This document discusses shoulder dystocia and umbilical cord prolapse. It defines shoulder dystocia as a vaginal delivery that requires additional maneuvers to deliver the fetus after the head has delivered. It also defines umbilical cord prolapse as the descent of the umbilical cord through the cervix alongside or past the presenting part in the presence of ruptured membranes. The document discusses risk factors, signs, management techniques like the McRoberts maneuver for shoulder dystocia. It also discusses types, risk factors, diagnosis and management of umbilical cord prolapse including relieving cord compression.

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