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.
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Incidence |
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Fetal wt < 4 kg |
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Fetal wt > 4 kg |
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0.15% |
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5% with Instrumental delivery |
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1.5% |
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25% with Instrumental delivery |
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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
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Maternal |
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Fetal |
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During pregnancy -Overdist. uterus |
During labor -Maternal birth tract injuries |
During puerperium SSS |
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1.Asphyxia 2.Encephalopathy. 3.Fetal death 4.Birth injuries: Brachial plexus, shoulder dilocation, fracture humerus... |
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Treatment |
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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.
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.