Open Journal of Obstetrics and Gynecology, 2011, 1, 174-177
doi:10.4236/ojog.2011.14033 Published Online December 2011 (http://www.SciRP.org/journal/ojog/
OJOG
).
Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJOG
Cord complications: associated risk factors and
perinatal outcome
Vijayata Sangwan, Smiti Nanda, Mukesh Sangwan, Roopa Malik, Manisha Yadav
Department of Obstetric & Gynecology, Pt. B. D. Sharma PGIMS, Rohtak, India.
Received 30 July 2011; revised 4 September 2011; accepted 15 September 2011.
ABSTRACT
Objective: To assess the perinatal outcome in patients
with cord presentation and cord prolapse over a pe-
riod of 2 years and to assess the obstetric risk factors
associated with these cord complications. Design: Re-
trospective case study. Setting: A tertiary health care
centre of India. Sample: All cases of cord presenta-
tion and cord prolapse diagnosed in the department
over a period of 2 years (2009-2010). Methods: The
information regarding maternal presentation at the
time of admission, mode of delivery, and neonatal out-
come was retrieved from case sheets of patients avai-
lable in Medical Record Department. Maternal fac-
tors in terms of age, parity, gestational age, mode of
presentation, mode of delivery were analysed. Foetal
outcome was assessed by Diagnosis to Delivery In-
terval, APGAR score at 0 minutes and 5 minutes, foe-
tal weight and need for NICU admission. Results: The-
re were 53 cases of cord complications, out of which 7
(13.20%) had cord presentation and 46 (86.80%) had
cord prolapse. Among these 46 patients, 11 patients
developed cord prolapse in labour room (3 after arti-
ficial rupture of membranes and 8 after spontaneous
rupture of membranes), rest 34 patients presented in
emergency with cord prolapse. There were 79.24%
multiparous patients, 16 patients had malpresenta-
tions and breech was commonest malpresentation.
Forty one patients had positive cord pulsations at the
time of admission, all these patients underwent emer-
gency caesarean section and all had live babies. Twe-
lve patients reported to us with absent cord pulsation,
3 among these underwent section for obstructed la-
bour with hand and cord prolapse, rest 9 delivered
vaginally. The average DDI was 26.00 minutes, DDI
in patients developed cord prolapse in hospital was
18.90 minutes ± 5.48 minutes, whereas in patients
admitted with cord prolapse as emergency, the DDI
was 29.34 minutes ± 6.37 minutes (p < 0.05). Conclu-
sion: Analysis of the study concluded that the delive-
ry interval between cord prolapse and delivery of the
foetus is very important. Shortening of this interval
can decrease neonatal complication at birth and re-
duce NICU admission.
Keywords: Cord Complications; Perinatal; Caessrean
Section
1. INTRODUCTION
Umbilical cord prolapse is a rare obstetric complication
usually necessitating emergent delivery. It is life threa-
tening emergency for the foetus as the blood flow th-
rough the umbilical vein is compromised by cord com-
pression. The incidence of cord prolapse reported in lite-
rature ranges from 0.1% - 0.6% and has remained con-
stant over the last centuary [1]. A number of unavoidable
risk factors have been associated with increased inci-
dence of cord prolapse which include malpresentation,
prematurity, multiple gestations, premature rupture of mem-
branes & polyhydramnios. Remarkably high correlation
of cord prolapse and obstetric interventions such as foe-
tal scalp electrode application, insertion of intrauterine
catheter, induction of labour with artificial rupture of
membranes (ARM) is reported. Post natal mortality and
morbidity has fallen significantly as a result of advances
in management of cord prolapse and NICU care. Diag-
nosis to Delivery Interval (DDI) of 20 minutes - 30 mi-
nutes has been recommended by various international
obstetric societies [2,3]. The primary objective of this
study was to assess the perinatal outcome in patients of
cord prolapse and cord presentation over a period of 2
years. A secondary objective was to assess the obstetric
risk factors associated with these cord complications.
2. METHODS
This was a retrospective study conducted at Pt. B D
Sharma PGIMS Rohtak, a tertiary health care unit with
an average of 11,000 - 12,000 deliveries per year. The
information was retrieved from case sheets of patients

V. Sangwan et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 174-177 175
available in Medical Record Department. Maternal con-
dition at the time of admission in terms of age, parity,
gestational age, foetal presentation, status of membranes
and mode of delivery were statistically analysed (Inde-
pendent sample T test). Different cord complications
were defined as follows to made diagnosis. Overt cord
prolapse was defined as the descent of the cord through
the cervix in to the vagina or onto the vulva. Cord pres-
entation meant the presence of one or more loops of um-
bilical cord between the fetal presenting part and the
fetal membranes overlying the cervical os. At admission,
the fetal condition was assessed and those with maturity
of >32 weeks and positive cord pulsations were immedi-
ately shifted for caesarean section. In these patients, in
order to alleviate pressure on cord, the cord was imme-
diately placed high up in vagina, presenting part was
elevated simultaneously and bladder filled with 500 ml
normal saline (Vago method) [4-10] until the patient was
on operating table. Foetal outcome was assessed in terms
of neonatal weight, APGAR score at 0 minutes and 5 mi-
nutes and NICU admission. Neonatal asphyxia was iden-
tified by the pediatrician on clinical grounds. In the pa-
tients getting admitted in emergency with complaint of
leaking per vaginum for varying duration, it was difficult
to comment on exact time of cord prolapse. Thus, Diag-
nosis to Delivery Interval was calculated as the time be-
tween reporting of patient and delivery of the foetus.
3. RESULTS
Amongst 22,681 deliveries over a period of 2 years, 53
cases of umbilical cord complications were identified,
giving the incidence of cord complication as 0.23 %. Out
of these 53 patients, 18 (33.96%) patients reported to us
with intact membranes and 35 (66.07%) patients re-
ported to us with complaints of leaking per vaginum for
varying duration and cord prolapse. In 18 patients with
intact membranes, 7 had cord presentation, 3 patients de-
veloped cord prolapse after artificial rupture of mem-
branes in the labour room and 8 admitted patients de-
veloped spontaneous leaking per vaginum leading to co-
rd prolapse. The details regarding patient profile are de-
scribed in Table 1.
Table 2 explains the risk factors of cord prolapse in
our study. Malpresentation was the commonest cause and
breech was the commonest malpresentation. The cervical
dilatation at the time of presentation was <5 cm in 34
(64.11%) and >5 cm in 19 (35.89%) patients.
Table 3 shows about perinatal characteristics in the
study. At admission, cord pulsations were present in 41
patients, rest of the fetuses (12) were already dead. All
patients with positive cord pulsations were immediately
shifted to operation theatre for urgent LSCS and all had
live babies. The fetal maturity in these was 32 weeks (1),
33 weeks - 36 weeks (8), rest 32 were >36 weeks. Among
these, birth weight of 18 babies was 1.5 kg to 2.5 kg, 23
babies were of 2.6 kg to 3.5 kg, and 2 babies weigh more
than 3.6 kg. Apgar score was <5 at first minute in 8
neonates, in 5 neonates it remained <5 at 10 min and
they were admitted in NICU. These 5 fetuses were born
to mothers who had been admitted as emergencies with
cord prolapse.
Of the 12 patients admitted with absent cord pulsa-
tions, 3 mothers had presented with obstructed labour
and had to be taken up for section for the sake of mother.
Rest 9 were delivered vaginally.
Table 1. Characteristic of patients with cord complications.
Characteristics No. of patients % of patient
Age group (years)
<20 03 5.6
21 - 25 37 69.81
>25 13 24.52
Parity
Nulliparous 11 20.75
multiparous 42 79.24
Gestational age (weeks)
<37 09 16.98
>37 44 83.01
Presentation
Vertex 37 69.81
Nonvertex 16 30.18
Cord complications
Cord presentation 07 13.20
Cord prolapse in hospital 11 20.75
Cord prolapse at admisson 35 67.92
Cervical dilatation (cm)
<5 34 64.15
>5 19 35.84
Table 2. Risk factors for cord prolapse.
Sr. no.Risk factor No. of patients % of patient
1 Multiparity 42 79.24
Malpresentation 16 30.18
Breech 08 15.09
Transverse lie 04 7.54
2
Compound presentation 04 7.54
3 Unengaged head 09 16.98
4 Twins 02 3.77
5 Prematurity 09 16.98
6 Artificial rupture of membranes 03 7.54
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Table 3. Perinatal characteristics.
Characteristic No. of patients % of patient
Cord pulsations at diagnosis
Present
Absent
41
12
77.35
22.64
Fetal Maturity
<28 wks
28 wks - 32 wks
33 wks - 36wks
≥37 wks
2
2
5
44
3.77
3.77
9.43
83.01
Apgar at 1 min.
<5
>5
10
31
18.86
58.49
Fetal weight at birth(kg)
<2.5
>2.5
16
37
30.18
69.81
Baby status
Live
dead
41
12
77.35
22.64
Sex
Male
female
35 (2 twins)
20
66.03
37.73
Mode of delivery
Emer. LSCS
NVD
44
09
83.01
16.98
Baby admission
NICU
With mother
5
36
9.43
67.92
The perinatal mortality in our study was 0.52 per 1000
births. The average DDI in our study was 26.00 minutes.
In the patients who had developed leaking in the hospital,
the DDI was 18.90 minutes ± 5.48 minutes with no
NICU admission and good Apgar score post delivery;
whereas in patients admitted with cord prolapse as emer-
gency, the DDI was 29.34 minutes ± 6.37 minutes (p <
0.05).
4. DISCUSSION
Cord prolapse and cord presentation are the obstetric
emergencies that change the management of a simple
pregnancy and necessiate urgent delivery. They are asso-
ciated with high perinatal mortality and morbidity. Suc-
cessful outcome depends on several maternal and foetal
factors. Incidence of cord prolapse in our study was 2.3
per 1000 deliveries .Other studies have reported the in-
cidence of 1.5, 1.4 per 1000 deliveries, 2.7 and 2.8 per
1000 deliveries [2,4-6].
Associated risk factors are those that predispose a
woman to have incompletely filled pelvis in the presence
of ruptured membranes. In the present study, the risk fa-
ctors for cord presentation and cord prolapse were found
in 39 (71.07%) patients. Multiparity is associated with
increased risk of cord prolapse. It is accounted by the
fact that in multipara, the engagement of presenting part
occurs late, and as a result with rupture of membranes,
cord slips down in vagina. In our study, 79.24% patients
were multiparous and 8 (15.09%) were >P4. Malpresenta-
tions were present in 16 (30.18%) and breech was com-
monest malpresentation. Prematurity was a cause in 9
(16.98%) patients. Other studies on risk factors associ-
ated with cord prolapse have also reported the same fac-
tors [7,8]
The perinatal mortility in our study was 0.52 per 1000
births. All these deaths were unavoidable as all had ab-
sent cord pulsations at the time of presentation. A few
studies reported high perinatal mortality [2,9]. Literature
suggests that cord prolapse occurring outside the hospi-
tal is consistently associated with a high perinatal mor-
tality rate (38% - 42%). In contrast, cord prolapse in a
labour room where patient is under monitoring, the peri-
natal mortality is very low (0% - 3%).
The cause of fetal distress in cord prolapse is cord
compression and urgent caesarean section releives that
compression. Studies revealed that DDI >30 minutes
associated with lower Apgar score [1]. In our study DDI
was found 26.00 minutes which is well within the rec-
ommended range and comparable with other studies re-
ported on cord prolapse. According to international bod-
ies, the time required to perform an emergency cesarean
section should not exceed 30 minutes [4]. The ACOG
also recommends incision time of 20 minutes - 30 minu-
tes to appropriate emergency caessrean section in patient
of cord prolapse. Literature suggests that DDI alone is
not the only contributing factor [9-12]. The other factors
like degree of cord compression, length of cord prola-
psed, prior hypoxia, CTG abnormalties may influence
foetal outcome. Inspite of widespread prevalence of risk
factors of cord prolapse, this problem is very rare. It may
be attributed to tone of the cord, its collagenous contents,
and its relation to lower segment. Studies also suggest
that intrapartum USG in patients prone for developing
cord prolapse before ARM may decrease the incidence
of cord prolapse [2,4].
The perinatal mortality and morbidity due to cord pro-
lapse has significantly improved over past century as a
result of advances in labour management, improved sur-
gical techniques and neonatal intensive care. However,
studies have revealed that perinatal outcome can further
be improved by a multiprofessional obstetric emergency
training sessions [3]. In our study, patients who had de-
veloped cord prolapsed in the labor room had average
DDI of 18.90 min, and no NICU admission. While pa-
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V. Sangwan et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 174-177 177
tients, who presented with cord prolapse, had an average
DDI of 29.34 min. This may be because of the extra time,
required in preparing patient for operation theatre. The
literature suggests that the main reason, why units fail to
comply with the 30 minutes target, delay in shifting pa-
tient to theatre [3]. Thus in order to achieve the advocated
DDI of <30 minutes, planned protocols for the manage-
ment of cord prolapse and the necessary drill of the rou-
tine staff to shift the patient on to OT table at the earliest,
needs to be strongly followed in the labour rooms.
OJOG
5. CONCLUSIONS
In our study, we concluded that the delivery interval be-
tween cord prolapse and delivery of the foetus is very
important. Shortening of this interval can decrease neo-
natal complication at birth and reduce NICU admission.
The preparatory time of patient for operation theatre and
her shifting to operation theatre where sister and para-
medical staff plays important role, is very crucial for the
patient. So, there should be written protocol for the staff,
alarming system in labour room to alert the whole team
should be there, to decrease DDI and improve neonatal
outcome.
REFERENCES
[1] Monique, G.L. (2006) Umbillical cord prolapse CME
review article. Obstetrical and Gynecological Survey, 61,
269-277.
[2] Khan, R.S., Naru, T. and Nizami, F. (2007) Umblical
cord prolapse-A review of diagnosis to delivery interval
on perinatal and maternal outcome. Journal of Pakistan
Medical Association, 57, 487-491.
[3] Siassakos, D., Harafa, Z., Sibanda, T., Fox, R., Donald, F.,
Winter, C. and Draycott, T. (2009) Retrospective cohort
study of diagnosis delivery interval with umbilical cord
prolapse: The effect of team training. British Journal of
Obstetrics and Gynaecology, 116, 1089-1096.
d oi: 10. 1111/j .14 71-0528.2009.02179.x
[4] Al Marzowki, A.M. and El Shobokshi, A.S. (2009) Audit
of cord prolapse. Management at King Abdulaziz Uni-
versity Hospital. Journal of King Abdulaziz University,
Medical Sciences, 16, 35-42.
[5] Bako, B., Chama, C. and Audu, B.M. (Sep2009) Emer-
gency obstetric care in a Nigerian tertiary hospital: A 20
year review of umbilical cord prolapse. Nigerian Journal
of Clinical Practice, 12, 232-236.
[6] Traore, Y., et al. (2006) Frequency of cord prolapse: Etio-
logical factors and foetal prognosis in 47 cases in a hea-
lth centre. Medicine For Mali, 21, 25-29.
[7] Dilbaz, B., Ozturkoglu, E., Dilbaz, S., Oztuck, N., Siva-
slioglu, A.A. and Haberal, A. (2006) Risk factors and
perinatal outcome associated with umbilical cord prola-
pse. Archives of Gynecology and Obstetrics, 274, 104-
107. doi:10.1007/s00404-006-0142-2
[8] Kahana, B., Sheinar, E., Levy, A. and Mazor, M. (2004)
Umbilical cord prolapse and perinatal outcomes. Interna-
tional Journal of Gynecology and Obstetrics, 84, 127-
132. doi:10.1016/S0020-7292(03)00333-3
[9] Faiz, S.A., Habib, F.A., Sporrong, B.G. and Khalil, N.A.
(2003) Results of delivery in umbilical cord prolapse.
Saudi Medical Journal, 24, 754-757.
[10] Bord, I., Gemu, O., Anleby, E.Y. and Shenhav, S. (2010)
The value of bladder filling in addition to manual eleva-
tion of presenting foetal part in cases of cord prolapse.
Archives of Gynecology and Obstetrics, 15.
[11] Tan, W.C., Tan, L.K., Tan, H.K. and Tan, A.S. (2003)
Audit of crash emergency caesarean section due to cord
prolapse in terms of response time and perinatal outcome.
Annals, Academy of Medicine, 32, 638-641.
[12] Prabulos, A.M. and Philipson, E.H. (1998) Umbilical
cord prolapse. Is the time from diagnosis to delivery cri-
tical? Journal of Reproduction Medicine, 43, 129-132.