IN THESE NOTES: SHOULDER DYSTOCIA - COMPOUND PRESENTATION - CORD PRESENTATION AND PROLAPSE

SHOULDER DYSTOCIA

Definition: Inability to deliver the shoulder inspite of the performance of the routine obstetric procedures after the head has been delivered.

			Incidence
	Fetal wt < 4 kg				Fetal wt > 4 kg
0.15%		5% with Instrumental delivery		1.5%		25% with Instrumental delivery

Causes:

1.Fetal macrosomia {mention causes}

2.Anencephaly, or collapsed head in IUFD..

Diagnosis:

*Shoulder dystocia should be expected in the presence of a PF, prolonged vaginal delivery & especially if the head was delivered instrumentally.

After delivery of the head:

*The chin becomes tightly applied to the perineum

*Gentle downward pressure on the fetal head fails to deliver the anterior shoulder which overides the S.P, while the posterior shoulder

over-rides the sacsal promontary(bilateral sh. dystocia)

Complications

	Maternal			Fetal
During pregnancy -Overdist. uterus		During labor -Maternal birth tract injuries	During puerperium SSS	1.Asphyxia 2.Encephalopathy. 3.Fetal death 4.Birth injuries: Brachial plexus, shoulder dilocation, fracture humerus...

Treatment

I.Prophylactic ttt:-very important-

1.Prevent macrosomia e.g good control of diabetic mothers.

2.Proper estimation of birth wt before delivery.(How?)

3.Avoid midforceps delivery.

4.If anticipated C.S is a safer method of delivery.

II.Active Emergency ttt:

-Stop any downward pressure on the shoulder(-->more impaction)

-Try the following maneuvers:

1-Generous episiotomy + suprapubic pressure by assisstant + maintain gentle downward pull on the head.If fails then---->

2.Mc Robert's Maneuver: Overflexion of matrnal hip joint by approximating the knee to the chest in order to rotate the symphisis pubis upwards [may free the anterior shoulder], and straightening of the sacrum relative to the lumbar vertebra-->

3.Try rotating the biacromial dtr from the A-P diameter to the oblique diameter by applying firm constant pressure by 2 fingers placed against the anterior aspect of the posterior shoulder + suprapubic pressure-->

4.Wood's corkscrew maneuver: Rotating the posterior shoulder 180 ( difficult & dangerous) -->

5.Delivery of the posterior arm --> follow the posterior shoulder to the cubital fossa-->pressure-->grasp the hand&pull it down.-->

6.If the fetus is dead---> Cleidotomy.=

7.C.S after head reduction! very difficult =Zavanelli maneuver

8.Symphisiotomy if failure of all maneuvers.

Shoulder girdle dystocia (Arrest of shoulder in breech presentation) may be considered a type of shoulder dystocia)

COMPLEX OR COMPOUND PRESENTATION

Definition: Presence of fetal limb(s)beside the presenting head.

Aetiology: as aetiology of cord prolapse.

Diagnosis: P/V examination the prolapesd limb is felt.

Exclude cord prolapse.

Managment:

-If head + hand----> Manual reposition.

-If manual reposition fails & labor is obstructed-->C.S

or craniotomy if dead fetus.

-If manual reposition fails&labor is not obstructed--->allow delivery.

-If head + foot ---------->C.S

-If cx fully dilated + engaged head + hand--->reposition+Forceps or ventouse

CORD PRESENTATION & PROLAPSE

Definitions:

Cord presentation: presence of the U.C below the PP with the membranes intact.

Cord prolapse: presence of the U.C below the PP(overt cord prolapse)

or beside the PP(occult cord prolapse) with the membranes ruptured.

Cord expression: Prolapse of the UC after full cervical dilatation.

Incidence: 0.5% in cephalic,5% in complete breech,15%in footling.

20% if transverse lie.

Aetiology:

Predisposing factors: Long cord , Pl. previa, battledore insertion.

Precipitating factors: absence of a well-fitting PP , as in:

1.All causes of non engagment(passage,passenger,...)

2.Version procedures

3.ROM before engagment.

Diagnosis:

P/V examination to detect cord & membranes.

Cord pulsating = living fetus

Managment:

1.Prolapsed non-pulsating cord--->allow V.D

2.Prolapsed pulsating cord--->

Cx partially dilated-->Rapid C.S , while preparing for C.S the patient is put in Trendlenberg position or Knee chest or left lateral + O2

Cx fully dilated+ PP not engaged---> C.S

Cx fully dilated + engaged breech or cephalic-->forceps or breech extraction

3.Cord presentation:

Exclude indications of C.S then:

a)Cx partially dilated-->Postural ttt + O2 + fetal monitoring +guard against ROM till cx becomes fully dilated then:

b)Cx fully dilated:

AROM--->Immediate delivery

If cephalic---->forceps

If breech------>Extraction

If transverse-->IPV+Breech extraction.