What is Umbilical Cord Prolapse?
Umbilical cord prolapse (UCP) is a rare but serious childbirth emergency. It happens when a baby’s umbilical cord slips through the mother’s cervix (the opening to the womb) before the baby does. This situation is dangerous because it can lead to serious harm or even death for the baby.
When the baby moves down during delivery, the cord can get squeezed, causing the baby to not get enough oxygen (a condition called ‘hypoxia’) and their heart rate to slow down (‘bradycardia’). This could lead to permanent disability or even death of the baby.
The key to prevent such outcomes is to quickly recognize what’s happening and take appropriate action. Early intervention can vastly improve the chances of avoiding harm to the baby.
What Causes Umbilical Cord Prolapse?
Some aspects of pregnancy can increase the likelihood of a condition called umbilical cord prolapse, where the baby’s umbilical cord slips into the birth canal before the baby does. This can be caused by various factors such as the baby not being positioned correctly in the womb, having more than one baby (multiple gestations), having too much amniotic fluid (polyhydramnios), the amniotic sac breaking prematurely before labor (preterm rupture of membranes), or the baby not growing at the usual rate within the womb (intrauterine growth restriction). Giving birth prematurely and abnormalities in the baby or the umbilical cord can also increase the risk.
About half of umbilical cord prolapse cases can be linked to medical interventions. These medical interventions might include breaking the water before the baby has moved into the right position to be born (amniotomy); attempts to manually turn the baby while the water has already broken (external cephalic version); infusion of fluid into the amniotic sac (amnioinfusion); attaching a monitor to the baby’s scalp to record the heartbeat (fetal scalp electrode) or inserting a device into the womb to measure contractions (intrauterine pressure catheter); or using a balloon device to help open the cervix (cervical ripening balloon).
Risk Factors and Frequency for Umbilical Cord Prolapse
The incidence or occurrence of umbilical cord prolapse, which is when the umbilical cord comes out ahead of the baby during birth, varies between 1.4 to 6.2 per 1000 pregnancies. Most of these cases are found in single baby pregnancies. However, in the case of twin pregnancies, the chances of experiencing this condition can increase for the second twin. Many of these prolapses happen shortly after the water breaks during childbirth – about 57% occur within five minutes and approximately 67% within the hour.
The noticeable decline in umbilical cord prolapse cases can be attributed to the increased use of C-sections, especially when the baby is not positioned ideally for birth – a factor that can lead to cord prolapse. The declining rates of women giving birth to many children worldwide also play a part in reducing the overall occurrence.
- The incidence of umbilical cord prolapse is typically 1.4 to 6.2 per 1000 pregnancies.
- These cases are mostly found in single baby pregnancies.
- In twin pregnancies, the second twin has a higher risk of experiencing this condition.
- About 57% of these prolapses happen within five minutes after the water breaks, and 67% occur within an hour of it happening.
- With the widespread use of C-sections for high-risk childbirths and less frequency of multiple pregnancies, the occurrence of umbilical cord prolapse is declining.
Signs and Symptoms of Umbilical Cord Prolapse
If a baby’s heart rate slows down during pregnancy after the rupturing of membranes, it’s crucial to check immediately for a possible umbilical cord prolapse. This is a condition where the umbilical cord, which connects the baby to the mother in the womb, slips out of the cervix before or alongside the baby. There are two types of umbilical cord prolapse.
- Overt prolapse: This is when the cord comes out before the baby. In this case, the umbilical cord can be felt as a pulsating structure in the vagina or even seen.
- Occult prolapse: This is when the cord comes out with the baby. The cord won’t be felt or seen in this situation.
In the case of an overt prolapse, it can often be diagnosed by a doctor feeling the pulsating cord in the vagina or seeing it protrude from the vaginal opening. This usually occurs alongside slowing of the baby’s heart rate or severe inconsistent changes in heart rate, although these changes might only happen in around two-thirds of cases.
In occult prolapse, the cord won’t be felt or visible, so the only sign may be abnormal changes in the baby’s heart rate. If there’s an unexplained change in the baby’s heart rate after the membranes have ruptured or after other procedures that increase the risk of prolapse (like attaching a monitoring device to the baby’s scalp), a doctor should consider the possibility of a cord prolapse.
Testing for Umbilical Cord Prolapse
Umbilical cord prolapse is a condition that can be identified by a healthcare provider during an examination, especially if the unborn baby’s heart rate decreases drastically or irregularly, especially right after the mother’s water breaks. To confirm this condition, the doctor would feel for a throbbing mass in the mother’s vagina; this would most likely be the umbilical cord.
Unfortunately, there are no X-rays or lab tests that can confirm umbilical cord prolapse. So, if a doctor suspects this condition, they’ll try to relieve the pressure on the cord as quickly as possible. Attempting to use an ultrasound ahead of time to predict umbilical cord prolapse hasn’t been very reliable.
Treatment Options for Umbilical Cord Prolapse
When an umbilical cord comes out of the womb before the baby does, a condition called umbilical cord prolapse, quick action is needed to ensure the baby’s delivery. Typically, doctors choose to perform a cesarean section, or C-section, which is a type of surgery used to deliver the baby. In some cases, vaginal delivery may be faster or safer, but this should only happen under the careful supervision of a seasoned childbirth doctor.
While the delivery method is being arranged, it’s crucial to relieve the pressure on the cord to ensure a good oxygen supply to the baby. This is done by gently moving the part of the baby closest to the birth canal away from the cord. This manual relief of pressure can be more important than the speed of the delivery overall. The doctor performs this by using their hand to gently shift the baby’s position. During this time, the mother may be positioned with her head down and feet up, or on her hands and knees, to help release the pressure on the cord.
In situations where the birth is likely to take a while, perhaps when a medical transfer to a birthing facility is needed, a special solution can be injected into the bladder which can help ease the cord’s compression without the need to continuously use hands to do so. If the baby’s heart rate decreases and birth is not immediate, medication can be used to relax the womb’s muscles and increase blood flow to the baby. If there’s still time until delivery can take place, the cord can be put back into the birth canal, but this is not normally suggested as it can lead to the baby’s increased risk.
If the cord is seen coming out of the birth canal, it’s important to keep it warm and moist. The cooler outside temperature can cause a spasm in the umbilical arteries which can affect the baby’s oxygen supply. To prevent this, the cord can be put back into the birth canal and held in place with a moist tampon.
In extremely rare cases of the cord prolapsing early in pregnancy, there are instances where careful monitoring and management can allow the pregnancy to continue until an optimal stage for delivery. However, this requires a detailed discussion with the patient about this strategy and its possible risks.
If the baby has untreatable abnormalities, or has tragically died inside the womb, a swift delivery would not be required. In such cases, a dilation and evacuation procedure, or encouraging labor, can be considered based on the mother’s preference and the stage of the pregnancy.
What else can Umbilical Cord Prolapse be?
If a doctor finds a noticeable lump in the vaginal vault area, it could be caused by the baby in the womb not being in the correct position for birth. There are also several factors that might cause the baby’s heart rate to slow down significantly for a long duration. These include:
- Low blood pressure in the mother
- Tearing of the uterus
- Vasa previa, a rare, but serious complication of pregnancy
- Abruptio placentae, a condition where the placenta detaches too early from the uterus
What to expect with Umbilical Cord Prolapse
The chance of an unborn baby dying due to an umbilical cord slipping out of place (prolapse) is now less than 10%. This is a big drop from previous estimates of 32% to 47%. Experts believe this decrease is because there are now more cesarean sections (C-sections) available and better methods to help newborn babies breathe (neonatal resuscitation).
The stage of pregnancy (gestational age) and where the umbilical cord prolapse happens (inside or outside the hospital) greatly affects the baby’s chances of survival. If the cord prolapse occurs outside the hospital, the chance of the baby dying is 18 times higher.
Also, premature babies and those with low birth weights face more birth-related complications and have double the risk of dying. These outcomes are more linked to the overall health condition of the baby and early delivery caused by the prolapse, rather than the prolapse itself.
Possible Complications When Diagnosed with Umbilical Cord Prolapse
Outcomes have significantly improved over recent years for babies born with their umbilical cord incorrectly positioned, or “prolapsed”. Despite this, there is still a risk to the baby’s life with this condition. While it’s rare, babies who do survive can face serious health problems due to a lack of oxygen, such as neonatal encephalopathy, a disorder that affects the structure or function of the brain, and cerebral palsy, a condition that affects movement and muscle coordination.
The Following Complications May Occur:
- Risk of death
- Potential for neonatal encephalopathy
- Possibility of cerebral palsy
Preventing Umbilical Cord Prolapse
Many people in countries with advanced medical facilities are choosing to give birth at home, guided by a non-doctor such as a midwife. However, if the baby’s umbilical cord slides out of the womb before the baby (a condition known as umbilical cord prolapse), the risk of the baby dying is nearly 20 times higher if the birth is happening outside a hospital. It is strongly advised that people who are at higher risk of umbilical cord prolapse, like those with a baby facing the wrong way in the womb or umbilical cord issues, choose to give birth in a hospital instead.
Patients might feel more comfortable about giving birth in a hospital if their other birth preferences, such as a quiet birth or minimal use of drugs, can still be respected. Since umbilical cord prolapse can occur even when there are no known risks, it’s important those helping with the birth who aren’t doctors are trained to act quickly if this arises. This could result in a better outcome for the baby.
Patients should also be taught how to recognize umbilical cord prolapse. If they feel a liquid flow followed by a sensation of something pushing in the vagina after their water breaks, they should immediately call an ambulance and kneel with their chest touching their knees while waiting for help.
Doctors also have a part to play in reducing the occurrence of umbilical cord prolapse. The American College of Obstetricians and Gynecologists advises against breaking the mother’s water (known as an amniotomy) during a smooth labor unless it’s necessary to monitor the baby’s health. If an amniotomy is necessary, the doctor should check that the baby’s head has moved into the birth canal. To reduce the risk of cord prolapse in riskier situations, a needle can be used to break the mother’s water in a controlled manner, slowing down the flow of the fluids. However, it’s important to note that this method hasn’t been thoroughly researched yet.
