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Velamentous Insertion of the Umbilical Cord

Here is a photo of a velamentous insertion of the umbilical cord. This is when the vessels of the cord imbed into the chorion and run inbetween the amnion and chorion (the amniotic sac) for some length. Sometimes, the insertion is a couple of centimeters, but others, like this, are quite far.

When the vessels are at or near the opening of the cervix (Vasa Previa), they can burst when the membranes rupture and cause terrible damage or death to the baby. The baby "exsanguinates" - loses all his/her blood within a few minutes. One of my previous clients (x2) was pregnant with her fourth baby, had had three previous homebirths and was expecting to birth this one at home, too, but her membranes spontaneously ruptured and blood poured out. They called 911 and she was taken to the hospital where, a mere 15 or so minutes later, her baby had already died. She was induced and the baby boy was born vaginally. His family spent several hours with him, taking pictures of him and loving him lots before letting him go to be ready for burial. She went on the have two more babies with me at home... beautiful births, but her son was always in our minds.

In Facebook, someone wisely asked what would happen if there was cord traction on this type of placenta. This next picture shows what happens.

 The cord falls off.

We were taught Active Management of Third Stage, doing controlled cord traction to get the placenta out in a "timely manner." If there is a velamentous insertion, the cord is tenuously connected, so it doesn't take much to break it off.

With this woman's placenta, we had to go in and manually remove it.

When the cord has come off, I've only seen going in to get the placenta, but always wondered about just letting the placenta be born on its own. Is that possible? If we're going to not do cord traction, even if to get the placenta out of the vaginal vault, would the organ plop out on its own if the woman was upright?

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Reader Comments (14)

From Kathy - kathy_petersen_283@yahoo.com - http://womantowomancbe.wordpress.com

Rixa said that Zari (her firstborn, a UC) had a velamentous insertion which they noted only after the placenta was born. So, yes, placentas can come out all on their own, without any traction whatsoever. :-) She notes that had she been in the hospital, they likely would have AROM'd her, and Zari might have died.

But if the placenta remains attached to the uterine wall and the cord falls off, won't that cause the mother to start bleeding *through* the insertion point? So if the cord (or remains of it) are bleeding profusely, isn't it the best course of action to manually remove the placenta, so that the uterus can start clamping down and minimize maternal blood loss? If the placenta is already detached, it makes sense that the mother can just push it out without any traction (in my 2nd birth, an unplanned UC, that's what happened -- several minutes after the birth, I felt the placenta at the os, squatted and pushed and it came out, with no traction from me or anyone else).

January 1, 2010 | Registered CommenterNavelgazing Midwife

Well, of course I know placentas can be born without assistance. I guess my question is... would signs would there be that the placenta was still attached? Would the cord start bleeding out? What if only part of it had detached? With the 2-3 that I've seen the cord detach, no one waited even a moment to see if there was bleeding, but just zipped in and got the placenta out.

And the first picture was a placenta that came out vaginally on its own without traction, so I know it can be done. (Re: Rixa's)

I've also seen/felt cords fall off with virtually no traction whatsoever. The placentas were horridly old or unhealthy.

And a note about a mom getting up to deliver her placenta. Many/most of the moms I've seen/had have preferred to have the placenta lifted out of their vaginal vault instead of doing the stand-up-holding-a-baby dance and, even more challenging, the squat-holding-a-baby dance. How do other midwives do it?

January 1, 2010 | Registered CommenterNavelgazing Midwife

From Kathy again:

I knew you knew. :-)

No answers to the more technical questions; but with both my babies, I handed the baby off to someone else to hold while I birthed the placenta. The first was a water-birth, and then moved almost immediately to the bed; the midwife applied gentle traction while I pushed. The cord was cut after pulsing had stopped but before the placenta was out. With my second, the cord wasn't cut until the midwives got there (about an hour later), while the placenta came out within a few minutes.

January 1, 2010 | Registered CommenterNavelgazing Midwife

Hmmm, I can't remember the last time I cut a cord before a placenta was born. Maybe that makes the logistical difference? *thinking*

January 1, 2010 | Registered CommenterNavelgazing Midwife

From doctorjen

So remember that the blood in the placenta is all fetal blood. There is no maternal blood *in* the placenta. If the cord comes off, you might see brisk bleeding from the cord/placental vessels at the site of the cord rupture, but it's fetal blood cells dripping out, not maternal. The maternal bleeding comes from the placental bed, after placenta separates, and is not affected by the attachment or not of the cord. The problem is if the placenta partially or completely detaches, but is still inside the uterus, so the uterus cannot clamp down and slow the bleeding, and now the cord is missing so you have to easily handle to provide traction - mom can bleed quite a bit from that situation, just as from any other postpartum hemorrhage.

The last velamentous insertion I saw ended with me accidentally avulsing the cord, but the placenta was already detached and mostly in the vagina. I was able to reach it with a ring forceps and give it a tug while mama pushed and out it came, no manual removal needed. I think if you avulse the cord and mom is not bleeding you can certainly give a try of just maternal pushing efforts and see if the placenta will come (especially if you suspect it's already detached - by noting a "separation gush" of blood, lengthening of the cord [before you avulsed is of course], rising of the uterine fundus, etc.) If there is brisk bleeding, or you think the placenta was not detached, manual removal is probably the way to go, much as it's not fun for the mother.

Also, I can't remember if this is in this post or a previous one, but another trick for trailing membranes is to use either a ring forceps or a piece of gauze and then twist the membranes gently until they detach - the twisting seems to sort of peel them away gently without shredding them as often happens when you are just pulling on them.

January 1, 2010 | Registered CommenterNavelgazing Midwife

Dr. Jen, this helped loads... thank you for taking the time to help us out. And I think why I was taught to go in right away to get it is in that just-in-case the placenta might be adhered & detached in different places.

And I *love* the term "avulsing" - I've never heard that before. I will try to remember it. Might have to use it in a sentence 4-5 times this week to do so, though.

And, yes! I'm sorry. I forgot about twisting the membranes out. I don't know how I forgot that trick, but thank you for pointing it out.

As always, thanks so much for reading and commenting.

January 1, 2010 | Registered CommenterNavelgazing Midwife

From doctorjen:

Oh my gosh, the typos. I have to get better at typing!

"now the cord is missing so you have to easily handle to provide traction "

Should be "now the cord is missing, so you have no easy handle to provide traction"


January 1, 2010 | Registered CommenterNavelgazing Midwife

As far as upright placentas - I usually have the mama sit on a birth stool. It seems to give all the gravity assistance as squatting or standing but much easier on the wobbly legs and while holding the baby. I also find that the long-drop placenta delivery is not comfortable for most women so I either offer a little traction to ease it out into my hands or if it is coming on it's own or with maternal effort I make sure to either catch it close to her vulva or, at least, bring the placenta bowl up close so that the release is slower.

January 4, 2010 | Unregistered CommenterGillian

Gillian: Oooo, another topic to ask about! Do you use a placenta bowl when delivering a placenta? I think I'll ask in FB.

I use a chux. I used to use a bowl while I was learning, but find it is much neater and softer to use a chux.

I can't wait to hear what women use!

Thanks for sharing your style. I don't have a birth stool because I watched women tear terribly on them... they swelled so much, it just put too much pressure on their bottoms. I know many midwives have stools (another great question!), but I've just never wanted one.

BUT, I forgot about the toilet! Putting a chux under the toilet seat and having mama sitting on the toilet... yes, that would be good, too. Hrrrmmm.

January 4, 2010 | Registered CommenterNavelgazing Midwife

Hi there! I am a pre-medical student preparing for medical school and I just randomly stumbled across this blog. It's a long/funny story but I have to tell you, I have been on your blog for hours because you have made me so fascinated by obstetrics and midwifery.

I just had a few questions, and please forgive me if they sound really dumb. Is a velamentous insertion a condition that occurs often? Is it something that can be avoided during a pregnancy? I read somewhere that it is difficult to tell if vasa previa will occur and you will only know when it actually happens. I was just wondering if this was something that was common and what the causes were.

Sorry if this is random, but I never thought I would be so interested in this field of medicine but your blog is such an excellent place to learn and be curious. :o)

- Future Dr. Mel

May 6, 2010 | Unregistered CommenterShermel

Random is fine and dandy.

A velamentous insertion according to the vasaprevia.org folks, happens in 1% of singleton pregnancies and almost 9% in twins. Vasa previa occurs in 6% of velamentous insertion placentas.

Rarely you will discover a vasa previa before the birth, usually detecting it on u/s, but even that is extremely difficult to see.

Apparently, the most common time to find the vasa previa is when the membranes are ruptured artifically. Great reason to keep your hands out of there!

One of my previous clients lost a baby to vasa previa. A nurse, she knew exactly what was happening and called 911 immediately when her water broke and a flood of blood poured out. By the time she got to the hospital, the baby was gone. She went on to have 2 more homebirth babies perfectly fine. I've never seen it before. (*knock on wood*)

I just had a velamentous insertion with a very short cord (12 inches) and with the slightest tug (because she was bleeding), the cord broke off and her placenta required a manual removal. I've seen it maybe 10 times? The other most recent time was about 4 years ago with twins.

There is nothing a mother can do to prevent a velamentous insertion. No one knows why it happens, but considering all the miracles it takes to make a placenta in the first place, that variation is not the worst nature can do. The development of the placenta is rather random... the mom being a passive bystander. Yet, her lifestyle affects the placenta greatly as the pregnancy progresses. Smoking, poor eating habits, drugs and more all affect the quality of the placenta over the course of growing a baby.

Thank you for the very kind comments about my blog! It certainly has evolved into more of a teaching blog of late. The earlier posts are more introspective, but evolution is a good thing, right?

Hope this helps and that I can keep teaching you (and others!).

May 7, 2010 | Registered CommenterNavelgazing Midwife

My birth last week produced an 'educational' placenta. Water birth, 4 hour labor. Everything went perfectly fine until right after, when my midwife decided that the amount of blood was a bit much. The cord had almost immediately stopped pulsing, so Dad went ahead and cut it. It was obvious something was not quite right, so we didn't wait for it to be cut after placenta birth.

She got me out onto the bed, where it was discovered the cord had detached, hence the lack of pulsation. However my uterus was contracting, and still no placenta. I was given a quick shot of pit to try to stop the bleeding, along with external massage and baby nursing. Still no show, so MW reaches in and tries to get the silly thing out so I can contract. Practically bangs her knuckles on it, it's sitting basically in the bowl of my cervix, totally blocking the exit and not able to slip out due to the combination of no edge in the vagina, and the uterus unable to contract it down. She found an edge and yanked it out, and bleeding stopped right away.

I'd had such a low-lying placenta that as it had detached right after the birth, it had slipped over my cervix. That left the cord at a horrid angle, and even minute amounts of pressure snapped it off at the insertion point. Looking at the (very healthy!) placenta afterwards showed not even a little nub left, totally flat.

The good part is that I didn't bleed out, obviously, but also - this birth happened to take place at a May Day party, and there were several of the local assistants attending who were able to get a good look at something they'd rarely get to see.

May 10, 2010 | Unregistered CommenterGwynne

During the new OB sono and the 20 week sono I look for the placenta location and BOTH insertions of the umbilical cord. Easier to find by far is the fetal end of the cord. This rules out abdominal wall defects and identifies 2 or 3 vessels. I also look for the uterine side insertion of the cord. Between the two sonos or doing another at term you can usually find a vasa previa.

Now with color Doppler it is easier to identify. If you see a bunch of blue and red Doppler pulses around the cervix you have your answer.

One such patient had a suspicion of a vasa previa or velamentous insertion with her second pregnancy. First one was a hospital vaginal birth. We offered an elective cesarean but she was hesitant. She was examined weekly from 36 weeks on and she dilated to 3 cm by 39 weeks. You could literally feel a pulse in the membranes on exam. After discussing these sono and clinical findings the patient agreed to an elective cesarean. We delivered the baby no problem since it was a posterior placenta but there was indeed a velamentous insertion. No second guessing what could have happened! The baby was alive.

This is one of my favorites, we all know what could have happened.

November 13, 2011 | Unregistered CommenterCaptainObvious66

i had a valementous cord insertion of one of my twins. she died at 21 weeks gestation. My surviving twin had a marginal cord insertion. my midwife was surprised almost shocked that she had survived. my question is can valementous cord insertion happen to me again with my next pregnancy? am i more likely to have this happen again? i want at least two more children. Living! anyways. thank you for any replies and reading. Monica

October 30, 2012 | Unregistered Commentermonica

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