Risk rises with an unengaged presenting part, malpresentation (breech, transverse), polyhydramnios, multiple gestation, and a long cord.
Before you read
Test yourself first: 4 questions
Question 1 of 4
A laboring client suddenly reports a gush of fluid. The fetal heart rate immediately drops and the nurse palpates a pulsating cord in the vagina. Which is the priority nursing action?
Answer: B. With a prolapsed umbilical cord, the priority is to relieve pressure on the cord. The nurse uses a gloved hand to push the presenting part off the cord and places the client in a knee-chest or Trendelenburg position while calling for help.
Question 2 of 4
A nurse performs a vaginal examination on a laboring client and palpates a pulsating cord in the vagina. The fetal heart rate drops to 80 bpm. What is the priority action?
Answer: B. A palpable, pulsating cord with bradycardia is an overt umbilical cord prolapse, an obstetric emergency. The nurse must keep a gloved hand in the vagina to lift the presenting part off the cord while positioning the client knee-chest or Trendelenburg and calling for help. The hand stays in place until delivery, usually by emergency cesarean.
Question 3 of 4
A laboring client at 5 cm dilation suddenly reports a gush of fluid. The nurse notes a fetal heart rate deceleration to 90 bpm that does not recover quickly. What is the priority nursing action?
Answer: B. A variable deceleration with sudden onset after membrane rupture suggests cord compression, possibly cord prolapse. The priority is to relieve pressure on the cord by repositioning the client (knee-chest or Trendelenburg) and, if a cord is palpated, lifting the presenting part off the cord. Increasing IV fluids and oxygen follow, but immediate repositioning to relieve compression comes first.
Question 4 of 4
During the second stage of labor, the nurse observes the fetal head retract against the perineum after crowning (the turtle sign) and the head fails to deliver the shoulders. What does the nurse suspect?
Answer: B. The turtle sign, where the head retracts tightly against the perineum after delivery, indicates shoulder dystocia, an obstetric emergency in which the anterior shoulder is impacted behind the symphysis pubis. This is distinct from cord prolapse, precipitous labor, or uterine inversion.
Keep the streak going with more questions like these, each with a full rationale.
What is umbilical cord prolapse?
It is an obstetric emergency that demands immediate action to relieve pressure on the cord. It is most likely after membrane rupture when the presenting part is not engaged.
Key points to remember
- Risk rises with an unengaged presenting part, malpresentation (breech, transverse), polyhydramnios, multiple gestation, and a long cord.
- Sudden, severe variable or prolonged decelerations or fetal bradycardia immediately after membrane rupture suggest cord prolapse.
- An occult prolapse is not visible; an overt prolapse may be seen at or felt in the vaginal introitus.
- Cord compression rapidly causes fetal hypoxia, so minutes matter.
- Definitive treatment is emergency delivery, usually by cesarean section.
Signs & symptoms
- Cord visible/palpable in vagina
- Sudden variable decelerations
- Fetal bradycardia
Nursing priorities
- Immediately place the client in knee-chest or Trendelenburg position to shift fetal weight off the cord.
- Insert a gloved hand vaginally and push the presenting part up off the cord, maintaining this elevation until delivery.
- Call for help and prepare for an emergency cesarean birth.
- Apply oxygen at 10 L/min via non-rebreather mask (when indicated) and increase IV fluids to support fetal oxygenation.
- Keep any visible cord moist with warm sterile saline gauze and do not attempt to push it back in.
Patient teaching
- If your water breaks and you feel something in the vagina or the baby's movements change, get on your hands and knees and call for help immediately.
- Once at the hospital, the team may need to deliver the baby quickly by cesarean to protect oxygen flow.
Red flags: report now
- A palpable or visible cord with fetal bradycardia is a true emergency; do not remove your hand from elevating the presenting part until the provider takes over in the OR.
- Never push a prolapsed cord back into the vagina; handling it causes vasospasm and worsens hypoxia.
- Sudden fetal bradycardia after rupture of membranes must be treated as prolapse until proven otherwise.
References
Clinical references for this topic
