Presented by Dr Haizum

1. SHOULDER DYSTOCIA &
UMBILICAL CORD
PROLAPSE
Nur Haizum Binti Mohamed Aris
O&G CME, Aug 2 2012

2. SHOULDER DYSTOCIA

3.  Definition
 Prevalance
 Risk factors
 HELPERR
 Complication
 Prevention
 Simulation
3

4. 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

5. 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
5

6.  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
6

7. RISK FACTORS FOR SHOULDER
DYSTOCIA
7

8. WARNING SIGNS
 Failure of restitution
 “Turtle Neck Sign”
8

9. 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

10. 10

11. MCROBERTS AND SUPRAPUBIC
PRESSURE
 McRoberts maneuver - flex the legs toward the
patient's chest to open the anterior posterior
diameter of the pelvis
11
Figure 1. The McRoberts' maneuvre

12. 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
12
Figure 2 Suprapubic pressure

13. 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.
13

14. 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
14

15. 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
15

16. 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
16

17. 17
Figure 3 Delivery of the posterior arm

18. 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

19.  In extreme situations try:
• Intentional clavicle fracture
• Symphysiotomy Rarely
• Zavanelli Maneuver
 Document severity of shoulder dystocia and
maneuvers, management and timing
19

20. 20

21.  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
21

22. 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
22

23. 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 help
23

24.  Shoulder dystocia simulation video
24

25. CORD PROLAPSE
25

26.  Definition
 Types
 Risk
 Diagnosis
 Management
 Prevention
26

27. 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
27

28. 28

29. 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
29

30. 30

31. RISK FACTORS
31

32. DIAGNOSIS
 Appearance of loop of umbilical cord
 Pulsation of cord on V/E
 Suspect in unexplained fetal distress
 Variable decelerations
 Prolonged bradycardia
32

33. 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 section
emergency CS, regardless of indications,
should be performed within 30 minutes
from the time decision was made
33

34. 34

35. 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
35

36.  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
36

37. 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

38.  Continuation of relieving of cord compression
during
 Induction of anaesthesia
 Placement of sterile sheet
 LSCS
 Remove hands only when the surgeon tells you!
38

39. 39
Trendelenberg position

40. 40

41. 41

42. PREVENTION
42

43. REFERENCES
43
 RCOG
 Green-top guideline No. 42 / 2nd
edition/ March 2012/
Shoulder Dystocia
http://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