Podcast Summary: Dr. Chapa’s Clinical Pearls

Episode: Funic Presentations at Term: CS or Not? Timing?

Date: February 20, 2025
Host: Dr. Sam (Dr. Chapa)
Audience: Medical students, residents, and practicing healthcare providers

Episode Overview

This episode tackles the challenging question of what to do when a funic presentation (umbilical cord presenting at the cervix) is seen at term on ultrasound. Dr. Sam addresses the rarity, risks, and evidence (or lack thereof) around funic presentation, especially as it pertains to the risk of umbilical cord prolapse and the difficult decision regarding timing and route of delivery. The episode emphasizes individualized, shared decision-making due to the absence of universal guidelines.

Key Discussion Points & Insights

1. Defining Funic Presentation and Its Clinical Significance

• Funic Presentation Explained:

  • Occurs when the umbilical cord is the leading structure at the cervix, seen typically in ultrasound.
  • Common and transient before 32 weeks; most cases resolve spontaneously.
  • Persistence beyond 36 weeks is worrisome due to the increased risk of cord prolapse.

• Umbilical Cord Prolapse:

  • A rare and unpredictable obstetric emergency that generally mandates urgent C-section.
  • Main danger is fetal hypoxia due to cord compression.

2. Distinguishing Funic Presentation from Vasa Previa

• Vasa Previa:
  • Involves fetal vessels crossing the cervix; rupture can cause rapid fetal exsanguination.
  • ACOG Committee Opinion 831 includes vasa previa as an indication for late preterm/early term delivery (34–37 weeks).
• Funic Presentation:
  • Not in ACOG’s table of late preterm/early term delivery indications.
  • Management less clear, more nuanced—no standardized protocols.

Quote
“While Vasa Previa is in that table of medically indicated late preterm and early term deliveries, funic presentation is not. So let's just say it right here. There is no set protocol… It's a lot of individualized care and our favorite three words. Say it with me now: shared decision making.”
— Dr. Sam (09:03)

3. Risk Factors and Prevalence

• Rare Phenomenon:

  • Persistent funic presentation at term is rare, around 0.01 to 5 per 1000 pregnancies—similar to the rate of cord prolapse.
  • Cord prolapse is more likely with risk factors: polyhydramnios, malpresentation, unengaged fetal head, multiparity, and rapid labor.

• Risk with Funic Presentation:

  • Increased risk of overt cord prolapse if the funic presentation persists at term.

4. Reviewing the Evidence on Outcomes

• Cord Prolapse Management (“Decision to Delivery” Interval):
  • Intuition suggests speed is critical, but limited study data challenge this.
• Key Research Discussed:
  • A 2023 BMC Pregnancy and Childbirth study: No correlation between decision-to-delivery interval and arterial cord pH across fetal heart rate patterns, though sample size was small.

Quote
“There was no correlation of cord arterial ph with decision to incision time based on the fetal heart rate pattern.”
— Dr. Sam (17:49)

• A 2021 study by Wong et al. did find that bradycardia to delivery interval was significant; in the case of bradycardia, urgency remains crucial.
• Takeaway:
  • Fast action is still best practice, especially with bradycardia.
  • Data interpretation limited by rarity and small sample size.

5. Real-World Management Dilemmas: Timing and Route

• Two Main Management Options:

  1. Scheduled Cesarean Section at Term
     • Especially reasonable if risk factors are present (multi or grand multiparity, advanced dilation, polyhydramnios, rapid labor history).
  2. Expectant Management with Close Monitoring
     • Suitable for lower-risk individuals (nulliparous, well-applied fetal head, no significant risk factors).
     • Induction of labor may be possible if cord resolves by term (usually by 39 weeks).

• No Single Best Practice:

  • Both approaches are acceptable; documentation and patient education are crucial.
  • Shared decision-making is emphasized.

6. Data on Outcomes with Funic Presentation

• Limited and Outdated Evidence:
  • References a 2003 study (n=13):
    • ≈50% had uncomplicated vaginal births.
    • ≈50% had cesarean for malpresentation or cord issues.
• Association Noted:
  • Increased malpresentation when a funic presentation is present.
• Recommendations:
  • If funic presentation persists by 39 weeks and risk factors are absent, waiting until 39 weeks for scheduled approach is probably reasonable.
  • C-section before 39 weeks not generally indicated unless additional risk factors present.

Quote
“There are no zip, nada, high quality data on which to base a strong recommendation for or against a Schedule C Section when a funic presentation is noted in a non laboring patient with a cephalic presentation at term.”
— Dr. Sam (23:41)

Notable Quotes & Memorable Moments

• On the Origin of “Funic”:
  “Funic is real... Funis in Latin means rope or... a thick cord. Hello. So funus actually makes sense, but it is a kind of a weird word.”
  — Dr. Sam (06:29)

• Humor and Medical Culture:
  “You remember the movie Tommy Boy?... I can't find any of the robes. Robes. Roads. Anyway, so Chris Farley and... Tommy Boy, not a sponsor.”
  — Dr. Sam & Guest (07:36–07:58; 23:18–23:41)

• Emphasizing Individualized Care:
  “Nobody should go, ‘I can't believe you did a C section for a funic presentation.’... because that is exactly what half of the expert opinion says to do, obviously. The other half is, ‘Well, hold on, play it by ear.’”
  — Dr. Sam (09:10)

• Clinical Pearl:
  “If the cord is just by the baby's side, but the baby's head is actually presenting, I'm okay with that. Because occult prolapses, baby alongside the fetal presenting part usually will move out of the way. If there's loops of... cord by the internal cervical os that looks like a coiled snake, that's less likely to move out of the way.”
  — Dr. Sam (29:50 approx.)

Timestamps for Key Segments

• 00:00–03:00: Introduction to funic presentation and why it matters
• 06:29–09:00: Distinction between funic presentation and vasa previa; etymology of “funic”
• 09:00–12:00: Absence of universal guidance; shared decision-making emphasized
• 13:30–18:45: Discussion on cord prolapse evidence, “decision to delivery” interval
• 23:41–26:30: Reviewing the (limited) data on management and outcomes
• 29:10–31:00: Practical advice/algorithms and making real-world decisions

Key Takeaways & Practical Algorithm

• Persistence of funic presentation at term is a red flag for possible cord prolapse, but the management pathway is not standardized.
• Both planned C-section and expectant management are acceptable—use detailed counseling, risk assessment, and shared decision-making.
• Most experts recommend holding off on delivery until 39 weeks unless risk factors are present.
• Use transvaginal and color Doppler ultrasound for proper diagnosis and monitoring.
• If funic presentation resolves by 39 weeks, induction is reasonable; if not, C-section is a safe choice, particularly when risk factors exist.
• Always document counseling and rationale. Shared, individualized care is central in these cases.

Conclusion

Dr. Sam emphasizes embracing ambiguity where data are lacking, focusing on patient-centered, shared decision-making for rare pregnancy complications such as funic presentation at term. The risk of cord prolapse is significant but not fully quantifiable; thus, each case must be approached with practical caution, careful monitoring, and individualized care.

Final Pearl:
“There is no one recommendation. You do what you do as long as you give the patient good education. You document. But whether you do a planned C-section or an induction of labor with no formal guidance, probably okay. Knowing that most would defer to 39 weeks...”
— Dr. Sam (31:00 approx.)