Eleje J Womens Health, Issues Care 2014, 3:1

http://dx.doi.org/10.4172/2325-9795.1000132

Journal of Womens
Health, Issues & Care

Research Article

Determinants of Umbilical Cord

Prolapse in a Low-Resource
Setting
Eleje George Uchenna1*, Ofojebe Chukwuemeka Jude1,
Udegbunam Onyebuchi I1 and Adichie Chuma Victor1

Abstract
Background: Cord prolapse is an infrequent and life-threatening
obstetric emergency in which blood flow through the umbilical cord
ceases due to an acute compression between the fetus and the
uterus, cervix, or pelvic inlet.
Objectives: To identify risk factors of cord prolapse and compare
the perinatal outcomes with those without cord prolapse.
Methods: Between January 2007 and December 2011, 38 cases of
umbilical cord prolapse seen in the labour ward of Nnamdi Azikiwe
University Teaching Hospital, Nnewi, South-East Nigeria were
retrieved. Two controls per case were used. Statistical analyses
were done using Epi info 2008 version 3.5.1.
Results: During the study period, there were 10,180 deliveries,
out of which 38 cases of cord prolapse were seen, giving an
incidence of 0.37%. Highest incidence occurred in women 30
years. Of all cases, 81.6% (31/38) were multiparous compared to
controls (P=0.05). Thirty of the 38 women (78.9%) were unbooked
compared with 10.5% (8/76) in the control group and this was
statistically significant (P=0.00). Thirty one (81.6%) cases occurred
during labor while only 7 (18.4%) occurred in women when they
were not in labor. Up to 36.8% of patients significantly had fetus
with birth weight <2.5 kg compared with 7.9% of controls (Odds
Ratio (OR)=6.81; P=0.0001). When cord prolapse and control
pregnancies were compared, we found significant differences
(P<0.05) concerning age, parity, birth weight and booking status.
In addition, fetuses with cord prolapse presented more frequently in
transverse lies and breech presentations than controls.
Conclusion: In our environment, cord prolapse is an infrequent
obstetric complication. Its incidence is significantly influenced by
multiparity, unbooked status, abnormal lies, malpresentations and
low fetal weight. Since most prolapses occur during labor as the
cervix dilates, women at risk of cord prolapse should be continuously
monitored to identify fetal heart rate abnormalities.

Keywords
Cord prolapse; Unbooked; Breech; Low birth weight

Synopsis
Cord prolapse is a rare obstetric complication in Nigeria. Its
occurrence is significantly determined by high parity, unbooked
status, malpresentations and low birth weight.
*Corresponding author: Eleje George Uchenna, Department of Obstetrics and
Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, PMB 5025,
Nnewi, Anambra State, Nigeria, Tel: 2348068117444; E-mail: georgel21@yahoo.
com
Received: April 24, 2013 Accepted: December 15, 2013 Published: December
20, 2013

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Introduction
Umbilical Cord prolapse is an infrequent and life-threatening
obstetric emergency in which blood flow through the umbilical cord
ceases due to an acute compression between the fetus and the uterus,
cervix, or pelvic inlet [1]. It differs from cord presentation in which
the cord is below the presenting part but with the fetal membranes
intact [2,3].
However, in the presence of a life fetus, umbilical cord prolapse
calls for prompt delivery [4]. Although, the incidence of overt
umbilical cord prolapse is affected by the mode of fetal presentation
[2], it has been noted to be waning because of the increasing use
of cesarean section in non-cephalic presentations and more active
intrapartum management of preterm pregnancies [5].
Any feto-maternal factors leading to inadequate filling of the
maternal pelvis and iatrogenic obstetric interventions [5] are two
major etiologic factors that predispose to cord prolapse. Any factors
maintaining the presenting part high in the pelvis will predispose a
woman to cord prolapse and is primarily related to fetal presentation
and secondarily to the station of the presenting part [2,3,6-9]. The
first clinical manifestation of cord prolapse is usually a severe,
prolonged fetal bradycardia or moderate variable declaration after
a previously normal tracing [5,10-13]. The optimal management is
prompt delivery to avoid fetal death from cord compression [14,15].
However, cesarean section is often the fastest approach for a
viable fetus unless vaginal delivery is in the offing. If the cervix is fully
dilated and presentation is cephalic, assisted vaginal delivery using a
vacuum or forceps can be done [2]. While preparation for the surgery
is being made it is imperative to commence on certain conservative
measures that prevent further compression or desiccation of the cord
[2,12]. These actions singly or in combination will raise the presenting
part off the cord and reduce the uterine activities.
A review of umbilical cord prolapse in Nnamdi Azikiwe
University Teaching Hospital, Nnewi, Nigeria has remained largely
uninvestigated. Against this backdrop, this study therefore identifies
the risk factors associated with cord prolapse and compares the
perinatal outcomes with those without cord prolapse.

Methods
This was a cross sectional with retrospective data collection
of cases of umbilical cord prolapse seen at the Nnamdi Azikiwe
University Teaching Hospital (NAUTH), Nnewi, South-east Nigeria
from 1st January, 2007 to 31st December, 2011 (a 5-year period). Two
controls per case were randomly selected from the remaining births
by selecting the case just before and after the umbilical cord prolapse
from the birth record.
A thorough scrutiny of the delivery records of the obstetric
unit as well the records of the Medical Records Department and
special care baby unit (SCBU) of the hospital was done to identify
these patients by checking on their names, case file numbers and
their diagnosis at presentation in the labor ward and subsequent
management of their babies if admitted in SCBU. Their case files
were subsequently retrieved and studied. The data extracted from the

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Citation: Eleje GU, Ofojebe CJ, Udegbunam OI, Adichie CV (2014) Determinants of Umbilical Cord Prolapse in a Low-Resource Setting. J Womens Health,
Issues Care 3:1.

doi:http://dx.doi.org/10.4172/2325-9795.1000132
Table 1: Association of maternal risk factors with umbilical cord prolapse.
Maternal risk
factor
N=76

study group
N=38

control group

7.9

7.1

OR

95%CI

P-value

Table 3: Perinatal outcome of all cases with cord prolapse compared with
control.
Perinatal outcome

study group N=38

control group N=76

OR

10.5

1.2

30

78.9

28 36.8% 0.80

10.5

1.3

Cesarean section

34

89.5

15

19.7

Vaginal delivery

10.5

61

80.3

95%CI

P-value

0.17- 3.91

0.79

Age
19 and below

0.80

0.163.94

0.79

Perinatal death
APGAR at 1st
minute

20-24

10

26.3

16

21.1

25-29

10

26.3

15

19.7

Less than 8

30-34

12

31.6

30

39.5

35-39

7.9

1.3

APGAR at 5th
minute

40 and above

0.0

0.0

18.4

28

36.8

Less than 8
Mode of delivery

Parity
Nulliparous
Multiparous

31

81.6

48

63.2

Booked

21.1

68

89.5

Unbooked

30

78.9

10.5

0.39

0.150.99

0.04

0.010.09

0.00

Booking status
0.03

Table 2: Association of fetal risk factors with umbilical cord prolapse.

Fetal risk factors

study group N=38 % control OR

group N=76

Gestational age

Less than 36
weeks

11

28.9

14

18.4

36 weeks and
above

27

71.1

62

81.6

Cephalic

24

63.2

70

92.1

Breech

10

26.3

Transverse

10.5

Singleton

32

84.2

Multiple

15.8

95% CI

P-value

1.80 0.73- 4.48

0.20

5.3

0.13 0.04- 0.48

0.00

2.6

0.17 0.03- 0.10

0.03

73

96.1

0.22 0.05- 0.93

0.03

3.9
6.81 2.35-19.70

0.00

Presentation

Number of fetuses

Birth weight
Less than 2.5 kg

14

36.8

7.9

2.5 kg

24

63.2

70

92.1

patients case files included; age, nationality, literacy level, booking

status, parity, gestational age, fetal presentation, number of fetuses,
route of delivery, APGAR score at the first and the fifth minutes, birth
weight of fetus and whether or not neonate survived i.e. the outcome
of the baby (at delivery or within one week of life, or admission in
the special care baby unit). The proforma was initially used for data
collection which was transferred to data sheet before entering them
into the Epi-info software. The total deliveries for the period were also
determined. The perinatal outcome of the babies was also determined
by noting the APGAR scores at delivery and the condition of the
babies on or before one week of admission in the SCBU or condition
at discharge. In a multiple pregnancy, only the fetus with a prolapsed
cord was included in the study.
The study was approved by the hospital research ethics committee.
Umbilical cord prolapse was defined as the presence of cord below
the presenting part following rupture of membranes. We excluded
all fetuses with congenital abnormality. All the cases with live fetuses
were managed with manual elevation of presenting part, instillation
of 500 ml of normal saline in the bladder or positioning in head down
position before delivery.

Volume 3 Issue 1 1000132

34.57 10.62-112.50

0.00

The odds ratios were calculated to identify the relationship

between umbilical cord prolapse and some of the potential risk factors.
The adjusted (corrected) odds ratios (OR) were calculated using the
Mantel-Haenszel method, and a P value of <0.05 was considered as
significant at 95% confidence interval (CI). Data analysis was done
using Epi info 2008 (v 3.5.1; Epi Info, Centers for Disease Control and
Prevention, Atlanta, GA).

Results
There were ten thousand one hundred and eighty deliveries
within the study period out which thirty eight had umbilical cord
prolapse. A total of 76 controls were used in the study. The incidence
of umbilical cord prolapse was 1 in 268 births (0.37%). A total of 34
(89.5%) cases of cord prolapse were delivered by caesarean section
while that of control was 15 (19.7%). Vaginal delivery was conducted
in 4 (10.5%) cases. These fetuses were already dead before arrival at
the hospital. None of the babies whose mothers had umbilical cord
prolapse died after delivery in the neonatal care unit. Thirty one
(81.6%) cases occurred during labor while only 7 (18.4%) occurred in
women when they were not in labor.
Out of the 38 women with umbilical cord prolapse 31 (82%) were
multiparous compared to 42 (63.2%) in the control group. As shown
in Table 1, unbooked cases constituted 30 (78.9%) while unbooked
status in the control was 8 (10.5%). This is statistically significant
(p<0.001). A total of 24 (63.2%) cases of cord prolapse had fetuses in
cephalic presentation compared with 70 (92.1%) in the control group.
Umbilical cord prolapse occurred in 26.3% of breech presentations
and 10.5% of transverse lies.
Out of the 38 cases of cord prolapse, 6 (15.8%) were multiple
gestation compared to 3 (3.9%) of the controls. Of the 38 cases with
cord prolapse, 14 (36.8%) babies weighed less than 2.5 kg compared to
6 (7.9%) in the control group (Table 2). This is statistically significant
(p<0.001).
As shown in Table 3, thirty (78.9%) of the 38 cases had fetus with
APGAR scores less than 8 at the first minute while the control group
had only 28 (36.8%) cases. For APGAR at fifth minute, 15 (39.5%)
cases of umbilical cord prolapse had scores below 8 while in the
control group only 8 (10.5%) had scores below 8.
There were 4 (10.5%) cases of perinatal mortality out of the 38
cases of umbilical cord prolapse compared with 3 (1.3%) out of 76
cases in the control group. All the cases with perinatal mortality were
unbooked cases.
Page 2 of 4

Citation: Eleje GU, Ofojebe CJ, Udegbunam OI, Adichie CV (2014) Determinants of Umbilical Cord Prolapse in a Low-Resource Setting. J Womens Health,
Issues Care 3:1.

doi:http://dx.doi.org/10.4172/2325-9795.1000132

Discussion
Umbilical cord prolapse can convert an apparently normal
pregnancy to that in which outcome can end in perinatal mortality.
It is an obstetric emergency that is associated with high perinatal
mortality. However early identification and proper management
will usually result in good outcome [16,17]. It is therefore important
that the associated risks factors are identified in pregnant women to
enhance management.
The incidence of umbilical cord prolapse in this study was 0.37%.
This is in keeping with the incidence of 0.14% and 0.62% reported in
other studies [5]. This agrees with the incidence of 0.47% recorded
by Enakpene et al. in Ibadan [18] and 0.46% by Kalu and Umeora in
Ebonyi State [5], all in Nigeria.
Non vertex fetal presentation is consistently associated with a
high risk of cord prolaspse [2]. In one review, the overall frequency
of cord prolapse in vertex, breech, and transverse lies was 0.24, 3.5,
and 9.6 percent, respectively [9]. In another study on umbilical cord
prolapse, breech accounted for 23.9% of the study group compared
to 4.3% in the controls [5]. In this study, breech accounted for 26.3%
of the study group while breech among the control group is 5.3%. In
this study transverse lie accounted for 10.5% of cord prolapse, while
in the control group it accounted for 2.6%. Therefore non-vertex
presentation accounted for 37.1% of the study group. Additionally,
umbilical cord prolapse expectedly should have been commoner in
transverse lie than in breech presenting fetuses. An explanation for
this peculiar finding is difficult except that it could be that breech
presentation is more commonly encountered in our obstetrics
practice. Thus, any obstetric condition that predisposes to poor
application of the fetal presenting part to the cervix can result in
prolapse of the umbilical cord.
Cord prolapse is associated with preterm delivery probably due
to the small size of the fetus relative to the amniotic fluid volume and
the increased frequency of malpresentations among preterm infants
[5,10,11,13]. This study has identified a possible relationship between
low birth weight and umbilical cord prolapse. In this study 36.8% of
the study group had birth weight less than 2.5 kg compared with 7.9%
of the control group. Since a significant number of premature infants
will have low birth weights, prematurity itself, is a contributor to the
incidence of umbilical cord prolapsed.
An association has been found between multifetal gestation and
umbilical cord prolapse. In two studies, significant number of women
with multiple pregnancy compared to controls had umbilical cord
prolapse [5,16]. In this study 15.8% of the study group had multiple
pregnancies compared to 3.9% of the control group. Other studies
have revealed that the risk of umbilical cord prolapse in multiple
pregnancy is confined to the second twin, in whom there may be
malpresentations [2,7,12].
This study also documented an association between umbilical
cord prolapse and unbooked status. Out of the 38 cases of cord
prolapse, 78.9% were unbooked compared to 10.5% in the control
group. This finding is very relevant coupled with the fact that
obstetrics intervention contributes to nearly half of case of umbilical
cord prolapse and such could be very common among the unbooked.
Almost 90% cases of cord prolapse in this study were delivered
by emergency cesarean section. Although, the recourse to cesarean
section is life-saving both to the mother and to the fetus, it may at
times be associated with some unfavorable complications. Thus, the
Volume 3 Issue 1 1000132

associated risks must be weighed against the genuine risk to the fetus
of continued hypoxia if labor were continued. However, maternal
risks encountered at vaginal delivery may include laceration of the
cervix, vagina or perineal tear resulting from a hastily performed
delivery or instrumentation.
Since most prolapses occur during labor as the cervix dilates,
women at risk of cord prolapse should be continuously monitored
to identify fetal heart rate abnormalities. Forewater amniotomy
should be avoided until the presenting part is well applied to the
cervix. However, should amniotomy be required and the presenting
part remain unengaged, cautious needling of the membranes and
unhurried release of the amniotic fluid can be performed until the
presenting part of the fetus settles against the cervix. Above all,
women with malpresentations of the fetus or poorly applied fetal
presentations should be considered for ultrasonographic examination
at the onset of labor to determine the lie of the fetus and position of
the cord within the uterine cavity.
The perinatal mortality noted in this study was 10.5% in the study
group compared to 1.3% in the controls. All the cases of perinatal
mortality were unbooked and the fetuses were already dead before
arrival at the hospital. This therefore shows the significance of
identification and interventions in management of cord prolapse.
This justifies the interventions done to prevent cord compression and
emergency caesarean section used in the delivery of most of these
cases when vaginal delivery is not imminent. The baby at delivery
may be hypoxic, acidotic or moribund. Therefore, a neonatology
team should be present to effect instant resuscitation of the newborn.
Nevertheless, the 1.3% mortality rate seen in the controls seems a
very high figure. This could be due to other the prevailing obstetrics
problems that are peculiar in our developing country settings.
One major limitation of this study was the small number
of patients used in the study and so certain findings cannot be
unquestionably be confirmed. Additionally, this study was cross
sectional with retrospective data collection and the records and units
have not been computerized. We could not evaluate all the factors
that could have predisposed to the umbilical cord prolapse since
some of them would have been missing in the case files.

Conclusion
In our environment, cord prolapse is an infrequent obstetric
complication. Its incidence is significantly influenced by multiparity,
unbooked status, abnormal lies, malpresentations and low fetal
weight and perinatal mortality is higher in unbooked cases. It is
therefore important that pregnant women book early and or present
early in labor for identification of these risk factors.

Conflicts of Interest
The authors have no conflict of interest in performing the research.
The authors alone are responsible for the contents and writing of the
paper. They have conducted this study in the course of their service
in the hospital and have not received funding from any organization.
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Citation: Eleje GU, Ofojebe CJ, Udegbunam OI, Adichie CV (2014) Determinants of Umbilical Cord Prolapse in a Low-Resource Setting. J Womens Health,
Issues Care 3:1.

doi:http://dx.doi.org/10.4172/2325-9795.1000132
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Author Affiliations

Top

Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching

Hospital, Pmb 5025, Nnewi, Anambra State, Nigeria
1

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