Umbilical Cord Prolapse
• Risk Factors
– Malpresentation, prematurity,
polyhydramnios, high presenting part, long
cord
• Epidemiology
Presentation
Vertex
Frank breech
Complete breech
Footing breech
Incidence
0.4%
0.5%
4.0 – 6.0%
15% - 18%
Rapid Response to Prolapse
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Recognize non-reassuring tracing
Visually inspect/palpate cord to diagnose
Assess fetal status (FHTs, ultrasound)
Assess labour progress (dilation, station)
Do not attempt to replace cord
Hold presenting part off cord
– Foley catheter
– Position change (Trendelenburg, Knee-chest)
• Tocolysis
Prevention of Prolapse
• Identify risk factors
– Malpresentation, high presentation
– Patient education re: membrane rupture
at home
• No AROM when station high
– May “needle” membranes under double
set-up
Multiple Gestation
• Occurs in 1.5% of U.S. births
• 2-5 X higher perinatal morality
• Maternal complications common
– HTN, anaemia, hyperemesis, abruption,
praevia, PPH, operative delivery
• Dizygosity (fraternal) = 2/3
– Increases with age, parity, familial
factors
• Monozygosity (identical) = 1/3
Diagnosis of Multiple
Gestation
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Ovulation induction
Family history
Hyperemesis
Uterine size > dates
Early PIH
Elevated MSAFP
Auscultation of > 1 fetal heart beat
Polyhydramnios
Associated Complications
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Prematurity
Congenital anomalies
Pregnancy-induced hypertension
Placenta praevia
Fetal death: 0.5% - 6.8%
Delivering Twin B
• Attempt internal podalic version
• Breech delivery is reasonable choice
when:
– External version unsuccessful or not
attempted
– Strong labour and Baby B deep in pelvis
– Cord prolapse or nonreassuring FHR
tracing
Summary
• Six types of malpresentations
• Diagnosis by physical exam and
imaging
• Be alert to etiologic association
• Be alert to potential complications
• Vaginal delivery may be considered
for OP, breech, face and compound
presentation