What is a Cord Prolapse?

What is a cord prolapse?

Cord Prolapse also called an Umbilical Cord Prolapse - or UCP - is a very rare obstetrical emergency which can result in a birth injury or worse - death.

What does it mean? This happens when your baby's umbilical cord descends alongside - or before - his head (or his bottom or feet if breech). Cord prolapse can be life threatening to your baby since blood flow - and therefore oxygen - through his umbilical cord is usually compromised due to cord compression.

Yet keep in mind that cord prolapse is very rare and occurs in 0.14 to 0.62 percent of all births. In a study performed at the John Radcliffe Hospital between January 1984 and December 1992, the incidence of cord prolapse was 1 in 426 births or .23%.

Picture curtesy of Megan Brust

Types of Cord Prolapse

There are three types of cord prolapse:

Overt cord prolapse

Occult cord prolapse

Funic presentation

Overt Cord Prolapse

This occurs when your baby's presenting part - usually her head but could be her feet or bottom - does not fit your pelvis snugly after your membranes have ruptured.

In this case, the risk is that her umbilical cord will slip past your baby and present at your cervix or descend into your vagina and as a result cut of your baby's oxygen supply.

This is the most common form of a cord prolapse.

Notes: This is most likely with small babies and the artificial rupturing of the membranes (AROM) and therefore even less likely during a homebirth than a hospital birth.

Midwives focus on nutrition, therefore prematurity and small babies are less likely with midwives than OBs. Moreover, midwives hardly ever rupture your membranes.

An overt cord prolapse is an obstetric emergency. Depending on its duration and degree of compression, fetal hypoxia (asphyxia), brain damage and even death can occur.

When a cord prolapse is detected - unless birth is imminent - a c-section will be performed.

Occult Cord Prolapse

An occult cord prolapse occurs when your baby's umbilical cord lies alongside her presenting part.

Funic Presentation

A funic presentation occurs when your baby's cord prolapses below her presenting part before the membranes have ruptured. This is very, very rare and the least common.

Survival Rates for a Cord Prolapse

Remember the John Radcliffe Hospital study mentioned earlier?

This study measured main outcome survival rates. This was measured in three ways:

by recording the Apgar scores at 1 and 5 minutes after birth

by assessing blood gas values on cord blood samples

by incidence of major handicap at three years of age

The results?

There were six stillbirths and six neonatal deaths. One baby died as a result of birth asphyxia.

The uncorrected perinatal mortality rate was 91 per 1000.

Of 120 survivors, only one baby was known to suffer from a birth trauma in the form of a major neurological handicap.

In conclusion the study confirmed that a cord prolapse occurs with a relatively stable incidence and that it is also very rare.

The researchers also concluded that your baby's outcome was not as poor as expected and that mortality was predominantly attributable to congenital anomalies and prematurity rather than birth asphyxia.

Note: Prematurity is a major risk factor for a cord prolapse. Most women will not have a homebirth with a premature baby.

Risk Factors for a Cord Prolapse

There are mainly two reasons for cord prolapse - both of which can be somewhat preventable:

1) Fetomaternal - "baby-mother" - factors that lead to an inadequate filling of your pelvis by your baby's presenting part

2) Obstetric interventions

Fetomaternal Factors

1) Fetal malpresentation

Your baby lies in a presentation other than head first:

Breech

Transverse

Oblique

Breech: 3 to 4% of births

Overt cord prolapse occurs in more than 1% breech deliveries:

0.5% Frank breech

This is when your baby's bottom comes first, and his or her legs are flexed at the hip and extended at the knees (with feet near the ears).

65-70% of breech babies are in the frank breech position.

5% complete breech

It is when your baby's hips and knees are flexed so that your baby is sitting cross-legged, with her feet beside her bottom.

15% footling breech

It is when your baby's feet come first, with her bottom at a higher position. This is rare at term but relatively common with premature babies.

Kneeling breech

It is when your baby is in a kneeling position, with one or both her legs extended at the hips and flexed at the knees. This is extremely rare.

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Transverse:

A transverse lie is associated with a risk of cord prolapse as high as 20%.

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Oblique lie:

Your baby is head down but her head is toward your hip and not engaged in the birth canal.

Note: Good size babies have a much harder time laying in odd positions for they have less room to fit. So again, a good diet is very important for your health, your baby's and also as you can see - labor as well.

2) Prematurity

Babies born before 37 weeks.

Premature babies have a higher rate of umbilical cord prolapse. This is due to a variety of factors but mainly their smaller size and the increased frequency of malpresentations.

3) Multiple gestation

At term, the risk of a cord prolapse is usually to the second twin. Again this is usually due to smaller babies and an increased probability of malpresentation. However, in well fed mothers low birth weight even with twins does not need to be. Most midwifes will report normal birth weights for twins.

Note: Florence has given birth to two sets of twins. Both sets were born at term (more than 38 weeks - which is normal for her and the same as her single babies). The smallest twin was 7 pounds and the largest 7 lbs 15 oz.

4) Multiparity

This means women who have had more than one birth.

This may be due to the increased likelihood of rupture of membranes prior to the engagement of your baby in your pelvis. In women who have already had a baby, engagement occurs after labor has begun or at least later than for first time moms.

Again we would contend that healthy active moms are less at risk. Walking is fantastic exercise and has been proven to reduce malpresentations.

5) Polyhydramnios

Polyhydramnios - too much amniotic fluid - is often associated with an unstable lie or an unengaged presenting part, as well as a copious flow of amniotic fluid after the membranes rupture.

However, polyhydramnios is seen in few pregnancies - 0.5 to 5%. Of these, about 20% of cases are due to maternal diabetes, which causes fetal hyperglycemia (high blood sugar in your baby) and results in polyuria (excessive urine output).

Note: A majority of your baby's amniotic fluid is composed of urine.

About another 20% of cases are associated with fetal anomalies that impair the ability of the baby to swallow.

Note: Your baby normally swallows the amniotic fluid.

However, do not be overly concerned for in 60-65% of cases of polyhydramnios, the cause is unknown.

6) Low birth weight

A baby weighing 2.5 kilos at term or about 5.5 pounds.

7) Fetal congenital abnormality

8) Cephalopelvic disproportion

The baby cannot fit through the mother's pelvis.

This is quite rare for your baby's head will mold and your pelvis can open up to 33% more depending on your birthing position!

9) Pelvic tumors

10) Low lying placenta or other abnormal placentation

11) High fetal station

The baby is still high in the pelvis rather than "engaged."

12) Long umbilical cord

13) Macrosomia

Macrosomia is - arbitrarily - defined as a birth weight of more than 4000 g or 8 lbs 13 oz. Many women - including Alisha and Florence - give birth to larger babies without any problem.

True macrosomia though is often associated with diabetes.

Obstetrical Interventions

Obstetrical intervention may result in an iatrogenic cord prolapse - iatrogenic means "doctor caused" - and therefore is totally preventable.

The main reason for a cord prolapse is the improper engagement of your baby's head and a gush of the amniotic fluid which then carries his cord with it.

Artificial rupture of membranes (AROM) - which is very common in hospitals - is the number one culprit for cord prolapse.

Another reason is induction for no medical reasons - which most of them are - and obviously before your baby is ready and properly engaged.

Those two reasons - AROM and induction - are very, very unlikely in a homebirth.

A cord prolapse is a complication which could be fatal in home or hospital. The National Birthday Trust Fund study of planned home births done in the United Kingdom, reported on the incidence of cord prolapse. In a study involving over 10,000 women, only one cord prolapse occurred at home but no death was reported.

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