SHOULDER DYSTOCIA & UMBILICAL CORD PROLAPSE

Nur Haizum Binti Mohamed ArisO&G CME, Aug 2 2012

SHOULDER DYSTOCIA

Definition Prevalance Risk factors

HELPERR Complication

Prevention Simulation

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DEFINITION Vaginal cephalic delivery that requires

additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed.

An objective diagnosis of a prolongation of head-to-body delivery time of more than 60 seconds

Occurs in 1% of births (normal birth weight) and up to 10% of births of infants of higher birth weight (>4500g) 4

PREVALANCE Studies involving the largest number of

vaginal deliveries (34 800 to 267 228) report incidences between 0.58% and 0.70%

Macrosomia shows the strongest correlation with shoulder dystocia Occurs more often with gestational diabetes and

twice as often in postdate pregnancies In women without diabetes, labor induction for

suspected fetal macrosomia does not lower the rates of shoulder dystocia or cesarean delivery

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There is a relationship between fetal size and shoulder dystocia but it is not a good predictor: partly because fetal size is difficult to determine

accurately large majority of infants with a birth weight of

≥4500g do not develop shoulder dystocia. Equally important, 48% of births complicated

by shoulder dystocia occur with infants who weigh less than 4000g

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RISK FACTORS FOR SHOULDER DYSTOCIA

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WARNING SIGNS Failure of restitution “Turtle Neck Sign”

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SHOULDER DYSTOCIA H Call for help E Evaluate for episiotomy L Legs (The McRoberts Maneuver) P Suprapubic (not fundal) pressure to

disengage the anterior shoulder E Enter maneuvers R Remove posterior arm R Roll the patient over

* Make sure to note start time of dystocia and delivery time 9

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MCROBERTS AND SUPRAPUBIC PRESSURE McRoberts maneuver - flex the legs toward

the patient's chest to open the anterior posterior diameter of the pelvis

11Figure 1. The McRoberts' maneuvre

SUPRAPUBIC PRESSURE (RUBIN I) Suprapubic pressure – apply a “rolling”

pressure over the fetal anterior shoulder on mother’s lower abdomen so that the shoulder will adduct and pass under the symphysis

12Figure 2 Suprapubic pressure

RUBIN II MANEUVER Hand is inserted into the vagina Digital pressure is applied to the posterior

aspect of the anterior shoulder Push towards the fetal chest, rotating the

shoulders forward into an oblique diameter.

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WOODS SCREW MANEUVER While maintaining pressure as above in the

Rubin II maneuver, a second hand locates the anterior aspect of the posterior shoulder.

Apply pressure to rotate the posterior shoulder.

Attempt delivery once the shoulders move into the oblique diameter.

If unsuccessful continue rotation through 180° and attempt deliver

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REVERSE WOODS SCREW MANEUVER Apply pressure to the posterior aspect of the

posterior shoulder Attempt to rotate it through 180° in the

opposite direction to that described in the Wood Screw maneuver

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POSTERIOR ARM Pass hand into the vagina over the chest of

the fetus to identify the posterior arm and elbow.

Apply pressure to the antecubital fossa to flex the elbow in front of the body, and/or grasp the posterior hand to sweep the arm across the chest and deliver the arm.

Rotate the fetus into the oblique diameter of the pelvis, or through 180°, bringing the anterior shoulder under the symphysis pubis

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Figure 3 Delivery of the posterior arm

SHOULDER DYSTOCIA Do not persist in any one maneuver if it is not

immediately successful. Try another maneuver. NEVER apply fundal pressure - this can

further engage the anterior shoulder under the pubic bone.

Uterine relaxants (nitroglycerin or general anesthesia with halothane) may be needed to overcome the expulsive forces of the uterus.

Rotation of the patient onto all fours may also facilitate delivery by increasing the pelvic diameters and allowing better access to the posterior shoulder. 18

In extreme situations try:• Intentional clavicle fracture• Symphysiotomy Rarely• Zavanelli Maneuver

Document severity of shoulder dystocia and maneuvers, management and timing

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DON’T 3 P’s:Pushing (on the head)Pulling (on the fundus)Pivoting (sharply angulating the head,

using the coccyx as a fulcrum)

Some add the 4th P:Don’t Panic

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COMPLICATIONS

• Postpartum hemorrhage

• Rectovaginal fistula • Symphyseal

separation or diathesis• Third or fourth degree

episiotomy or tear • Uterine rupture

Psychological trauma

• Brachial plexus palsy • Clavicle fracture • Fetal death • Fetal hypoxia, with or

without permanent neurologic damage

• Fracture of the humerus

Maternal Fetal

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PREVENTION Control maternal weight gain Optimize glycemic control in diabetics If concern for LGA offer C-section if

efw>5000 gm in non-diabetics, if efw>4500 gm in diabetics

In high risk patients, the head and shoulder maneuver can be used (delivery of head and shoulders in one move without suctioning the nasopharynx after delivery of the head)

Be prepared - call for help23

Shoulder dystocia simulation video

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CORD PROLAPSE25

Definition Types Risk

Diagnosis Management

Prevention

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DEFINITION Cord prolapsed: descent of the umbilical cord

through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes

Cord presentation : presence of the umbilical cord between the fetal presenting part and the cervix, with or without membrane rupture

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TYPES Occult prolapse: the prolapsed cord is

contained within the uterus usually by the side of the presenting part unnoticed

Overt prolapse: the cord protrude into the vagina

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RISK FACTORS

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DIAGNOSIS Appearance of loop of umbilical cord

Pulsation of cord on V/E

Suspect in unexplained fetal distress Variable decelerations Prolonged bradycardia

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DELIVERY- IS BABY VIABLE? IUD - Aim for vaginal delivery Alive - aim for most expedient delivery

method Instrumental delivery – only if os full and

expecting a relatively easy and fast delivery

Otherwise crash Caesarean sectionemergency CS, regardless of indications, should be performed within 30 minutes from the time decision was made

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MANAGEMENT Call for help Give explanations to the woman and her

birth partner Move the woman into the knee-chest or

exaggerated Sims’ position (see Appendix A) If syntocinon augmentation is in progress,

discontinue immediately Elevate the presenting part digitally or by

bladder filling

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Avoid excessive handling of umbilical cord. If cord is presenting outside of vagina, it can

be replaced gently or wrapped in warmed saline-soaked gauze to prevent reactive vasoconstriction.

Continue to assess fetal heart rate Expedite the birth of the baby Transport the woman to the operating

theatre, if required

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RELIEVE CORD COMPRESSION Replace cord gently into vagina Place hand in vagina, cord cradled in palm Tips of fingers elevating presenting part Mother in trendelenburg or knee-chest position Fill bladder (16 Foley catheter, 500-800ml of

saline) Several studies have shown reduced perinatal

mortality with elevation of the presenting part by bladder filling.

Allow time for anaesthesia & transfer of the woman to the secondary or tertiary unit from other settings. 37

Continuation of relieving of cord compression during Induction of anaesthesia Placement of sterile sheet LSCS

Remove hands only when the surgeon tells you!

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Trendelenberg position

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PREVENTION

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REFERENCES

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RCOG Green-top guideline No. 42 / 2nd edition/ March

2012/ Shoulder Dystociahttp://www.rcog.org.uk/files/rcog-corp/GTG42_150713.pdf

Green-top Guideline No. 50/ April 2008/ Umbilical Cord Prolapse http://www.rcog.org.uk/files/rcog-corp/uploaded files/GT50UmbilicalCordProlapse2008.pdf

http://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country/documents/Umbilical%20Cord%20Prolapse.pdf