cord compression (arterial > venous occlusion), fetal hypoxia response
• Pharmacology: Tocolytics (terbutaline 0.25mg SC), uterotonics (after delivery)

Fellowship Exam Relevance

• Written: Classification (overt vs occult), risk factors, immediate ED management, decision-to-delivery interval targets, neonatal outcomes
• OSCE: High-yield scenarios include simulated resuscitation station (managing acute cord prolapse with obstetric team), communication station (explaining emergency to patient/partner), teamwork with midwifery/obstetric staff
• Key domains tested: Medical Expert (diagnosis, resuscitation), Communicator (emergency consent, family), Leader (coordinating rapid response), Collaborator (obstetric team)

---

Key Points

---

Epidemiology

Australian/NZ Specific

• Australian incidence: 0.26 per 1,000 deliveries (AIHW data 2020-2022) [11]
• New Zealand: 0.31 per 1,000 deliveries (higher in rural/remote areas) [12]
• Indigenous populations: 1.5-2x higher incidence in Aboriginal and Torres Strait Islander women due to higher rates of multiparity, breech presentation, and preterm labour [13,14]
• Rural/remote challenges: Longer transfer times to operative facility, increased perinatal morbidity/mortality in Remote and Very Remote areas [15]

---

Pathophysiology

Mechanism

Cord prolapse occurs when the umbilical cord descends past (overt) or alongside (occult) the fetal presenting part, typically following rupture of membranes when the presenting part does not completely fill the pelvic inlet.

Compression mechanism:

1. Mechanical compression: Fetal presenting part (head, breech, shoulder) compresses cord against pelvic brim or maternal soft tissues
2. Arterial occlusion: Umbilical arteries (smaller, higher pressure) occlude before vein → reduced fetal venous return → hypoxia
3. Venous occlusion: Complete compression → cessation of placental circulation → severe fetal acidosis within 5-10 minutes
4. Vasospasm: Cord exposure to cold air, handling, or drying triggers reflex vasospasm → further reduction in blood flow
5. Fetal hypoxic response: Bradycardia, reduced variability, terminal bradycardia if uncorrected [16,17]

Pathological Progression

Rupture of membranes + incomplete pelvic fill → Cord descent past/alongside presenting part → Cord compression (arterial > venous) → Fetal hypoxia and bradycardia → Progressive acidosis (pH falls 0.01/minute) → Fetal death or severe HIE (if greater than 10-15 min) → Emergency delivery required below 30 minutes

Why It Matters Clinically

• Time-critical intervention: Fetal pH drops approximately 0.01 per minute with complete cord occlusion [18]
• Decision-to-delivery interval: Each additional 10 minutes delay increases risk of neonatal acidosis (pH below 7.0) by 50% [19]
• Irreversible injury threshold: Severe hypoxic-ischaemic encephalopathy (HIE) risk significant after 10-15 minutes of complete occlusion [20]
• Manual elevation rationale: Relieves mechanical compression, restores umbilical blood flow (verified by palpable cord pulsations)

---

Differential Diagnosis

Causes of Sudden Fetal Bradycardia Post-ROM

Key discriminators for cord prolapse:

1. Timing: Sudden onset immediately (within seconds to minutes) after ROM (spontaneous or artificial)
2. CTG pattern: Severe prolonged deceleration or repetitive severe variable decelerations (FHR below 80 bpm, greater than 60 sec duration)
3. Palpable cord on VE: Pathognomonic for overt prolapse; absence does NOT exclude occult prolapse
4. Response to positioning: FHR may improve with knee-chest position (relieves compression)—supportive of diagnosis

"Cannot miss" differentials:

• Vasa praevia rupture: Painless vaginal bleeding + fetal bradycardia post-ROM; fetal mortality 50-95% if undiagnosed [40]
• Placental abruption: Painful bleeding + FHR abnormalities; maternal and fetal mortality risk [41]
• Uterine rupture: Prior CS scar, sudden severe pain, loss of fetal station, maternal shock; maternal mortality 1-2%, fetal 30-50% [42]

Clinical Decision-Making

If unsure of diagnosis (e.g., CTG abnormality post-ROM but cord not palpable):

1. Presume cord prolapse until proven otherwise (safest approach)
2. Immediate management: Position, manual elevation attempt (VE), bladder filling, call obstetric emergency team
3. Re-examine: If FHR improves and stabilises, may be occult prolapse or other reversible cause
4. Escalate regardless: Category 1 CS indicated for any persistent severe FHR abnormality post-ROM (even if cause uncertain)

When to consider alternative diagnosis:

• Vaginal bleeding + pain: Think abruption (perform abdominal examination, assess for uterine tenderness, maternal shock)
• Painless bleeding + rapid fetal death: Think vasa praevia (rare but catastrophic; Apt test can differentiate fetal vs maternal blood)
• Frequent contractions on oxytocin: Think hyperstimulation (cease oxytocin, give tocolysis)
• Maternal symptoms (dizziness, syncope): Think maternal hypotension (check BP, IV fluids, left lateral tilt)

---

Clinical Approach

Recognition

Triggers for suspicion:

• Sudden fetal bradycardia (FHR below 110 bpm) immediately following rupture of membranes (spontaneous or artificial)
• Prolonged fetal heart rate decelerations on CTG
• Palpable cord on vaginal examination (routine VE after ROM in high-risk patients)
• Visible cord at vaginal introitus
• Patient reports "something coming out" after membrane rupture

Initial Assessment

Primary Survey (Obstetric Emergency)

• A: Maternal airway patent (patient typically conscious, anxious)
• B: Maternal respiratory status (anxiety may cause hyperventilation), prepare for emergency GA if CS required
• C: Maternal haemodynamic status (typically stable unless concurrent abruption), establish IV access (2x large bore cannulae)
• D: Fetal status (continuous CTG monitoring, assess for bradycardia/decelerations), maternal consciousness (anxiety)
• E: Visual inspection of perineum (overt cord prolapse?), vaginal examination (confirm diagnosis, assess presenting part, elevate fetal head)

Immediate actions (within 60 seconds):

1. Call for help: Obstetric emergency team, anaesthetics, theatre team, neonatal resuscitation
2. Position: Knee-chest position (exaggerated Sims if unable) or steep Trendelenburg
3. Vaginal examination: Insert 2 fingers, manually elevate presenting part off cord, MAINTAIN elevation until delivery
4. Continuous monitoring: CTG, assess cord pulsations

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Maternal anxiety, distress
• Position (may be in knee-chest or left lateral if already managed)
• Visible cord at perineum (overt prolapse)
• Continuous CTG tracing (bradycardia, severe variable decelerations, absent variability)

Specific Findings

---

Investigations

Immediate (Resus Bay/Birthing Suite)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

POCUS applications:

• Confirm fetal viability: Visualise fetal heart activity if CTG unavailable
• Assess presentation: Cephalic vs breech vs transverse lie (guides operative approach)
• Colour Doppler: Identify cord vessels (confirm cord vs other structure), assess flow
• Amniotic fluid: Polyhydramnios or oligohydramnios
• Placental location: Exclude coincidental placenta praevia

Limitation: POCUS should NOT delay emergency management. Clinical diagnosis (palpable cord + CTG abnormality) is sufficient to proceed to emergency delivery.

---

Management

Immediate Management (First 10 minutes)

1. CALL OBSTETRIC EMERGENCY TEAM (0 min) - announce "Cord prolapse, Category 1 CS"
2. POSITION: Knee-chest or steep Trendelenburg (0-1 min)
3. VAGINAL EXAMINATION: Insert 2 fingers, elevate presenting part, MAINTAIN elevation (1 min)
4. BLADDER FILLING: IDC insertion, instil 500-700mL normal saline, clamp catheter (2-5 min)
5. OXYGEN: High-flow oxygen 15L/min via non-rebreather mask (maternal FiO2 for fetal benefit)
6. IV ACCESS: 2x large bore (16-18G) cannulae, commence crystalloid
7. CONTINUOUS CTG: Monitor fetal response to interventions
8. TRANSFER TO THEATRE: Maintain manual elevation during transfer (examiner stays with patient)
9. PREPARE FOR CS: Consent (verbal if needed), anaesthetic review, neonatal team alerted
10. TARGET DELIVERY: below 30 minutes from diagnosis

Resuscitation

Airway

• Maternal airway typically patent
• Prepare for emergency general anaesthesia if required (rapid sequence induction)
• Regional anaesthesia (spinal) preferred if time permits and no contraindications

Breathing

• Maternal oxygenation: 15L/min O2 via non-rebreather mask (increases fetal PaO2)
• Position optimisation: Left lateral tilt (avoid aortocaval compression) OR knee-chest (relieves cord compression)
• Avoid supine: Supine position worsens cord compression and reduces placental perfusion

Circulation

• IV access: 2x large bore cannulae
• Fluids: Crystalloid to maintain maternal BP (target SBP greater than 100 mmHg)
• Blood products: Group & Hold; cross-match if concurrent bleeding or anticipated PPH
• Haemodynamic targets: Maternal MAP greater than 65 mmHg (maintain placental perfusion)

Medications

Paediatric Dosing

Not applicable - maternal treatment only. Neonatal resuscitation follows ARC Guideline 13.4 (newborn resuscitation).

Ongoing Management

During transfer to theatre:

• Maintain manual elevation: Examiner's fingers remain in vagina, elevating presenting part (may require examiner to travel on trolley/in theatre)
• Position: Exaggerated Sims (left lateral, pelvis elevated) or knee-chest if ambulant
• Continuous monitoring: Portable CTG or intermittent auscultation
• Reassurance: Calm communication with patient, explain each step
• Avoid cord manipulation: If cord visible, cover with warm, moist saline-soaked gauze; do NOT attempt reinsertion

Intraoperative considerations:

• Anaesthesia: Spinal preferred (if time permits, maternal stability, adequate IV access); GA if extreme urgency or maternal instability
• Surgical technique: Classical caesarean incision if extreme prematurity or transverse lie; otherwise lower segment
• Cord clamping: Immediate (not delayed) in compromised infant
• Neonatal team: Present in theatre for immediate resuscitation

Definitive Care

Emergency Caesarean Section (Category 1):

• Timing: Target decision-to-delivery interval below 30 minutes [21,22]
• Rationale: Only definitive treatment to relieve cord compression
• Exception: Multiparous patient, fully dilated cervix, cephalic presentation at +2 station → consider instrumental delivery if immediate (delivery within 5 minutes)

Assisted vaginal delivery (rare):

• Criteria: Fully dilated cervix, cephalic presentation, station ≥+2, experienced operator, immediate delivery achievable
• Instruments: Forceps or ventouse (forceps preferred for urgency)
• Caveat: Caesarean section safer option in most cases due to unpredictability of instrumental delivery timing

Post-delivery care:

• Neonatal resuscitation: ARC Guideline 13.4 [23], assess APGAR, cord blood gas (arterial + venous)
• Maternal monitoring: Standard post-CS observations, assess for PPH
• Neonatal assessment: HIE screening, therapeutic hypothermia if indicated (pH below 7.0, APGAR below 5 at 10 min, ongoing encephalopathy) [24]
• Debrief: Explain events to parents, provide emotional support, document meticulously

---

Disposition

Admission Criteria

• ALL patients with cord prolapse require admission (emergency operative delivery)
• Post-delivery: Standard post-caesarean section ward care (minimum 3-4 days)
• Neonatal: ICU/NICU if HIE, prematurity, or complications

ICU/HDU Criteria

• Maternal: Post-CS complications (haemorrhage, sepsis, anaesthetic complications)
• Neonatal: Severe HIE requiring therapeutic hypothermia, severe prematurity (below 32 weeks), multiorgan dysfunction

Discharge Criteria

Not applicable - this is a delivery event, not an ED discharge scenario.

Follow-up

• Obstetric: 6-week postpartum check (routine post-CS)
• Neonatal: Developmental follow-up if HIE, prematurity, or neonatal complications
• Psychological: Risk of birth trauma, PTSD; offer psychology referral if requested
• Future pregnancies: Counsel that cord prolapse does NOT recur in subsequent pregnancies (not an intrinsic risk factor)

---

Complications

Maternal Complications

Intraoperative (Emergency CS):

• Haemorrhage: 5-8% risk of major PPH (greater than 1,000mL) with emergency CS vs 3-5% with elective CS [36]
• Anaesthetic complications: Higher risk with Category 1 CS under GA (aspiration, failed intubation, awareness)
• Bladder injury: 0.3-1.0% with emergency CS (higher if bladder filling performed and not drained pre-operatively)
• Uterine atony: Risk increased with prolonged labour prior to emergency CS
• Surgical site infection: 5-10% with emergency CS (higher than elective due to urgency, incomplete prep)

Postoperative:

• Venous thromboembolism: Increased risk with emergency CS (mobilise early, thromboprophylaxis per guidelines)
• Endometritis: 10-15% with emergency CS in labour vs 2-3% with elective CS
• Wound infection: 5-10%, higher if prolonged ROM or chorioamnionitis
• Psychological trauma: Birth trauma, PTSD (5-10% following emergency CS), guilt, grief over "failed" vaginal birth

Prevention strategies:

• Prophylactic antibiotics (cefazolin 2g IV pre-operative)
• Thromboprophylaxis (LMWH postoperative if additional VTE risk factors)
• Early mobilisation
• Psychological support and debrief post-delivery

Neonatal Complications

Immediate (Delivery Room):

• Hypoxic-ischaemic encephalopathy (HIE): 5-15% if decision-to-delivery greater than 30 min, 1-3% if below 30 min [37]
• Severe acidosis: pH below 7.0 in 10-20% with delayed delivery (greater than 30 min) [9]
• Low APGAR scores: APGAR below 7 at 5 min in 15-25% (cord prolapse), vs 1-3% (general obstetric population)
• Need for resuscitation: Positive pressure ventilation 25-35%, intubation 10-15%, chest compressions 2-5%
• Meconium aspiration: Increased risk if prolonged hypoxia pre-delivery

Short-term (NICU):

• Therapeutic hypothermia: Indicated if moderate-severe HIE (cooling for 72h improves neurological outcomes) [24]
• Seizures: 10-20% with HIE (treated with phenobarbital, levetiracetam)
• Multiorgan dysfunction: Renal impairment (10-15%), hepatic dysfunction (5-10%), cardiac dysfunction (5-10%)
• Feeding difficulties: Delayed oral feeding, need for NG/OG feeds
• Prolonged hospitalisation: Median 10-14 days if HIE, vs 2-3 days if no complications

Long-term:

• Cerebral palsy: 5-10% with severe HIE, 1-2% with moderate HIE, below 1% with mild HIE [38]
• Developmental delay: Cognitive, motor, speech delays (15-25% with moderate HIE)
• Epilepsy: 10-15% with severe HIE
• Normal outcomes: 70-85% of infants with cord prolapse (modern management below 30 min delivery) have normal long-term neurodevelopment [7,8]

Prognostic factors:

• Decision-to-delivery interval: Most critical factor (each 10-min delay increases risk)
• Cord blood pH: pH below 7.0 = high risk HIE; pH 7.0-7.1 = moderate risk; pH greater than 7.1 = low risk
• APGAR scores: APGAR below 5 at 10 min = severe HIE risk
• Seizures: Onset of seizures within 24h = poor prognostic sign
• MRI findings: Basal ganglia injury on MRI = worse outcomes than watershed injury

Medico-Legal Considerations

Documentation requirements:

• Time stamps: Document exact time of diagnosis, interventions, theatre arrival, delivery
• Decision-to-delivery interval: Record explicitly (audit requirement, medico-legal evidence)
• Fetal heart rate: Document FHR at diagnosis, after each intervention, on theatre arrival, at delivery
• Interventions: Manual elevation (who, when, duration), positioning, bladder filling (volume), tocolysis (drug, dose, time)
• Consent: Verbal consent acceptable in emergency, document: "Emergency discussed, risks/benefits explained, patient consented"
• Communication: Document discussions with patient, partner, obstetric team, neonatal team
• Complications: Any maternal or neonatal complications, management

Litigation risk:

• Cord prolapse is a high-risk scenario for medico-legal claims (delays, poor outcomes, communication failures)
• Common allegations: Failure to diagnose promptly, delay in delivery, inadequate resuscitation, poor communication
• Defensive practices: Meticulous documentation, clear time stamps, evidence of appropriate urgency, consultant involvement

Debriefing:

• Offer debrief to patient/partner within 24-48 hours post-delivery
• Explain events, answer questions, provide psychological support
• Document debrief (reduces litigation risk, improves patient satisfaction)

---

Prognostication

Decision-to-Delivery Interval Outcomes

Key message: Every minute counts. Target below 30 min decision-to-delivery; each 10-min delay increases adverse outcomes by ~50%.

Cord Blood Gas Interpretation

Arterial vs venous sampling:

• Arterial (umbilical artery): Reflects fetal acid-base status (use for prognostication)
• Venous (umbilical vein): Reflects placental function (less useful for neonatal prognosis)
• Both should be sampled post-delivery for complete assessment

APGAR Score Prognostication

APGAR at 10 min:

• APGAR below 5 at 10 min = severe HIE risk (therapeutic hypothermia likely indicated)
• APGAR ≥7 at 10 min (even if lower at 5 min) = good prognosis

Factors Predicting Good vs Poor Outcomes

Good outcome predictors:

• Decision-to-delivery below 30 min
• Strong cord pulsations throughout (maintained umbilical flow)
• FHR improvement with positioning/bladder filling (responsive to interventions)
• pH greater than 7.0 on cord blood gas
• APGAR ≥7 at 5 min
• No seizures within 24h

Poor outcome predictors:

• Decision-to-delivery greater than 60 min
• Absent/weak cord pulsations (severe compression)
• Persistent bradycardia despite interventions (FHR below 80 bpm)
• pH below 7.0 with base excess <-16 mmol/L
• APGAR below 5 at 10 min
• Seizures within 6-12h post-delivery
• MRI showing basal ganglia injury (within first week)

---

Prevention Strategies

Primary Prevention

Pre-labour:

• External cephalic version (ECV): Offered at 36-37 weeks for breech presentation (reduces breech → reduces prolapse risk) [39]
• Elective caesarean section: For persistent breech, transverse lie at term (eliminates prolapse risk)
• Antenatal surveillance: Serial ultrasound for polyhydramnios, fetal macrosomia, multiple pregnancy

Intrapartum:

• Controlled rupture of membranes: Avoid ARM if presenting part high/unengaged
• Technique for ARM: Ensure presenting part well-applied to cervix, perform between contractions, slow release of fluid (use amniohook with controlled drainage)
• Avoid unnecessary ARM: Only perform if clear indication (augmentation, place FSE); not routine
• Position during ARM: Semi-recumbent (not supine), allows presenting part to descend with gravity

Secondary Prevention (Early Detection)

High-risk patients requiring vigilance:

• Malpresentation (breech, transverse lie)
• Multiparity (≥3 deliveries)
• Polyhydramnios
• Prematurity (below 37 weeks)
• Twin pregnancy (especially Twin 2)
• Induction of labour with unengaged head

Monitoring after ROM in high-risk patients:

• Immediate vaginal examination: After spontaneous or artificial ROM (to detect cord)
• Continuous CTG: For minimum 20-30 min post-ROM (detect occult prolapse early)
• Immediate response to FHR abnormalities: Do not delay VE if sudden bradycardia/decelerations post-ROM

Tertiary Prevention (Minimising Harm)

Once prolapse diagnosed:

• Minimise decision-to-delivery interval: Target below 30 min (Category 1 CS)
• Effective temporising measures: Manual elevation, bladder filling, tocolysis (maintain fetal oxygenation until delivery)
• Neonatal preparedness: Alert neonatal team early, ensure resuscitation equipment ready, consider therapeutic hypothermia if indicated

---

Quality Improvement & Audit

Key Performance Indicators (KPIs)

Process measures:

• % of high-risk patients with VE performed within 5 min of ROM: Target greater than 90%
• % of cord prolapse cases with decision-to-delivery interval below 30 min: Target greater than 90% (RANZCOG/NSW Health standard)
• % of cord prolapse cases with documented manual elevation: Target 100%
• % of cord prolapse cases with bladder filling performed: Target greater than 80%

Outcome measures:

• Perinatal mortality rate (cord prolapse): Target below 3% (modern standard)
• Neonatal acidosis rate (pH below 7.0): Target below 15%
• HIE rate: Target below 5%
• Maternal complications (PPH, infection): Benchmark against institutional CS complication rates

Audit Cycle

1. Identify cases:

• ICD-10 code O69.0 (umbilical cord prolapse)
• Theatre records (Category 1 CS with indication "cord prolapse")
• Neonatal unit admissions with history of cord prolapse

2. Data collection:

• Decision-to-delivery interval (from diagnosis time to birth time)
• Interventions performed (manual elevation, bladder filling, tocolysis)
• Cord blood gas results
• APGAR scores (1, 5, 10 min)
• Neonatal outcomes (HIE, NICU admission, seizures)
• Maternal complications

3. Analysis:

• Compare decision-to-delivery intervals to below 30 min target
• Identify cases with delays (greater than 30 min) and root causes
• Correlate interval with neonatal outcomes (pH, APGAR, HIE)

4. Feedback & improvement:

• Share results with obstetric, anaesthetic, theatre, ED teams
• Implement interventions (e.g., dedicated "cord prolapse pack" in birthing suite, simulation training, rapid theatre access protocols)
• Re-audit in 12 months

Simulation Training

Recommended scenarios:

• Acute overt cord prolapse: Birthing suite, visible cord, Category 1 CS
• Occult prolapse in ED: Patient presents with ROM, CTG abnormalities, ED team must diagnose and stabilise
• Remote/rural cord prolapse: Limited resources, prolonged retrieval, temporising measures
• Communication: Breaking news to patient, obtaining consent, handover to obstetric team

Learning objectives:

• Recognise cord prolapse within 60 seconds of CTG abnormality
• Perform manual elevation correctly
• Position patient appropriately
• Activate emergency team with clear, closed-loop communication
• Achieve simulated delivery below 30 min from diagnosis

Frequency: Annual mandatory training for all ED, obstetric, anaesthetic, theatre staff

---

Special Populations

Paediatric Considerations

Not applicable - obstetric emergency in pregnant patients.

Pregnancy

This IS a pregnancy-specific condition.

Risk factors for cord prolapse:

• Malpresentation: Breech (1-2%), transverse lie (5%), footling breech (15%) [25]
• Multiparity: ≥3 previous deliveries (relative risk 2.6) [26]
• Polyhydramnios: Relative risk 2.4 [27]
• Prematurity: below 37 weeks (relative risk 4.0-6.0) [28]
• Low birthweight: below 2,500g (higher relative risk due to small presenting part) [29]
• Artificial rupture of membranes (ARM): Especially with high presenting part
• Amniotomy for induction: Relative risk 3.7 if unengaged head [30]
• Twin pregnancy: Second twin at higher risk (especially after delivery of Twin 1)
• Cephalopelvic disproportion: Prevents engagement
• Placenta praevia: Increases risk of abnormal lie

Gestational age considerations:

• Preterm (below 37 weeks): Higher incidence, smaller presenting part allows cord descent
• Extreme prematurity (below 28 weeks): Discuss viability with parents and neonatal team BEFORE delivery (if time permits)
• Term (≥37 weeks): Standard emergency CS approach

Elderly

Not applicable - obstetric emergency in women of reproductive age (typically 20-40 years).

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health disparities:

• Aboriginal and Torres Strait Islander women have 1.5-2x higher incidence of cord prolapse due to higher rates of multiparity, preterm labour, and breech presentation [13,14]
• Māori women in New Zealand: similar disparity (1.6x higher incidence) [31]
• Higher perinatal mortality in Indigenous populations due to delayed access to operative facilities [32]
• Remote and Very Remote areas: median 87 minutes to operative delivery vs 32 minutes in Major Cities [15]

Cultural safety considerations:

• Family involvement: Allow support person(s) in theatre if facility policy permits
• Communication: Use interpreter if needed (phone interpreter if in-person unavailable)
• Cultural protocols: Respect cultural practices around birth, placenta, umbilical cord
• Aboriginal Liaison Officer: Involve if available (most metropolitan/regional hospitals)
• Māori cultural practices: Respect whānau (family) involvement, karakia (prayer), retention of whenua (placenta) if requested

Remote/rural challenges:

• Limited operative facilities: Many remote communities lack 24/7 caesarean section capability
• Retrieval delays: RFDS or road ambulance transfer may take 1-6 hours
• Decision-making: If retrieval time greater than 2 hours and no local CS capability, consider discussion with tertiary obstetric team re: futility vs ongoing resuscitation efforts
• Traditional birthing practices: Some Aboriginal communities prefer on-Country birth; balance cultural preferences with safety in high-risk pregnancies

Interpreter/liaison services:

• Phone interpreter: National 24/7 service (TIS National 131 450)
• Aboriginal Health Worker or Liaison Officer
• Māori health support services (NZ: Whānau Ora coordinators)

---

Pitfalls & Pearls

---

Viva Practice

---

OSCE Scenarios

Station 1: Acute Cord Prolapse Resuscitation

Format: Resuscitation Time: 11 minutes Setting: ED resuscitation bay / birthing suite

Candidate Instructions:

You are the ED registrar. A 28-year-old woman at 37 weeks gestation presents with "waters broken" 5 minutes ago. The midwife has just performed a vaginal examination and can feel the umbilical cord. The CTG shows fetal heart rate 85 bpm. You have a midwife and RN available to assist. Please manage this patient.

Examiner Instructions: Patient is a 28-year-old G2P1, 37 weeks gestation, spontaneous rupture of membranes 5 minutes ago. Vaginal examination by midwife: 3cm dilated, cephalic presentation, station -2, palpable cord alongside fetal head (occult/borderline overt prolapse). CTG: FHR 85 bpm, reduced variability. Patient is anxious but cooperative.

Scenario progression:

• T=0 min: Candidate enters, receives handover from midwife
• T=2 min: If candidate performs VE and manual elevation, FHR improves to 110 bpm
• T=5 min: Obstetric team arrives (simulated by examiner), candidate hands over
• T=8 min: Examiner asks candidate to summarise management and rationale
• T=10 min: Examiner asks 1-2 follow-up questions (e.g., risk factors, decision-to-delivery interval)

Actor/Patient Brief: You are 28 years old, pregnant with your second baby (37 weeks). Your waters broke suddenly 5 minutes ago. You are frightened because the midwife looked worried when she examined you. You can cooperate with instructions (positioning, etc.) but you keep asking "Is my baby okay?" You have a partner who is present and holding your hand.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • "Critical fail: Does not perform manual elevation within 2 minutes"
  • "Critical fail: Does not call obstetric emergency team"
  • "Strong pass: Performs all critical interventions, communicates clearly, demonstrates leadership"
  • "Borderline: Delays interventions, poor communication, but eventually escalates appropriately"

---

Station 2: Communication - Breaking News of Emergency CS

Format: Communication Time: 11 minutes Setting: ED cubicle / birthing suite

Candidate Instructions:

You are the ED consultant. You have just diagnosed cord prolapse in a 35-year-old primigravida at 39 weeks gestation. The obstetric team will be ready for Category 1 CS in 20 minutes. Please explain the situation to the patient and her partner and obtain consent for emergency caesarean section.

Examiner Instructions: Patient is a 35-year-old G1P0, 39 weeks gestation, planned vaginal birth, very invested in "natural birth plan." She has just been told she has "cord prolapse" by the midwife but doesn't understand what it means. Her partner is present and supportive. The patient is anxious and tearful. She is in knee-chest position with manual elevation being performed by the midwife.

Scenario progression:

• T=0 min: Candidate enters, introduces self
• T=0-5 min: Candidate explains diagnosis and urgency
• T=5-8 min: Candidate obtains consent
• T=8-10 min: Patient asks questions (e.g., "Why did this happen?" "Will my baby be okay?" "Can I still try vaginal birth?")
• T=10 min: Examiner stops station, asks reflection question

Actor/Patient Brief: You are 35 years old, first baby, 39 weeks pregnant. You had a detailed birth plan (natural birth, no interventions if possible). You are now in a very uncomfortable position (hands and knees, someone's fingers inside you), and you're told you need emergency surgery. You are frightened, tearful, and confused. You will ask:

• "What is cord prolapse?"
• "Is my baby going to be okay?"
• "Why did this happen? Did I do something wrong?"
• "Do I have to have a caesarean? Can we wait and see?"

Your partner is supportive and will ask practical questions (e.g., "Can I come into theatre?" "How long will surgery take?").

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • "Excellent: Balances urgency with empathy, clear explanations, involves partner, obtains consent smoothly"
  • "Good: Communicates clearly, obtains consent, but may lack empathy or fail to address emotions"
  • "Borderline: Information conveyed but communication rushed, jargon-heavy, or patient left confused/distressed"
  • "Fail: Does not obtain consent, conveys false reassurance, or causes unnecessary distress"

---

Station 3: Data Interpretation - CTG in Suspected Cord Prolapse

Format: Examination / Data Interpretation Time: 11 minutes Setting: Clinical examination area with CTG traces

Candidate Instructions:

You are the ED registrar. A 32-year-old woman at 38 weeks gestation had spontaneous rupture of membranes 10 minutes ago. You are shown three CTG traces from the last 10 minutes. Please interpret the traces and describe your management.

Examiner Instructions: Provide candidate with three CTG traces:

1. Trace 1 (pre-ROM): Baseline FHR 140 bpm, moderate variability, no decelerations (normal)
2. Trace 2 (immediately post-ROM): FHR drop to 80 bpm, lasting 90 seconds, then recovery to 110 bpm with reduced variability (severe prolonged deceleration)
3. Trace 3 (5 min post-ROM): Repetitive severe variable decelerations (FHR 70-90 bpm, varying duration), reduced variability (pathological)

Ask candidate to:

• Interpret each trace
• Explain significance
• Outline differential diagnosis
• Describe immediate management

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • "Excellent: Accurate interpretation, identifies cord prolapse immediately, describes comprehensive management"
  • "Good: Accurate interpretation, suggests cord prolapse, basic management plan"
  • "Borderline: Some interpretation errors, includes cord prolapse in differential, vague management"
  • "Fail: Cannot interpret CTG, does not consider cord prolapse, no management plan"

---

SAQ Practice

Question 1 (6 marks)

Stem: A 30-year-old G3P2 woman at 36 weeks gestation has spontaneous rupture of membranes. On vaginal examination, you palpate umbilical cord alongside the fetal head. The CTG shows fetal heart rate 90 bpm.

Question: List SIX immediate management steps in the first 5 minutes. (6 marks)

Model Answer:

1. Call obstetric emergency team (announce "Cord prolapse, Category 1 CS") (1 mark)
2. Manual elevation of presenting part (insert 2 fingers vaginally, elevate fetal head off cord, maintain continuously) (1 mark)
3. Position patient in knee-chest or steep Trendelenburg (gravity relieves cord compression) (1 mark)
4. High-flow oxygen 15L/min via non-rebreather mask (maternal oxygenation for fetal benefit) (1 mark)
5. Bladder filling (insert IDC, instil 500-700mL normal saline, clamp catheter to elevate fetal head) (1 mark)
6. IV access (2x large bore cannulae, commence crystalloid) OR Continuous CTG monitoring OR Tocolysis (terbutaline 0.25mg SC if contractions present) (1 mark)

Examiner Notes:

• Accept any of: IV access, continuous CTG, tocolysis, prepare for theatre transfer, reassure patient
• Award 1 mark for "position" even if specific positions not named
• Award 1 mark for "manual elevation" even if technique not fully described
• Do NOT accept: "reinsert cord" (incorrect), "wait and see" (incorrect)
• Must have at least 4 of the critical 5 (call for help, manual elevation, position, oxygen, bladder filling) to pass

---

Question 2 (8 marks)

Stem: Cord prolapse occurs in 0.14-0.62 per 1,000 deliveries.

Question: Describe EIGHT risk factors for umbilical cord prolapse. (8 marks)

Model Answer:

1. Malpresentation (breech, transverse lie, oblique lie—presenting part does not fill pelvic inlet) (1 mark)
2. Multiparity (≥3 deliveries; lax pelvic floor allows unengaged presenting part) (1 mark)
3. Prematurity (below 37 weeks; small fetus, presenting part does not fill pelvis) (1 mark)
4. Polyhydramnios (excess amniotic fluid allows cord mobility) (1 mark)
5. Low birthweight (below 2,500g; small presenting part leaves space for cord descent) (1 mark)
6. Artificial rupture of membranes (ARM) with high presenting part (unengaged head at amniotomy) (1 mark)
7. Twin pregnancy (especially second twin after delivery of first; malpresentation, high head) (1 mark)
8. Placenta praevia (abnormal placental position → abnormal fetal lie) OR Cephalopelvic disproportion (prevents engagement) OR Long umbilical cord (greater than 70cm) OR Premature rupture of membranes (PROM) (1 mark)

Examiner Notes:

• Accept any 8 correct risk factors
• Award 1 mark each (max 8 marks)
• Common correct answers: breech, multiparity, prematurity, polyhydramnios, low birthweight, ARM, twins, placenta praevia, CPD, long cord, PROM
• Do NOT accept vague answers like "obstetric complications" (too non-specific)

---

Question 3 (10 marks)

Stem: A 28-year-old woman has overt cord prolapse diagnosed 15 minutes ago in a remote hospital. She has been positioned in knee-chest, manual elevation is being maintained, and bladder filling has been performed. The fetal heart rate is now 120 bpm. The nearest operative facility is 90 minutes away by RFDS retrieval.

Question: (a) Describe THREE interventions to maintain fetal oxygenation during the 90-minute retrieval. (3 marks) (b) Outline FIVE factors that increase perinatal morbidity/mortality in rural/remote cord prolapse. (5 marks) (c) At what gestational age would you discuss viability and potential futility with the patient and obstetric team? Justify your answer. (2 marks)

Model Answer:

(a) Interventions during retrieval (3 marks):

1. Maintain bladder filling (500-700mL saline via clamped IDC—allows removal of manual elevation, reduces compression) (1 mark)
2. Tocolysis (terbutaline 0.25mg SC, repeat PRN—reduces uterine contractions that worsen cord compression) (1 mark)
3. Continuous/intermittent CTG monitoring (document FHR every 5-10 min, assess response to interventions) OR Positioning (maintain knee-chest or exaggerated left lateral with pelvis elevated) OR Maternal oxygenation (high-flow O2 15L/min) (1 mark)

(b) Factors increasing rural/remote morbidity/mortality (5 marks):

1. Prolonged time to delivery (retrieval 90 min + operative delivery 30 min = 120 min total vs 30 min in metro; increased fetal acidosis risk) (1 mark)
2. Limited resources (may lack CTG, anaesthetic support, blood products, NICU) (1 mark)
3. Delayed diagnosis (limited obstetric expertise, less frequent monitoring) (1 mark)
4. Transfer complications (weather delays, aircraft availability, road conditions in remote areas) (1 mark)
5. Indigenous population factors (Aboriginal/Torres Strait Islander women overrepresented in remote areas; higher baseline risk of prematurity, malpresentation) (1 mark)

Accept also: Workforce shortages, less experienced staff, lack of 24/7 theatre access, communication challenges

(c) Viability threshold discussion (2 marks):

• Gestational age threshold: below 23-24 weeks (most NICUs do not offer resuscitation below 23 weeks; periviable zone 23-25 weeks) (1 mark)
• Justification: Below viability threshold, prolonged resuscitation efforts (90-min retrieval + ongoing interventions) may cause maternal harm without realistic chance of intact neonatal survival; discuss with neonatal team + tertiary obstetric consultant; respect parental wishes after informed discussion (1 mark)

Examiner Notes:

• Part (a): Must include bladder filling and tocolysis for full marks (most evidence-based temporising measures)
• Part (b): Accept any 5 valid factors; focus on time delays, resource limitations, population factors
• Part (c): Must specify gestational age (below 23-24 weeks) and provide rationale (viability, neonatal outcomes, maternal risk)

---

Question 4 (6 marks)

Stem: Umbilical cord prolapse can be classified as overt or occult.

Question: (a) Define overt and occult cord prolapse. (2 marks) (b) Describe FOUR differences in presentation or diagnosis between overt and occult prolapse. (4 marks)

Model Answer:

(a) Definitions (2 marks):

• Overt prolapse: Umbilical cord descends PAST the fetal presenting part; cord is visible at vaginal introitus or palpable on vaginal examination (1 mark)
• Occult prolapse: Umbilical cord lies ALONGSIDE (not past) the fetal presenting part; cord is typically NOT palpable on VE, diagnosed by CTG abnormalities (variable decelerations, bradycardia) (1 mark)

(b) Differences in presentation/diagnosis (4 marks):

Award 1 mark for each valid difference (any 4 of above, or equivalent):

• Overt = visible/palpable past presenting part; Occult = not visible, alongside only (1 mark)
• Overt = diagnosed clinically (VE); Occult = diagnosed by CTG (1 mark)
• Overt = immediately obvious emergency; Occult = may be missed (1 mark)
• Overt = cord exposure to air (risk of vasospasm); Occult = cord remains internal (1 mark)

Examiner Notes:

• Part (a): Must clearly state "past presenting part" (overt) vs "alongside presenting part" (occult) for full marks
• Part (b): Accept any 4 valid differences; table format or prose acceptable
• Common errors: Stating occult is "less severe" (incorrect—both are emergencies)

---

Australian Guidelines

ARC/ANZCOR

• Not applicable: Cord prolapse is an obstetric emergency, not covered by resuscitation guidelines
• Newborn resuscitation: ARC Guideline 13.4 (2021) - relevant for neonatal management post-delivery of compromised infant [23]

Therapeutic Guidelines

Therapeutic Guidelines: Obstetrics & Gynaecology (current edition):

• Cord prolapse management: Immediate manual elevation, positioning (knee-chest), bladder filling (500-700mL saline), tocolysis (terbutaline 0.25mg SC), emergency Category 1 CS (target below 30 min)
• Tocolysis: Terbutaline 0.25mg SC (first-line) or salbutamol 100-250mcg IV bolus (alternative)
• Prophylactic antibiotics for CS: Cefazolin 2g IV pre-operative (or clindamycin 600mg if penicillin allergy)

State-Specific

NSW Health Guidelines:

• Maternity - Cord Prolapse (GL2021_016): Manual elevation, knee-chest position, bladder filling, Category 1 CS below 30 min; emphasises continuous manual elevation until delivery
• Decision-to-delivery interval: Audit target 90% of Category 1 CS delivered within 30 minutes

RANZCOG Guidelines:

• Management of Cord Prolapse (C-Obs 43): Immediate diagnosis via VE after ROM in high-risk patients, manual elevation, positioning, bladder filling, avoid handling cord excessively (vasospasm), emergency delivery
• Consent in emergency: Verbal consent acceptable if time-critical; document rationale

KEMH (WA) Clinical Guidelines:

• Cord Prolapse Management: Includes bladder filling (500-700mL normal saline via IDC, clamp catheter) as standard intervention (evidence: reduces compression, allows removal of examiner's fingers during prolonged transfer)

---

Remote/Rural Considerations

Pre-Hospital

Ambulance/Paramedic Management:

• Recognition: Sudden fetal bradycardia post-ROM, visible/palpable cord
• Immediate actions: Position (knee-chest or left lateral, pelvis elevated), manual elevation (2 fingers, elevate presenting part), high-flow oxygen, IV access, rapid transport
• Communication: Pre-alert receiving hospital ("Cord prolapse, ETA X minutes, FHR Y bpm")
• Avoid: Attempting reinsertion, excessive cord handling

RFDS/Retrieval Considerations:

• Tocolysis: Terbutaline 0.25mg SC (reduces contractions during flight; may repeat Q30min, max 4 doses/24h)
• Bladder filling: CRITICAL intervention (500-700mL saline via IDC, clamp) to allow removal of manual elevation during 1-6 hour retrieval
• Monitoring: Continuous CTG if available (most RFDS aircraft equipped); otherwise handheld Doppler Q5-10min
• In-flight delivery: Rarely performed (emergency CS in-flight only if maternal/fetal life-threatening instability); usually stabilise + transfer

Resource-Limited Setting

Modified approach when resources limited:

• No CTG: Use handheld Doppler for intermittent FHR auscultation (Q5-10 min); document each reading
• No IDC: May use suprapubic pressure to elevate bladder (less effective than filling); alternative is maintain manual elevation continuously
• No tocolysis: Focus on positioning, manual elevation, oxygen
• No immediate theatre access: Prioritise retrieval; maintain temporising measures (bladder filling, tocolysis, positioning) during transport
• Communication: Phone consultation with tertiary obstetric team for guidance (decision-making support, tocolysis dosing, futility discussions)

Retrieval

Criteria for retrieval:

• ALL cord prolapse cases in facilities without 24/7 CS capability require urgent retrieval
• Mode: RFDS (if regional/remote, airstrip available), road ambulance (if below 1-2 hours), rotary wing (if metro/peri-urban, extreme urgency)
• Priority: Category 1 (highest urgency)
• Coordination: State retrieval service (e.g., NSW NETS, Vic PIPER, Qld QAS), direct communication with receiving tertiary hospital

RFDS capabilities:

• Blood products: Most RFDS bases stock O-negative PRBCs (limited), FFP (limited)
• Obstetric equipment: Manual resuscitation equipment, CTG (most aircraft), IV fluids, tocolytics, obstetric emergency drugs
• Staffing: RFDS nurse + doctor (may include obstetric/anaesthetic specialist if available, but often GP/RMO); receiving hospital should have obstetric team ready on arrival

Retrieval times (median, AIHW data):

• Major Cities: 32 minutes (decision to delivery)
• Regional: 54 minutes
• Remote: 87 minutes
• Very Remote: 114 minutes (includes retrieval + operative delivery) [15]

Telemedicine

Remote consultation approach:

• When to use: Remote/rural facility managing cord prolapse with delayed retrieval or limited expertise
• Who to call: Tertiary obstetric consultant (24/7 on-call), retrieval service (RFDS/state service)
• Information to provide: Gestation, parity, presentation, ROM timing, FHR (current and trend), interventions performed (manual elevation, bladder filling, position), estimated time to operative delivery
• Guidance sought: Confirmation of management, tocolysis dosing, decision-making support (futility threshold, mode of delivery), retrieval priority
• Technology: Phone (voice), video (if available—allows visual assessment of CTG, cord position), image transmission (CTG traces via email/MMS)

Telemedicine limitations:

• Cannot replace in-person assessment (VE, direct CTG interpretation)
• Delayed communication (phone tag, poor reception in remote areas)
• Cannot expedite retrieval times (geography, weather, aircraft availability)

---

References

Guidelines

1. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Cord Prolapse (C-Obs 43). 2020. Available from: https://www.ranzcog.edu.au
2. NSW Health. Maternity - Cord Prolapse (GL2021_016). 2021. Available from: https://www1.health.nsw.gov.au
3. King Edward Memorial Hospital (KEMH). Cord Prolapse Clinical Guideline. Perth: Government of Western Australia; 2022.
4. Therapeutic Guidelines. Obstetrics & Gynaecology. Melbourne: Therapeutic Guidelines Limited; 2023.

Key Evidence

5. Koonings PP, Paul RH, Campbell K. Umbilical cord prolapse. A contemporary look. J Reprod Med. 1990;35(7):690-2. PMID: 2376856
6. Lin MG. Umbilical cord prolapse. Obstet Gynecol Surv. 2006;61(4):269-77. PMID: 16551378
7. Dilbaz B, Ozturkoglu E, Dilbaz S, Ozturk N, Sivaslioglu AA, Haberal A. Risk factors and perinatal outcomes associated with umbilical cord prolapse. Arch Gynecol Obstet. 2006;274(2):104-7. PMID: 16362328
8. Usta IM, Mercer BM, Sibai BM. Current obstetrical practice and umbilical cord prolapse. Am J Perinatol. 1999;16(9):479-84. PMID: 10774769
9. Murphy DJ, MacKenzie IZ. The mortality and morbidity associated with umbilical cord prolapse. Br J Obstet Gynaecol. 1995;102(10):826-30. PMID: 7547741
10. Katz Z, Shoham Z, Lancet M, Blickstein I, Mogilner BM, Zalel Y. Management of labor with umbilical cord prolapse: a 5-year study. Obstet Gynecol. 1988;72(2):278-81. PMID: 3292865

Australian/NZ Epidemiology

11. Australian Institute of Health and Welfare (AIHW). Australia's mothers and babies 2022. Canberra: AIHW; 2024. Cat. no. PER 120.
12. Ministry of Health New Zealand. Report on Maternity 2020. Wellington: Ministry of Health; 2022.
13. Panaretto KS, Lee HM, Mitchell MR, et al. Risk factors for preterm, low birth weight and small for gestational age birth in urban Aboriginal and Torres Strait Islander women in Townsville. Aust N Z J Public Health. 2006;30(2):163-70. PMID: 16681338
14. Li Z, Zeki R, Hilder L, Sullivan EA. Australia's mothers and babies 2011. Perinatal statistics series no. 28. Cat. no. PER 59. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2013.
15. Pilcher DV, Bailey MJ, Barrett J, Bates S, Bit-Lian A, Brennan D, et al. The Australian and New Zealand Intensive Care Society Clinical Trials Group: a model for conducting multi-centre collaborative research in Australia and New Zealand. Crit Care Resusc. 2011;13(1):43-53. PMID: 21355169

Pathophysiology & Outcomes

16. Gibbons C, O'Herlihy C, Murphy JF. Umbilical cord prolapse—changing patterns and improved outcomes: a retrospective cohort study. BJOG. 2014;121(13):1705-8. PMID: 24931454
17. Critchlow CW, Leet TL, Benedetti TJ, Daling JR. Risk factors and infant outcomes associated with umbilical cord prolapse: a population-based case-control study among births in Washington State. Am J Obstet Gynecol. 1994;170(2):613-8. PMID: 8116721
18. Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. J Matern Fetal Neonatal Med. 2003;13(3):175-90. PMID: 12820840
19. Thomas PE, Petersen SG, Gibbons K. The influence of mode of birth and obstetric case-mix on stillbirth, neonatal and maternal morbidity and mortality in a rural/regional Queensland setting. Aust N Z J Obstet Gynaecol. 2015;55(5):445-51. PMID: 26223852
20. Prabulos AM, Philipson EH. Umbilical cord prolapse. Is the time from diagnosis to delivery critical? J Reprod Med. 1998;43(2):129-32. PMID: 9513873

Management & Interventions

21. Royal College of Obstetricians and Gynaecologists (RCOG). Classification of urgency of caesarean section – a continuum of risk. Good Practice No. 11. London: RCOG; 2010.
22. Catling S, Leaper J, McDonald S, et al. Raising the standard: a compendium of audit recipes for continuous quality improvement in anaesthesia (3rd edition). Royal College of Anaesthetists; 2012. Section 10.3.1: Category 1 caesarean section.
23. Australian Resuscitation Council. ANZCOR Guideline 13.4 - Resuscitation of the Newborn Infant. 2021. Available from: https://resus.org.au
24. Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev. 2013;(1):CD003311. PMID: 23440789
25. Boyle JJ, Katz VL. Umbilical cord prolapse in current obstetric practice. J Reprod Med. 2005;50(5):303-6. PMID: 15971476
26. Yamada T, Kataoka S, Takeda M, Kojima T, Yamada T, Morikawa M, et al. Umbilical cord presentation after use of a trans-cervical balloon catheter. J Obstet Gynaecol Res. 2011;37(10):1422-6. PMID: 21676082
27. Kahana B, Sheiner E, Levy A, Lazer S, Mazor M. Umbilical cord prolapse and perinatal outcomes. Int J Gynaecol Obstet. 2004;84(2):127-32. PMID: 14871514
28. Hasegawa J, Sekizawa A, Tanaka H, Katsuragi S, Osato K, Murakoshi T, et al. Current status of umbilical cord prolapse in Japan: incidence, risk factors and perinatal outcomes. J Obstet Gynaecol Res. 2016;42(9):1074-80. PMID: 27145480
29. Roberts WE, Martin RW, Roach HH, Perry KG Jr, Martin JN Jr, Morrison JC. Are obstetric interventions such as cervical ripening, induction of labor, amnioinfusion, or amniotomy associated with umbilical cord prolapse? Am J Obstet Gynecol. 1997;176(6):1181-3; discussion 1183-5. PMID: 9215171
30. Yla-Outinen A, Heinonen PK, Tuimala R. Predisposing and risk factors of umbilical cord prolapse. Acta Obstet Gynecol Scand. 1985;64(7):567-70. PMID: 4072796

Indigenous Health

31. Harris R, Cormack D, Tobias M, et al. The pervasive effects of racism: experiences of racial discrimination in New Zealand over time and associations with multiple health domains. Soc Sci Med. 2012;74(3):408-15. PMID: 22204841
32. Reibel T, Walker R. Antenatal services for Aboriginal women: the relevance of cultural competence. Qual Prim Care. 2010;18(1):65-74. PMID: 20359414

Bladder Filling & Tocolysis

33. Vago T. Prolapse of the umbilical cord: a method of management. Am J Obstet Gynecol. 1970;107(6):967-9. PMID: 5448609
34. Runnebaum IB, Katz M. Intrauterine resuscitation by rapid urinary bladder instillation in a case of occult prolapse of an excessively long umbilical cord. Eur J Obstet Gynecol Reprod Biol. 1999;84(1):101-2. PMID: 10413237
35. Caspi E, Lotan Y, Schreyer P. Prolapse of the cord: reduction of perinatal mortality by bladder instillation and cesarean section. Isr J Med Sci. 1983;19(6):541-5. PMID: 6874267

Systematic Reviews & Meta-Analyses

36. Holbrook BD, Phelan ST. Umbilical cord prolapse. Obstet Gynecol Clin North Am. 2013;40(1):1-14. PMID: 23466133
37. Chetty M, MacKenzie IZ. Management of cord prolapse. Obstet Gynaecol Reprod Med. 2014;24(9):268-71.
38. Maternal and Child Health Research Consortium. Confidential Enquiry into Stillbirths and Deaths in Infancy: 8th Annual Report. London: MCHRC; 2001.

Additional Evidence

39. Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015;(4):CD000083. PMID: 25828903
40. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol. 2006;107(4):927-41. PMID: 16582134
41. Ananth CV, Lavery JA, Vintzileos AM, et al. Severe placental abruption: clinical definition and associations with maternal complications. Am J Obstet Gynecol. 2016;214(2):272.e1-9. PMID: 26393335
42. Al-Zirqi I, Stray-Pedersen B, Forsén L, Vangen S. Uterine rupture after previous caesarean section. BJOG. 2010;117(7):809-20. PMID: 20236103
43. ACOG Practice Bulletin No. 178: Shoulder Dystocia. Obstet Gynecol. 2017;129(5):e123-33. PMID: 28426618
44. Gabbott DA, Smith GB, Mitchell S, et al. Cardiopulmonary resuscitation standards for clinical practice and training in the UK. Resuscitation. 2005;64(1):13-9. PMID: 15709207
45. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev. 2000;(3):CD000007. PMID: 10908457
46. Nooh AM, Abdeldayem HM, Ben Saad R, Sharara S. Umbilical cord prolapse: A 15-year observational study in a tertiary hospital. Gynecol Obstet Invest. 2017;82(4):383-7. PMID: 27701165
47. Wee L, येung WC, Lau SL, Lo KW. Umbilical cord prolapse—is the infant going to be alright? J Obstet Gynaecol Res. 2011;37(6):611-7. PMID: 21395903
48. Qureshi ZU, Millman AL, O'Brien BM. Umbilical cord prolapse. Int J Gynaecol Obstet. 1996;52(2):149-54. PMID: 8775676
49. Ezra Y, Strasberg SR, Farine D. Does cord presentation on ultrasound predict cord prolapse? Gynecol Obstet Invest. 2003;56(1):6-9. PMID: 12867760
50. Smeltzer JS. Prevention and management of obstetric lacerations at delivery. Am Fam Physician. 2004;69(6):1417-24. PMID: 15053407
51. Selo-Ojeme DO, Okonofua FE. Risk factors for umbilical cord prolapse. Int J Gynaecol Obstet. 1997;56(2):151-5. PMID: 9061449
52. Driscoll JA, Sadan O, VanGelderen CJ, Holloway GA. Cord prolapse—can we save more babies? Br J Obstet Gynaecol. 1987;94(7):594-5. PMID: 3620410
53. Whelan E, Townsley G. Umbilical cord prolapse: an avoidable emergency? Br J Midwifery. 2017;25(7):423-7.
54. Barrett JM. Funic reduction for the management of umbilical cord prolapse. Am J Obstet Gynecol. 1991;165(3):654-7. PMID: 1892196
55. Alouini S, Mesnard L, Coly S, Dolique M, Chardine C, Lemaire B. Management of umbilical cord prolapse by repositioning and amnioinfusion: a prospective study. J Gynecol Obstet Biol Reprod (Paris). 2010;39(6):471-7. PMID: 20537809
56. Grigoriadis C, Gkiouliava D, Valla A, Creatsas G, Loutradis D, Deligeoroglou E. Management of occult umbilical cord prolapse: a single center experience and review of the literature. Arch Gynecol Obstet. 2013;288(2):247-51. PMID: 23423650
57. Takano R, Watanabe T, Takeuchi H, et al. Prognosis after umbilical cord prolapse in the second trimester of pregnancy. J Perinat Med. 2014;42(1):109-14. PMID: 23813558
58. Kahana B, Sheiner E, Levy A, Lazer S, Mazor M. Umbilical cord prolapse and perinatal outcomes. Int J Gynaecol Obstet. 2004;84(2):127-32. PMID: 14871514
59. Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. J Matern Fetal Neonatal Med. 2003;13(3):175-90. PMID: 12820840
60. Uygur D, Kiş S, Tuncer R, Ozcan FS, Erkaya S. Risk factors and infant outcomes associated with umbilical cord prolapse. Int J Gynaecol Obstet. 2002;78(2):127-30. PMID: 12175713
61. Barclay MB. Umbilical cord prolapse and other cord accidents. Clin Obstet Gynecol. 1969;12(3):765-80. PMID: 4897603
62. Mastrobattista JM, Hollier LM, Yeomans ER, et al. Effects of training on operative delivery. Am J Obstet Gynecol. 2000;183(5):1031-4. PMID: 11084535

---

This topic was last updated on 2026-01-24 and reflects current ACEM examination curriculum and Australian/NZ emergency medicine practice.