Umbilical Cord Prolapse• Risk Factors

– Malpresentation, prematurity, polyhydramnios, high presenting part, long cord

• Epidemiology

Presentation IncidenceVertex 0.4%

Frank breech 0.5%Complete

breech 4.0 – 6.0%

Footing breech 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