Cord Prolapse

If you think it is happening now

The RCOG's instructions are short and specific. If you think you can feel the cord in your vagina, or you can see it:

• Phone 999 for an emergency ambulance immediately, and say that you are pregnant and think you have a prolapsed umbilical cord.
• Do not attempt to push the cord back into your vagina, and do not touch the cord.
• Do not eat or drink anything, in case you need an operation.
• Get onto your knees with your elbows and hands on the floor, then bend forward — the knee-chest position — and stay there until the ambulance or midwife arrives.

The RCOG offers an alternative if that is not possible: lie on your side with pillows under your hip. In the ambulance, that side-lying position is safer because the crew can strap you in.

What has happened

The umbilical cord carries oxygen-rich blood to your baby. A cord prolapse "happens when the umbilical cord slips down in front of the baby after the waters have broken", passing through the open cervix. It usually happens during labour, but can happen when the waters break before labour starts.

Why it is urgent: the cord can be squeezed by the baby or by the uterus during a contraction. That reduces blood flow and so reduces the baby's oxygen supply. In the RCOG's words, "the baby may need to be delivered immediately to prevent the lack of oxygen causing long-term harm or death of the baby".

How rare it is

The RCOG publishes a range rather than a single figure: cord prolapse is "uncommon, occurring in between 1 in 200 and 1 in 1000 births". When it does happen, it usually happens close to the end of pregnancy, after 37 weeks. No UK body publishes a more precise figure, and the range is the honest answer.

What makes it more likely

The mechanism explains the list. The RCOG: when the baby's head or body moves down into and completely fills your pelvis, the cord cannot usually prolapse. If it does not, there is space for the cord to slip past.

The chance is higher if the baby is not head-first, particularly breech or transverse; if your waters break before 37 weeks or you labour before 37 weeks; if you are carrying more than one baby; if you have more fluid than usual around the baby; if you are having a small baby; if you have a low-lying placenta; or if "your waters are broken by a doctor or midwife ... when the baby's head is higher up in your pelvis".

That last one is why the timing of having your waters broken is not arbitrary. The RCOG: "Your doctor or midwife will usually only break your waters if the baby's head is low down in your pelvis to try to avoid cord prolapse. If there is uncertainty, your doctor or midwife might break the waters in an operating theatre" — so that if a prolapse happens, you are already in the safest place.

Can it be predicted or prevented?

No, on both counts. The RCOG: "It is not possible to predict a cord prolapse. An ultrasound scan does not show which women will have a cord prolapse, as the cord and the baby change position during the pregnancy." And: "Umbilical cord prolapse cannot be prevented."

What can be changed is where you are when the risk is highest. If you are at increased risk you may be offered admission to hospital so that immediate action can be taken if your waters break or labour starts. The RCOG names one situation specifically: admission from 37 weeks may be discussed if your baby is lying transverse or changing position frequently.

How it is spotted by the team

The RCOG lists the signs: you can feel something in your vagina; you can see the cord; a midwife or obstetrician can see or feel it; or "the baby's heart rate slows (bradycardia) soon after your waters break". It adds, plainly, that "in some women there are no signs".

This is one of the reasons the fetal heart rate is listened to after the waters break. NICE's fetal monitoring guideline treats a sudden change in the baby's heart rate as something requiring immediate review of the whole clinical picture, and NICE's intrapartum guideline names cord prolapse among the obstetric emergencies that trigger transfer to obstetric-led care. Cord presentation — the cord felt in front of the baby before the waters break — is on NICE's list of findings at initial assessment that mean obstetric-led care.

What happens in hospital

The RCOG describes the holding measures first. "A midwife or doctor may insert a hand in your vagina to lift your baby's head to stop it squeezing the cord. This may need to continue until your baby is born." Sometimes a catheter is put into the bladder and used to fill it with fluid, which helps hold the baby's head away from the cord. A cannula goes into a vein for fluids and medicines.

Then the birth. "As your baby needs to be born as soon as possible, your care team may advise you to have an emergency caesarean birth but a vaginal birth may also be possible." If your cervix is fully dilated, a normal or assisted birth may be possible, "but only if this can happen quickly".

If a caesarean is needed, the anaesthetic may be different from the one you expected. The RCOG: "You may need to have a general anaesthetic instead of a spinal or epidural for your caesarean, so the baby can be born quickly as general anaesthetic works quicker." That is the reason, and it is worth knowing in advance rather than being told at the door of theatre.

Where this leaves planning

Cord prolapse is not a reason to change most birth plans. It is a reason to know two things: that ringing 999 and getting into the knee-chest position are the right first moves, and that if your waters break at home when the baby's head is high, or before 37 weeks, or with the baby in an awkward lie, the advice to come in and be checked has a specific emergency behind it rather than general caution.

The NHS's guidance on choosing where to give birth notes that transfer to hospital may be needed from any setting if complications occur; NICE asks that transfers be categorised by urgency, with a life-threatening emergency treated as the highest ambulance category.

NICE's guideline on inducing labour builds the same concern into induction itself, asking teams to take precautions "to avoid the adverse effects of cord prolapse, which may occur if labour is induced", starting with an abdominal assessment of the level and stability of the baby's head before induction begins.