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OBGYN 4MB > Shoulder Dystocia/Cord Prolapse > Flashcards

Shoulder Dystocia/Cord Prolapse Flashcards

1
Q

Define shoulder dystocia

A

Vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed

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2
Q

List the associations and risk factors of shoulder dystocia

A

Maternal:

  1. Diabetes mellitus
  2. Obesity

Fetal:

  1. Large for gestational age
  2. Macrosomia >4.5kg
  3. Post-maturity
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3
Q

What is the incidence of shoulder dystocia?

A

0.6-0.7% (RCOG - Greentop 42, 2012)

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4
Q

How do we manage shoulder dystocia?

A

HELPERR

H = Call for Help
E = Evaluate for Episiotomy 
L = Legs - McRoberts manoeuvre 
P = External Pressure - suprapubic 
E = Enter - rotational manoeuvres 
R = Remove the posterior arm
R = Roll the patient to her hands and knees

*If all this fails, repeat or use surgical manoeuvres

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5
Q

What is the McRoberts manoeuvre?

A
  • Flexion and abduction of maternal hips, positioning the maternal thighs on her abdomen
  • Increases relative AP diameter of pelvis
  • Success rate = 90%
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6
Q

Why do we apply suprapubic pressure?

A
  • Reduces the fetal bisacromial diameter and rotates the anterior shoulder into the wider oblique pelvic diameter
  • Shoulder then freed to slip under the symphysis pubis with routine axial traction
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7
Q

What are the internal rotational manoeuvres?

A
  • Woods and Rubin
  • Rotation most easily achieved by pressing on anterior or posterior aspect of posterior shoulder
  • Pressure on posterior aspect of posterior should also reduces shoulder diameter by adducting the shoulders
  • Shoulders should be rotated into wider oblique diameter
  • If posterior shoulder unsuccessful, pressure should be applied to posterior aspect of anterior shoulder
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8
Q

Why and how do we remove the posterior arm?

A
  • Reduces diameter of fetal shoulders by width of the arm
  • Fetal wrist should be grasped and the posterior arm should be gently withdrawn from the vagina in a straight line
  • Associated with humeral fractures (2-12%)
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9
Q

What is the positional change that the patient should adopt if other manoeuvres fail?

A
  • All fours position

- 83% success rate

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10
Q

List the surgical manoeuvres that can be performed if all others fail

A
  1. Zavanelli manoeuvre
  2. Symphysiotomy
  3. Cleidotomy
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11
Q

What is the Zavanelli manoeuvre?

A

Vaginal replacement of the head and then delivery by C-section

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12
Q

What is a symphysiotomy?

A

Dividing the anterior fibres of the symphyseal ligament

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13
Q

What is a cleidotomy?

A

Surgical division of the clavicle of the fetus or bending with a finger

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14
Q

List the fetal complications of shoulder dystocia

A
  1. Brachial plexus injuries (Erb’s palsy [C5-C6] most common, also T1 and C8 injuries, rarely T4 injuries) 2-16%
  2. Hypoxic brain damage
  3. Fractured clavicle, fractured humerus
  4. Pneumothorax
  5. Death
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15
Q

List the maternal complications of shoulder dystocia

A
  1. PPH
  2. Third and fourth degree perineal tears (3.8%)
  3. Vaginal lacerations
  4. Cervical tears
  5. Rupture - bladder/uterus
  6. Symphyseal separation
  7. Sacroiliac joint dislocation
  8. Lateral femoral cutaneous neuropathy
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16
Q

Define cord prolapse

A

Descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membranes

17
Q

Define cord presentation

A

The presence of the umbilical cord between the fetal presenting part and the cervix, with or without intact membranes

18
Q

Why is cord prolapse important?

A

ASPHYXIA:

  • Cord compression
  • Umbilical arterial spasm (cold air outside uterus causes this)

PMR = 91 per 1000

19
Q

What is the incidence of cord prolapse?

A

0.1-0.6%

20
Q

What factors are associated with cord prolapse?

A

General:

  1. Multiparity
  2. Low birthweight (<2.5kg)
  3. Preterm labour (<37wks)
  4. Fetal congenital anomalies
  5. Breech presentation
  6. Transverse, oblique and unstable lie
  7. Second twin
  8. Polyhydramnios
  9. Unengaged presenting part
  10. Low lying placenta

Procedural:

  1. ARM with high presenting part
  2. Vaginal manipulation of fetus with ruptured membranes
  3. External cephalic version (ECV)
  4. Internal podalic version
  5. Stabilising induction of labour
  6. Insertion of intrauterine pressure transducer
  7. Large balloon catheter IOL
21
Q

What is the management of cord prolapse?

A

CORD

C = Consider
O = Organise help
R = Relive pressure
D = Decision for birth
22
Q

When should we consider?

A
  • At every VE during labour
  • Abnormal fetal heart with SROM
  • Membrane rupture with risk factors
23
Q

What help should be organised?

A
  1. Obstetricians and midwives
  2. Anaesthetist and perioperative team
  3. Neonatal team
  4. Porter
24
Q

How can we relive pressure?

A
  1. Manually elevate presenting part or fill bladder
  2. Encourage into knee chest position OR left lateral position with pillow placed under left hip
  3. Consider tocolysis (Terbutaline beta 2 agonist)
25
Q

What decisions need to be made regarding birth?

A
  • Emergency transfer to hospital labour ward
  • Assess and assist birth by quickest means
  • Urgency dependent on FHR and gestational age
  • If C-section, consider if regional anaesthesia appropriate

OBGYN 4MB (25 decks)

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