Velamentous umbilical cord insertion and vasa previa are rare ultrasound findings during pregnancy but carry an extremely high morbidity and mortality without prenatal diagnosis. Increased risk is associated with in vitro fertilization, multiple gestation, velamentous umbilical cord insertion, and vasa previa. At present, the recommendations continue to be based on a risk approach with ultrasound as the gold standard for diagnosis. The evaluation is improved with the addition of transvaginal ultrasound and Doppler flow. With known diagnosis, fetal growth surveillance is recommended due to increased risk for growth restriction. Current recommendations for vasa previa are cesarean delivery between 34 and 37 weeks. Inpatient management with known vasa previa is still unclear and a patient centered decision.