Snapshot A 30-year-old G1P0 woman of 38 week gestation presents to the hospital with contractions. In the labor and delivery room, she undergoes rupture of membranes. Shortly after, the fetal heart monitor reveals variable decelerations. A vaginal exam is conducted and the umbilical cord is palpated between the presenting part of the fetus and the cervical os. An ultrasound is done to confirm this diagnosis. As intrauterine manipulation is attempted, the fetal heart monitor shows bradycardia. The patient is prepped for a cesarean section. Introduction Overview umbilical cord prolapse results from umbilical cord that presents anterior to the presenting part of the fetus, causing it to protrude first from the cervical os this is an obstetrical emergency as compression or occlusion of the umbilical cord will lead to fetal oxygen deprivation treatment is usually emergent delivery Epidemiology Incidence rare, 0.16-0.18% of live births Risk factors obstetrical intervention (50%) manual rotation of fetal head iatrogenic rupture of membranes forcep or vacuum delivery malpresentation low lying placenta prematurity polyhydramnios prolonged labor ETIOLOGY Pathogenesis mechanism unclear, may be related to increased outward flow of amniotic fluid during rupture of membranes Presentation Symptoms common symptoms abrupt onset of fetal rhythm abnormalities bradycardia variable decelerations occurs after rupture of membranes or obstetrical intervention usually painless Physical exam inspection visualization of umbilical cord ahead of presenting fetus Imaging Ultrasound indications suspected diagnosis of umbilical cord prolapse findings umbilical cord visualized between presenting fetus and cervical os Differential Abruptio placentae key distinguishing factors may also present with fetal heart rate changes characterized by vaginal bleeding and abdominal pain Treatment Medical intrauterine manipulation to free the fetus indication initial treatment modalities elevating presenting part changing maternal position (i.e., in Trendelenberg) Surgical immediate delivery via cesarean section indications intrauterine manipulation is not successful fetal or maternal distress Complications Fetal mortality 0-3% mortality rate Prognosis Worse prognosis if prolapse occurs outside the hospital