Shoulder presentation :- when the long axis of fetus
lies transversely with long axis of maternal spine, as a
result shoulder of fetus occupies the birth canal.
Position of fetus
Dorso-anterior- more common.
Mechanics of presentation:
long axis of the fetus is perpendicular to long axis of
mother (ie occurs in transverse lie)
mostly the shoulder presents in a transverse lie, but
alternative presentations are
hand and arm (may be prolapsed into the vagina)
nil (fetal back is down, and above the level of the inlet)
Anomaly esp. subseptate uterus
high maternal parity (80% of cases occur in women who are
para3 or more)
Asymmetrical enlargement of uterus.
Abdomen is transversely broad.
Fundal ht.:- smaller than gestational age.
Fundal grip:- absent.
Lateral grip:- head of fetus in one side and breech on
Pelvic grip:- empty.
Auscultation :- FHS is heard at higher level and
more distinct in dorso-anterior position
During pregnancy:- high presenting part.
During labour:- shoulder is identified by palpating
the following parts:- acromian process, scapula,
clavicle and axilla.
After rupture of membrane- hand may be prolapsed.
Investigation :- USG abdomen pelvis at antenatal
Blood grouping, Rh typing & cross match at least 1 pint
Parenteral antibiotics – ampicillin 1 gm, metronidazole
When more than 1 presenting part enters birth canal at a time or,
When a fetal extremity prolapses alongside the presenting
part, and both enter the maternal pelvis at the same time
vertex-hand or cord
breech-hand or cord
Exclude cord prolapse
occurs in up to 20% of cases
vertex-foot: try to gently reposition the lower extremity
if arm prolapses in vertex-hand - deliver by CS
Def – when the umbilical cord descends along with the presenting
part, it is called cord prolapse/presentation.
Clinically, it can be divided as –
1.Occult prolapse – cord remains by the side of the presenting
part & is not felt .
2. Cord presentation – cord is slipped down below the presenting
3.Cord prolapse – cord is lying inside the vagina or outside the
vulva following rupture of membranes
Incidence – 1 in 300 deliveries. Mostly found in parous
Etiology – following factors play a great role.
2. Contracted pelvis
3. Pre maturity.
6. Long cord
7. Iatrogenic – low rupture of membrane, rotation /
Occult prolapse – difficult to diagnose.
Cord presentation – by feeling the pulsation of cord.
Cord prolapse – cord can be felt pulsating if the fetus
Cord pulsation may cease during uterine contraction
but returns soon after contraction passes off.
Fetus may be alive even in the absence of cord
pulsation, hence USG helps determine cardiac
1. Once the diagnosis is made, try to preserve
the membranes & to expedite the delivery.
2. If immediate vaginal delivery is not possible
or contraindicated, caesarean section is the
3. Management Aim is guided by –
a. baby living or dead.
b. maturity of the baby.
c. dilatation of the cervix.
Baby living –
-i.v. fluids & oxygen by mask.
-Bladder filling to be done to raise the presenting
part, 400-750 ml of NS is used with a Foleys
catheter, the balloon is inflated & catheter is
clamped. Empty the bladder before CS.
- lift the presenting part off the cord.
- keep the pt. in sims position.
- to replace the cord inside the vagina (to
minimize vasospasm due to irritation).
- caesarean section is the best treatment when the
baby is viable.
Immediate safe vaginal delivery is possible
if the head is engaged. Immediate
delivery to be completed by forceps.
If breech – by breech extraction.
Baby dead – labour should be allowed to
proceed. No need of CS.
Fetal – fetus is at greater risk of anoxia.
The hazards to the fetus is more in vertex
The perinatal mortality is about 50%.
Maternal – operative delivery risks of anesthesia,
blood loss & infection.