1. 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%

2. 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

3. 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

4. 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

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

6. Associated Complications
Prematurity
Congenital anomalies
Pregnancy-induced hypertension
Placenta praevia
Fetal death: 0.5% - 6.8%

7. 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

8. 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