velamentous insertion ??

  1. Question here: Can you "feel" a velamentous insertion when you do a SVE?

    Reason I'm asking is this, last night at work I had a pt from he**, and it finally got so bad that another nurse came in to help me. The pt was more anxious than I have ever seen anyone (it all started with the anesthesiologist getting cranky with her on the prior shift when he put in her epidural) and it continued to escalate from there. When I did a vag exam on her I felt sort of a membranous lump on the BOW. Little later, I almost had the patient semi-calm and she said she wanted to push...the other RN checked for me so I could continue eye contact with my pt and keep her calm. She called me out of the room and said she thought it was a velamentous insertion and I should call in the OB asap. So I called the OB, told her what I felt, and told her what the senior RN thought. OB came in. I'm in the room the whole time, so I didn't know a circus was being created...unbeknownst to me or the OB, they called in the Ped, the anesthesiologist, the scrub and had them open for a crash section. The OB did SVE, AROM, and put in internals, and we vag delivered a healthy normal baby. The OB said "you couldn't feel a velamentous insertion." We looked over the placenta and bag afterwards and could not find what either of us felt (and I didn't mention what I felt to the 2nd RN that checked.) So then stuff was started about who called who, what went on, pointing fingers and the whole 9 yards after the fact. The delivery wasn't calm like I was aiming for, with 10 thousand people in the room. Good grief.

    I asked a different OB if you could feel the vel. insert. and she disagreed with the first OB and said you could. What do you guys say?? I've tried to look up info, but can't find anything really informative. I would have to say I didn't think it was what I felt, but didn't want to be naive when a senior person said it was. Anyone else experience this or anything like it, or have info??
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  2. 5 Comments

  3. by   SmilingBluEyes
    i have never felt such a thing doing an SVE. but i have only been in ob for 6 years.
  4. by   Rissi-Roo
    I would think that you'd be able to feel the vessels in the membranes upon SVE... I myself have not.... He should have really made sure that the placenta was not Velamentous prior to AROM b'c he could have caused broken vessels and the baby could dies due to blood loss. I don't know how you WOULD be able o DX such a problem OTHER than SVE unless upon US you can see pulsations in the membranes. I don't think I"D want to be the one sticking MY fingers into one of thoses vessels though... YIKES...... Glad it was a good outcome .. but that is really a thinker.....
  5. by   L&D.RN
    I would think it would also depend on where the insertion was if we could feel it or not. The OB was positive from the moment she felt it that it wasn't, but when she asked for the amni-hook, neither of us really wanted to hand it to her just in case it was, we were still in the LDR and the OR was across the hall...we were thinking of the few minutes we would have if it truely were that.

    Anybody else have info on this??
  6. by   OB4ME
    Well, I would imagine that one would feel pulsing of blood vessels in velamentous insertion...but I certainly wouldn't want to go there because of the risk.

    Velamentous insertion that crosses the cervical os is actually called vasa previa. I've always seen that diagnosed during prenatal care via u/s...and never during sve. I have also read that they diagnose it in advance via abnormal AFP and HCG levels. Of course, those pts have always been c/s in my experience.

    I guess that this is a small risk one might see, particularly in a pt without prenatal care? But, I would think you'd have to have a pretty questionable OB to miss that on a pt with full prenatal care.
  7. by   imenid37
    here's some info. i found on the web about this topic.
    http://www.vasaprevia.com/

    Vasa previa is a rarely (1:3000) reported condition in which fetal blood vessel(s) from the placenta or umbilical cord crosses the entrance to the birth canal, beneath the baby. The condition has a high fetal mortality rate (50-90%). This can be attributed to rapid fetal exsanguination resulting from the vessels tearing when the cervix dilates, membranes rupture or if the vessels become pinched off as they are compressed between the baby and the walls of the birth canal.

    The aberrant vessels result from:

    Velamentous Insertion of the Umbilical Cord

    Pathology

    Little is known about the cause of these conditions. The most widely recognized theory is called trophotropism. According to Dr. Harris Finberg, trophotropism in placental tissue can be compared to the tendency of a plant to lean towards the sun to get the light it needs to survive. Since the lower segment of the uterus is not as nourishing as the upper segment, the placenta will grow upwards to reach more nourishing tissue.

    In bilobed/succenturiate lobed placentas, the placental tissue may erode from the cervix, but vessels don't. With velamentous insertion of the cord, the mass may erode and the new growth may occur away from the location where the cord inserts, connected by unprotected bloodvessels.

    Vasa previa often appears together with a low-lying placenta or Placenta Previa, where the placenta is in front of the birth canal.

    Warning Signs

    Vasa previa might be present if any (or none) of the following conditions exist:

    bilobed placentas

    succenturiate-lobed placentas

    low-lying placentas (may be caused by previous miscarriages and/or curreting of the uterus (D&C), which causes scarring in the uterus)

    pregnancies resulting from in-vitro fertilization

    multiple pregnancies

    Management

    When vasa previa is detected prior to labor, the baby has a much greater chance of surviving. Since vasa previa is rarely detected prenatally (an estimated 70-90 percent of cases are undiagnosed), survival rates are not available.

    Vasa previa can be detected during pregnancy as early as the 16th week of pregnancy with use of transvaginal sonography in combination with color Doppler.

    When vasa previa is diagnosed, elective delivery by cesarean before labor begins can save the baby's life. Exactly when to schedule the c-section should be decided by the patient and her doctor. Ideally, it should be performed early enough to avoid an emergency, but late enough to avoid problems associated with prematurity.

    Steroid treatments can help accelerate the maturation of the baby's lungs. An amniocentesis can assess fetal lung maturity.

    When there is bleeding during pregnancy, investigation for the source of the blood is necessary. If the blood is determined to be maternal (from the mother), the baby is not in danger. If the blood is determined to be fetal (from the baby), immediate action must be taken to assess the condition of the baby.

    i hope this helps. interesting subject. i think you did the right thing, especially when you consider what could've happen if your suspicions were true.

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