Umbilical Cord Prolapse Risk Factors Malpresentation, prematurity, polyhydramnios, high presenting part, long cord Epidemiology Presentation Incidence Vertex 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