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

• 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

Ovulation induction Family history Hyperemesis Uterine size > dates Early PIH Elevated MSAFP Auscultation of > 1 fetal heart beat Polyhydramnios

•••••

Associated Complications

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