Cord prolapse, nuchal cord and cord compression

What is it?

The umbilical cord runs from the placenta to the baby. It carries oxygenated blood in and deoxygenated blood out. If it is squeezed, that flow stops.

Cord prolapse happens when the cord slips below the baby, usually as the membranes rupture. The baby's presenting part then presses the cord against the pelvis. Because the baby is compressing their own supply, and because contractions increase that pressure, this is an immediate emergency. ¹

It is more likely when the baby is not well engaged in the pelvis: breech or transverse position, a preterm or small baby, a lot of amniotic fluid, twins, or when the membranes are ruptured artificially before the head is well applied. ⁴

Cord compression without prolapse is common. The cord can be squeezed between the baby and the uterine wall during contractions, which produces variable decelerations on the monitor. Most of the time this is well tolerated. ¹

Nuchal cord means the cord is wrapped around the neck. It is found frequently at delivery and most babies with one are born without any problem. It is worth stating plainly, because it is one of the most common things parents are told and then worry about for years. ²

A true knot in the cord is uncommon and is usually only recognized after delivery.

What does standard care look like?

Recognition. A sudden prolonged deceleration, particularly right after the membranes rupture, prompts an immediate vaginal examination to check for a prolapsed cord. ¹

Immediate measures if the cord has prolapsed. Relieving pressure on the cord by elevating the presenting part, positioning the mother to take weight off the cord, and preparing for immediate delivery.

Immediate delivery, almost always by cesarean, unless vaginal birth is imminent. This is the situation the 30-minute decision-to-incision benchmark exists for, and faster is better. ⁵

Continuous fetal monitoring in labor, which is how compression is detected. ¹

Care with artificial rupture of membranes when the presenting part is high, since that is a recognized moment for prolapse.

Response to variable decelerations. Guidance lists position change, fluids, oxygen, and stopping oxytocin among the measures for a concerning tracing. ⁶

What can go wrong?

A prolonged deceleration after rupture of membranes not examined. A sudden change at that moment is the classic presentation of cord prolapse. ¹

Delay between recognition and delivery. This is the variable that matters most, because the oxygen supply is interrupted throughout. ⁵

Pressure on the cord not relieved while preparing for delivery.

Repetitive severe variable decelerations not acted on. Cord compression is well tolerated up to a point and not beyond it. ¹

Membranes ruptured artificially with a high presenting part without regard for the risk.

A concerning tracing in a breech or transverse baby not treated with extra caution, where the risk of prolapse is higher. ⁴

Whether any of this caused injury in a particular case takes a physician expert reading the whole record. ³

Which injuries can follow?

Where the oxygen supply is interrupted long enough:

• Hypoxic-ischemic encephalopathy. A sudden complete interruption tends to injure the deep brain structures. ^{3 2}
• Neonatal seizures. ⁷
• Dyskinetic cerebral palsy, which is the pattern associated with deep gray matter injury. ²
• Meconium aspiration syndrome.
• Multi-organ effects including kidney injury.

A nuchal cord found at delivery in a baby who was born well is not an injury and does not require any follow-up.

What does this look like in the records?

The fetal monitoring strip is the central document. Look for:

• The moment the membranes ruptured, which is recorded in the notes.
• What the heart rate did immediately afterward.
• The depth, duration and recovery of any variable decelerations.
• Any prolonged deceleration, and the time it began.

The notes

• The time of rupture of membranes, and whether it was spontaneous or artificial.
• The vaginal examination findings, including the station of the presenting part.
• The time cord prolapse was recognized.
• What was done to relieve pressure, and when.
• The decision-to-delivery interval. ⁵

The delivery note

• Whether a nuchal cord was present, and how many loops.
• Whether a true knot was present.
• The condition of the baby at birth.

Alongside

• cord blood gas results. ³
• Apgar score scores. ⁸
• The resuscitation record. ⁹
• The placental pathology report, which describes the cord and its insertion.

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.