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Dr. Sam (6:29)

So I told one of our it. One of our media students who kind of helps with this sometimes, said, hey, we're going to cover funic presentation. And she said, you made up that word. I'm like, what? Funic is a real. Funic is real, right? Funusitis. Funic. And she cracked up. She's like, I. I don't believe it. You know, that's why it's always important to go back to, like, either the Greek or the Latin, the origins of words, because it's pretty clear what that means in Latin. That's funus. Funis. Funis in Latin means rope or. Or a thick cord. Hello. So funus actually makes sense, but it is a kind of a weird word. Fun. As I always remember. You remember the movie Tommy Boy? That was in the 80s. It was Chris Farley, David Spade, and they're driving this jank old car down the highway and, like, their carbon exhaust is all backed up, so they're all getting carbon monoxide. Goofy. And one of the carriage, I think David Spade goes, oh, I can't find the roads on this map. And they start cracking up at. Why is it roads? It's actually roads, but it's just like funis. Yeah, it actually is a real word.

Podcast Guest or Co-host (7:36)

Robes on it. Rogues.

Dr. Sam (7:41)

Roots.

Podcast Guest or Co-host (7:43)

I can't say that word.

Dr. Sam (7:45)

Roads.

Podcast Guest or Co-host (7:52)

Rads. That's a total weird word, isn't it?

Dr. Sam (7:58)

That is a freaky word. Fewness. Yeah, that is kind of a freaky words. But I also remember that I can't find any of the robes. Robes. Roads. Anyway, so Chris Farley and. God bless him and David Spade and Tommy Boy, not a sponsor. So fewness. Yes, it is a thing. Super obvious and also super scary, similar to Vasa Previa. So let's just knock out vasoprevia, which is not what we're talking about, but similar in the same vein as horrifying because it has to do with vessels crossing the internal cervical os. Of course, the umbilical cord is a combination of maternal and. Or. Oh, my gosh, maternal and. Or fetus. Venus and arterial is what I was trying to say. Whereas Vasa Previa, if those ruptures, if those vessels break, it's a quick way for fetal exsanguination. Not that rupture of the cord isn't. But vasoprevia is specifically worrisome because of the quick blood loss that can happen through the child. So very quickly, Vasa Previa is in ACOG's Committee Opinion 8, 31. That is an indication for late preterm early term delivery. And according to the college, you can be out with diagnosed vasoprevia and you need color Doppler to see that. In addition to trans vaginal ultrasound, you can be out at 34 to 37 and zero days. Right? You got to get out because you don't want her to rupture. If there's rupture, that's bad. Whereas if you had a funic presentation and you have rupture but you're only like 1cm dilated or even up to 2 maybe, then it's a very low chance that the entire cord or a loop of cord is going to come out just based on your amount of dilation. So you see why Vasa previa is similar to funic presentation yet more acute. That's why you can be out at 34 to 37 in zero, according to Committee Opinion 831. However, and here's a catch, guys, while Vasa Previa is in that table of medically indicated late preterm and early term deliveries, funic presentation is not. So that's 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. Share decision making. Because it depends on a lot of things. And we're going to get into those factors where you make a practical plan here at the end of the podcast. All right, so let me just say it in case someone's thinking, well, I'm just going to section that. That's totally fine. No one would question that. Nor should you ever go to peer review because you did a primary section with a funic presentation that persists after whatever 38 weeks because there's no one set criteria of when you pull the plug on that, that is totally reasonable, especially in a multi gravita with rapid labors. Does that make sense? So nobody should go, I can't believe you did a C section for a Phoenix presentation. Of course I did, because that is exactly what half of the expert opinion says to do, obviously. The other half is, well, hold on, plate by ear. And it depends on a lot of other factors, like where it is if the baby's head can actually be presenting down. If the baby's head Pushes the cord out of the way with fundal pressure called Halus maneuver. So there's all of these things that can be potentially taken into account versus a very conservative move of I'm just out, which is totally fine if the patient has shared decision making. So very quickly, again, I'm going to give you these practical approaches to how to end up with one of those two options. Option A is, look, we've checked every week, confirmed it was a transvaginal ultrasound. That cord is right there and it makes me nervous. But you have prima gravita. You know, you're not dilated yet. We have time to wait and plate by ear, that's fine. Or you could say we're just going to be out because it makes me nervous and there's too much to risk. Primary section done. Fine. Notice I didn't tell you the timing of that because we're going to get that in a minute, or to say, look, you have it. I'm going to give you watchful criteria. If you think you broke your bag of water, think you're labor, you got to come in quickly. All of those are acceptable based on your level of comfort, based on the patient's distance from a work facility, home and or other to the hospital. All of these things come into play because, guys, here it is. There is not one generalized agreement or recommendation as to the timing of delivery or the mode of delivery. And I'm going to make this clear at the end. I'm going to give again, give you a practical algorithm here. But I have to say there is no uniform criteria between acog, rcog. Nice. It doesn't pretty much anywhere because I've looked, because it's so individualized, because of the unstableness of that presentation. Now, unstableness meaning it can go away, which is good, or unstableness because it can come out the vagina, which is not good. Y' all get this. So very, very complicated. So those are our two questions. When to do it and how to do it. Vaginal or C section? We'll get into that at the end. Very interesting. Very complicated. Thankfully, umbilical cord prolapse, as we mentioned in the intro, pretty rare. Like one up to five, maybe six per thousand based on who you read. And the levels of funic presentation is completely unknown because that means everybody would have to have a late pregnancy ultrasound or at least after 37 weeks to see if it's down there. And we just don't do that. Most of these are found incidentally during vaginal exam, intrapartum or because of A fetal heart rate abnormality, typically either big variables or after rupture of membranes from which polyhydramniosis is a risk factor. Of course, if there's a fetal non descended fetal head, in other words, non engaged, that's a risk factor. All of these things increase the risk of cord prolapse, and it is horrifying. All right, now intuitively, listen to this, guys. Intuitively, what would you think? Oh, my gosh, the cord's out of the vagina. That's not good. Because the cord shouldn't beat the kid for delivery. It's basic rule in obstetrics. So we got to get out. And so the quicker that we get out, called the decision to incision, you would think intuitively that would be better for the child. Makes sense, right? Well, it totally makes sense, except that may not be exactly what happens based on very limited data. So let me explain, because this was out just in 2025 in BMC pregnancy and childbirth. Guys, this is just like a year and a half ago. Okay? Now the reason that we don't have a lot of data is because again, one to six per thousand, most of these are occult, meaning it's by the baby's head. It's not really an issue, versus overt, truly clinical, which is, oh, my gosh, I'm feeling the core through the vagina. That's, that's the other extreme. So this doesn't happen a lot. All right? But in this 2023 publication from BMC Pregnancy in Childbirth, a very interesting report. This was a database query. This was a retrospective study. It was a tertiary medical center. And look how long they had to look for. Right? From 2008 to 2021. So 2008 to 2021, guys, that's a lot. Again, because it doesn't happen very frequently. Now, this wasn't about funic presentation. Remember this? This is about true cord prolapse. And the idea for this study is, does it make a difference? Very easy. From once we find a cord prolapse from incision, from decision to incision time, our baby's outcomes, neonatal outcomes, improved at all. Right? And then divided the tracing here based on what they saw in the monitor into three categories. One, bradycardia, which is typical. Second, is some other deceleration without bradycardia. Meaning like variables or three, wow, you kind of find a cord. But oddly enough, the kid's heart rate is still reassuring. All right, so those are the three buckets, all in patients who are already found to have cord prolapse. Let's Take a look at those who had brady. Let's look at those who had D cells without brady. And then those who had a reassuring heart rate. Right? Short of it is very easy because remember, our commitment here is to try to do this quicker. The outcome was is decision to incision based on those three fetal heart rate patterns. Is any those linked to fetal acidosis? Meaning you find it and then you get out with C section. Well, kind of disappointing and interesting at the same time, but there's a big asterisk here, so. Listen to this quote. There was no correlation of cord arterial ph with decision to incision time based on the fetal heart rate pattern. End quote. What? Now, that doesn't make any sense, because intuitively, what do we say? Oh, hey, the cords in the vagina. Well, I'm gonna get my coffee. I'm gonna put the medical student here to hold the head up. You'll be fine. You'll be fine. Don't worry about it. And then we're gonna do a section, you know, when my other partner finishes the one that's already in the or. Nobody does that because it's an obstetrical emergency. You go, oh, cord in the vagina, head down. Let's refill the bladder or do something. Let's try to elevate the fetal head, not touch the cord so we don't throw the ve to vasospasm. And we're gonna go, like, in the next five minutes to the OR to some or. If all are busy, you gotta get this kit out. That's the usual response, but in this 2023 publication, there was no correlation of arterial core ph from decision to incision interval. What is going on there? And I should be clear, when I'm saying incision to decision to incision, it's actually decision to delivery. Right? Like incision, as in terms of hysterotomy, not skin incision. So to be clear, decision to delivery, that's the actual interval that they're looking at. I just get so stuck. It's so easy to say decision to incision, but it is from decision to delivery based on those three categories, right? Brady. D cells without brady are reassuring. All right, so that's it. In general, they found no real correlation. But. But here's why you have to look at all of the data, because the authors explain it. They're like, yeah, I can't explain, especially with brady. I mean, you'd figure with bradycardia that we'd find something. But here's why. This is why. This is Reassuring. We should all look at this and go, phew. Seems like we dodged a bullet there. However. However, very small sample size. So it's possible that it is really bad. They just didn't have enough numbers to show that. All right, so you see how tricky this is. So let me read you this directly from what the authors say. Quote, we could not demonstrate a correlation between the decision to delivery interval and cord arterial physical in any of the fetal heart rate tracing groups. End quote. All right, we've already said that. That's fine. But here it is. Quote, in cases of fetal bradycardia in general, it is intuitively clear that the decision to delivery interval is crucial. Yeah, so they say, hey, we didn't find anything, but we really should have found something. Y' all follow me here. So listen to this. Quote, Accordingly, in a cohort of women with umbilical cord prolapse, Wong et al. So here they're referencing a study from not long ago. Guys, this was 2021. Out of ACTA Obstetrics and Gynecology Scandinavia took a look at this publication. This is Wong et al. W O N G. Wong et al. So they're explaining here what they found. Quote, Wong et al. Found a significant correlation between cord arterial ph and the bradycardia to delivery interval. But significance was not maintained when the fetal heart rate monitoring demonstrated decelerations only. End quote. In other words. All right, seems to be that the worst is brady. That makes sense. No surprise. However, if it's just kind of like deep variables, you can buy more time knowing, of course, that no one's going to lollygag and go according to a 2023 study. I can take my time. Doesn't really matter. Decision to delivery. I'll get to it when I get to it. That's nonsense. And you'd probably be written up by peer review. If you have a core prolap, it is a recognized obstetrical emergency in the same categories of quick action necessary as eclampsia, postpartum hemorrhage and shoulder dystocia. All right? So you gotta act fast. I'm just telling you how limited and how confusing this data is. Because if you just looked at the 2023 publication, like decision to delivery doesn't matter. No, no, no, no, no, no. That's because it's likely a very small sample size issue. So these very authors from 2023, here's what they say after reviewing the Wong data in 2021, right? Quote, Our findings. Here it is, guys. That the decision to delivery interval did not significantly correlate with neonatal neonatal acidosis, even in the fetal bradycardia group. Here it is. This might probably be a consequence of the very rapid response to the cord prolapse and the very small size of the bradycardia group. End quote. In other words, well, you didn't make much difference because you got the hell out of There you go. Oh my gosh, the kids. Kids in trouble. The cord is leaving the nest before the child. You gotta get out. So that is why decision to delivery likely didn't matter because the interval was pretty darn short. All right, everybody. So now let that sit in for a minute knowing that funic presentation happens. Funic. It's a funny word. Few unit presentations happen. Let's take a quick break. We come back, we're going to get into these two questions, when to deliver and is a C section needed? We'll be right back. Hey, we're glad you're part of our podcast community. You're listening to Clinical Pearl.

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Podcast Guest or Co-host (23:18)

It's got all those robes on it. Rogues.

Dr. Sam (23:24)

Ro.

Podcast Guest or Co-host (23:27)

I can't. I can't. I can't say that word. Roads, Row, woods. That's a total weird word, isn't it?

Dr. Sam (23:41)

That is a freaky word. All right, I know it's childish, but Tommy boy. Oh, my goodness, just slapstick. My wife hates it because it's so slapstick. It's kind of silly, but the message is pretty heartwarming. It's the same with the Adam Sandler movies. I can't get her watch any of those. She goes, I'm losing IQ points watching this. I'm like, that's exactly the point is to be dumb and silly and just laugh at stuff. Oh, my goodness. Grown ups. Great movie. Anyway, so, yeah. Oh, was it, Was it. Was it Tommy Boy or was that Black Sheep? I don't remember. Anyway, so whichever was somebody please don't send me a message and correct me that that was. I think it was Black Sheep. Tommy Boy, Is it the same? I don't know. Boy. None of this is relevant. None of that is relevant. Back to what we're talking about. Funic presentation, super complicated. If you find that after 32 weeks, you gotta keep looking. Gotta keep looking. And the question is. All right, well, damn. It's 36 weeks and that cord is still down there. What to do, guys? This happened to us. It is real world. Because the last thing you want to do is go, don't worry about it, move out of the way, and then she has a cord prolapse and then they come back and go, that's a number one modifiable risk factor. So, yes, you have a chance to intervene. The question is when and how. And unfortunately, the answer to both of those is we do not know. So let me just say it real clear, okay? So right now, here's a clinical pearl and we're going to dissect into this and we're going to be done. 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. So we have no guidance. So don't ever let somebody tell you I can't believe you're going to section that. The reason you can is because there's no guidance against it. And the reason that you can say, well I think I'm going to let my patient labor for that is because there's no guidance against that either. There's a lot of individualized care here, guys, and a lot of shared decision making. Okay, so it's interesting that there is a chance that the cord just moves away, but it's not a really high chance. And remember, we don't have a lot of data. Like the last data set that did this was like 20 years ago, guys. I looked for it and the best I could Find was in 2003 in gynecology Obstetrics investigations who looked at this and it was an N over a period of years. An n of 13, that's 1, 3. So these were patients not in labor. These were antepartum who got to late term. I'm sorry, got to early term, like you know, 37, 38, up to 38 and 6 and found a. And they had a third trimester ultrasound with a funic presentation. So watch this. Look at these numbers. So here's the odds based on 20 year old data because we just don't know what happens to these because most people just get out like I said, others, maybe it's an occult prolapse and you don't even know as a kid delivers with some variables. So there's a lot of ambiguity here. Okay, so remember, two options. I'm just going to section before anything happens or I'm going to wait and see what happens. Both are acceptable based on your level of comfort and patient factors. Obviously if she has, if she's a grand multi Paris patient with precipitous labor who's already at 2cm and has poly, you probably want to section that. I know it sucks to section multigravida, but the chance of her having a cord prolapse now has a hazard ratio much higher than a nulla gravida with normal amniotic fluid and well applied fetal head. It's just that the cord is, is in the way in that situation. Do you all see the differences here? Okay, so a box A, I'm just going to section everybody. Box B, I'm just going to see how it goes. Both are acceptable with shared decision making. But look at this data, end of 13, they're gonna start wrapping this up. End of 13 from 22,003. 20 years old, guys. Okay, now what? 22 years old. I guess out of gynecology, obstacles, investigations of the end of 13, 6. So almost half had an uncomplicated vaginal birth. Actually, five were vertex and one was breach. Okay, so six uncomplicated, it's not bad. Depends how you look at that. 50 things are going to be okay. 50%. Something happened and. And that's the worrisome part. Okay, So I don't know how you look at that. I look at that as. As a coin toss, and I'm not happy with that. If it was 80% who had an unsuccessful. Who had a successful vaginal birth, no issues, then that's different. This literally was 50% ish in this study. So of the 13, six had uncomplicated vaginal births, six had cord presentation with some kind of malpresentation, who had the C section like they were breech, and one was transverse. So that's the six. So they had a straight section, and then one had a cesarean section for failure to progress. So of the 13, only one had a C section for a non funic cause. Y' all get this. She just got stuck in labor. So 50% ish, no problem. The others have some kind of fetal malpresentation. And why is that linked? Because there is some kind of association between phenic presentation and fetal malpresentation because the cord's in the way. Homies. Okay, so if the cord is down there, head can't really get down there. Well, so there is a loose association between the two. Anyway, you take from that what you will. Six uncomplicated, six had a C section at the time of delivery scheduled. Okay. Because of fetal malpresentation and the cord. And then one had a C section for failure to progress. So we don't know. There is no one best way to do this. It is possible to deliver these patients vaginally under a very controlled environment. I would definitely bring them in if they have not labored by 39 weeks with shared decision making. However, guys. However, doing a C section for these patients at term is not a problem. The question is, is it okay to do that at 37? Should we do it a little earlier at 38? And there's no data. Most people would say, let's just wait to 39 and be done. So bring them in at 39 weeks. If you do a transvaginal ultrasound and it's still there, then that's why you have a schedule section. And if it moved out of the way, then you can do an induction. But nobody knows. Nobody knows when is the best time to do this delivery. However, based on expert opinion, it does seem that you can probably wait until 39 weeks. This is why. Guys, listen to this. We're about to be done here. This is why it's not listed on the medically indicated late preterm. Okay, so that's 34 to 36 and 36 and early term, which is 37 up to 38 and six deliveries. It's not referenced in that meaning. By implication, if phenic presentation is not listed, then potentially you don't have to do a late preterm early term delivery. You can wait until term if. Here it is, guys, if. Here's the asterisk. If these factors are not present, if she doesn't have precipitous labor, there's no advanced cervical dilation, there's no history of polyhydramniosis. That makes sense. This is why it is shared decision making. I'm very comfortable offering these patients a C section if they want to, and I can. I also tell them there's a chance you can deliver this vaginally. And it also depends on what the cord looks like. If it's 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 bowel, loops of cord by the internal cervical os that looks like a coiled snake, that's less likely to move out of the way. Does that make sense? So 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 plan C section or an induction of labor with no formal guidance, probably okay. Knowing that most would defer to 39 weeks since it is not referenced in the medically indicated late preterm and early term delivery guidance. All right, podcast family, I hope you found that interesting because we sure did when we found this. Oh, FYI, in our case, it moved out of the way, so dodged a bullet. Thank goodness we were not part of the one to six per thousand chord prolapse of some form with the flag of a Phoenix presentation. All right, podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Now that we've done all that, let's take it home, Podcast family. We really are thankful for you. We hope you enjoyed this episode. We'll see you next time on Clinical Pearls. Sam.