د. ياسمين حمزة Shoulder dystocia Shoulder dystocia :is when the shoulders remains impacted in the pelvis after delivery of the fetal head. It is a serious complication but fortunately rare u with babies more than 4 kg.It is the most frightening obstetrical emerg. As delay beyond 5 min. leads to hypoxia & fetal death& traction of the head leads to damage to cervical plexus N.root Incidence: less than 1% &recurrence rate 10-15% Risk F:1-D.M 2-postdate 3-maternal obesity 4-multiparity 5-maternal pelvic fracture&abn.

The warning signs are:1- slow crowning of the fetal head . 2-difficulty in delivery of the fetal face . 3-Slow restitution of the occiput to lateral position. 4-The fetal chin is retracted firmly back into the perineum after delivery of the head. Incidence is increased with:1-induced labour 2-primery dys. Labour 3-operative delivery .

Treatment Prepare plan of action(shoulder dystocia drill)that involve these steps : (Don't Panic) 1-Simple measures: which always tried &usually successful in 90% of cases. _McRoberts maneuver: in which we do hyper flexion of the maternal thighs onto the abdomen with abduction of the hips either by her self or by assistant ,this will flattened the lumbosacral curve &decrease obstruction from sacral promontory . _Suprapubic pressure: as pressure exerted obliquely on the posterior aspect of the ant. Shoulder .

2- Advance measure: do episiotomy and rotate the shoulders into oblique diameter using a fingers hooked into one axilla moving the shoulder towered the chest then traction of it . If failed do (wood’s screw maneuver): rotate the posterior shoulder 180 to become anterior shoulder If failed also advance our hand into the uterus posteriorly and after finding the fetal hand deliver the posterior arm by sweeping it across the fetal chest. As a last resort and only if these maneuvers have failed and the fetus has died an experienced obstetrician would considered (division of the clavicles )or even (symphysiotomy) which lead to 2-3 cm increase in diameter of the bony pelvis

If failed, replace the fetal head followed by C/S which is called (Zavanelli maneuver). ****(Decapitation).

If a women has had shoulder dystocia she and her attendant will be anxious to avoid this complications in future pregnancies so she should had US to estimate the fetal wt.at term and CS is indicated if there is evidence of a baby that’s large Shoulder dystocia is a serious complications to the mother and the fetus as it associated with high PM with brachial plexus injury and Erb’s palsy for the infant

Cord prolapse: It means the presence of a segment of the umbilical cord at the cx os as a presenting part. Prolapse is present when the membranes have ruptured and the segment of the cord may be at any level from the upper vagina to outside the introitus. It’s incidence is about 1:500.

Risk factors: *The stage preceding cord presentation is the presence of cord beside the presenting part and may manifest as variable decelerations of F.H. *The length of the cord affects the increased incidence of prolapse. *The fit of the presenting part in the pelvic brim . Abnormal cord site insertion in the placenta.

C/F: *common in malpresentation(breech),(Transverse lie),& (Pl.Pr.),associated with palpable cord. *abnormal gush of per vaginal fluid , with palpable loop of cord in or outside the vagina , s.t.pulsating with fetal H. negative or with bradycardia .

Management: *When the cx is not fully dilated & the baby is alive→immediate ClS is arranged after positioning the pt. in knee – chest position and maintain digital pressure to keep off the cord especially during contraction. *When the baby is alive & the cx is fully dilated →vigorous attempts to secure vaginal delivery providing FHR is good, other wise immediate C/S to secure the fetus is done.

*If the fetus is dead→attempts of vaginal delivery if no CI as in transvers lie ,previous 2c/s or abruption placenta.