Vaginal Delivery with Velamentous Umbilical Cord Insertion
Patients with velamentous umbilical cord insertion can safely deliver vaginally as long as vasa previa has been ruled out. Vaginal delivery remains the preferred mode of delivery for most cases of velamentous cord insertion without additional complications 1.
Understanding Velamentous Cord Insertion
Velamentous cord insertion (VCI) is an abnormal placental cord insertion where:
- Umbilical vessels branch before reaching the placenta
- Blood vessels travel unprotected through the membranes
- Occurs in approximately 1% of singleton pregnancies
- More common in multiple gestations (up to 22% in monochorionic twins) 1
Delivery Recommendations
When Vaginal Delivery is Appropriate
- VCI without vasa previa
- No signs of fetal compromise
- No other obstetric indications for cesarean delivery
- Normal fetal growth and development
When Cesarean Delivery Should Be Considered
- Presence of vasa previa (when velamentous vessels cross the internal cervical os) 1, 2
- Fetal distress or non-reassuring fetal status
- Intrauterine growth restriction (IUGR) with abnormal Doppler studies
- Other obstetric indications (e.g., malpresentation)
Risks Associated with Velamentous Cord Insertion
Velamentous cord insertion increases the risk of:
- Stillbirth
- Small-for-gestational-age neonates
- Preterm delivery
- Placental abruption
- Low Apgar scores 1, 3
However, these risks alone do not necessitate cesarean delivery in all cases.
Management During Labor
For patients with VCI attempting vaginal delivery:
- Continuous fetal monitoring is essential
- Careful monitoring for signs of fetal distress
- Avoid artificial rupture of membranes when possible (to prevent cord compression)
- Have blood products available in case of emergency
- Pediatric team should be present at delivery
Evidence Supporting Vaginal Delivery
There are documented cases of successful vaginal deliveries with velamentous cord insertion, even in complicated scenarios. One case report describes successful vaginal delivery in a patient with cord prolapse and velamentous cord insertion with good neonatal outcomes 4.
The American College of Radiology acknowledges that while velamentous cord insertion increases risks, the primary concern is to rule out vasa previa, which would be a contraindication to vaginal delivery 5.
Special Considerations for Twin Pregnancies
Velamentous cord insertion is more common in multiple gestations, particularly monochorionic twins:
- Increases risk of twin-twin transfusion syndrome (TTTS)
- Associated with discordant growth between twins 1
- May require earlier delivery and closer monitoring
Key Practice Points
- Prenatal diagnosis of velamentous cord insertion is crucial using ultrasound with color Doppler
- Always evaluate for vasa previa, which would contraindicate vaginal delivery
- Increased surveillance with ultrasound every 2-3 weeks beginning at 16 weeks gestation
- Monitor for fetal growth restriction, amniotic fluid abnormalities, and Doppler abnormalities
- Have emergency protocols in place for potential complications during labor
While velamentous cord insertion increases certain risks, the presence of VCI alone is not an absolute indication for cesarean delivery. The decision should be based on the presence of vasa previa, fetal status, and other obstetric factors rather than the velamentous insertion itself.