Cord prolapse at a facility without theatre

1. Call for help and record the time. The exact time of diagnosis and of every intervention determines the quality of the handover and the review; a prolapsed cord is a category-1 emergency in which minutes of compression cause hypoxic injury.
2. Elevate the presenting part with a sterile gloved hand in the vagina and keep it there. The purpose is to relieve pressure of the head on the cord so that blood flow continues. The hand stays in place during examination, transfer and preparation - it is not removed 'to see' whether the cord is still pulsating.
3. Position her to reduce pressure: knee-chest, exaggerated Sims or Trendelenburg with pillows under the hips. Gravity helps the presenting part fall away from the cord. She should not be left supine, and she should not walk to the ambulance.
4. Do not handle the cord, and do not attempt to replace it into the uterus. Manipulation causes vasospasm and further compromise; replacement is not a recognised management option. Cover the cord with a warm, moist sterile dressing if it is outside the introitus to prevent drying and cooling.
5. Give oxygen, start continuous or very frequent auscultation, and arrange immediate transfer. Tocolysis with terbutaline 250 micrograms subcutaneously can be considered if contractions are strong and frequent and there is no maternal contraindication, because it reduces compression. If there is any delay and a skilled practitioner is present, fill the bladder with 500-750 mL of sterile saline through a Foley catheter and clamp it - this lifts the presenting part internally - but the bladder must be documented and emptied before caesarean, and bladder filling must never delay departure.

Why position matters: cord prolapse causes fetal hypoxia through compression of the umbilical vessels between the presenting part and the pelvis, and sometimes through vasospasm from cooling and handling. In the supine position the fetal head is pressed directly onto the cord against the sacral promontory with each contraction, so flow is interrupted during contractions and may not recover between them. Knee-chest, exaggerated Sims and Trendelenburg positions use gravity to move the head away from the pelvis, and elevating the foot of the trolley achieves the same effect during transfer. Combined with a hand elevating the presenting part, this preserves umbilical circulation until delivery. The knee-chest position is effective but difficult to maintain during a 25-minute journey, so on the stretcher the exaggerated Sims or left lateral with pillows under the hips is usually more practical, with a hand maintaining elevation.

If the cord stops pulsating and no fetal heart is heard: the situation has changed from a fetal emergency to a fetal death, and the priority shifts to the mother's safety. Confirm with the Doppler, inform the woman and her family sensitively and truthfully, and inform the receiving hospital. Continue transfer for assessment and delivery planning, but the immediate threat of maternal harm from a rushed transfer is reduced. Do not remove your hand abruptly while the head is still high, and do not perform any procedure outside your scope. Document the times of loss of pulsation, the absence of fetal heart, and who confirmed it, and arrange bereavement support.

Handover (SBAR):

• Situation: Samira, G2P1, 38+2, cord prolapse diagnosed at 09:10 with fetal bradycardia to 72.
• Background: spontaneous labour, 6 cm at diagnosis, head at -1, membranes ruptured at 09:10, no maternal hypertension or other comorbidity.
• Assessment: presenting part elevated by hand since 09:10, maternal observations, contraction pattern, fetal heart trend, estimated arrival time.
• Recommendation: theatre on arrival, paediatric team present, and specifically whether the bladder was filled and with how much, so it can be emptied before surgery.

Infection prevention: the vaginal hand is a major infection risk in a woman who will proceed to surgery. Use sterile gloves, minimise the number of vaginal examinations, keep the cord covered with a sterile moist dressing, use an aseptic technique for catheterisation, and document the bladder volume. Antibiotic prophylaxis is given at caesarean according to protocol; the midwife should not omit it because 'she is already on antibiotics' without checking. Hand hygiene before and after every contact remains the single most effective measure.

Quality issues: a cord prolapse should trigger a review of whether the membranes were ruptured artificially with a high head, whether presentation was confirmed before amniotomy, and whether the referral pathway and ambulance response met the standard. Debrief the junior colleague, complete an incident report, and check that the unit has a written cord prolapse drill with a designated role for the person who holds the presenting part. Documenting times, who performed which action, and the woman's condition protects both the woman and the team.