Cord prolapse

Diagnosis a vaginal examination should be performed immediately on spontaneous rupture of the membranes.

Bradycardia variable or prolonged decelerations due to cord compression the cord is felt below or beside the presenting part on vaginal examination. The cord may be felt in the vagina or in the cervical os or a loop of cord may be visible at the vulva

Immediate action -midwife must call for urgent assistance. -The midwife should explain to the woman and her birth partner her findings and any emergency measures. -If an oxytocin infusion is in progress this should be discontinued. If the cord lies outside the vagina, then it should be gently replaced to prevent spasm, to maintain temperature and prevent drying. Administering oxygen to the woman by face mask at 4 l/min may improve fetal oxygenation.

Relieving pressure on the cord hypoxia and death as a result of cord compression. Increase risk with prematurity and low birth weight -The midwife may need to keep her fingers in the vagina and hold the presenting part off the umbilical cord, especially during a contraction. -The woman can be supported to change position and further reduce pressure on the cord.

-adopts the knee–chest position, the fetus will be encouraged to gravitate towards the diaphragm -The foot of the bed may also be raised (Trendelenburg position) to relieve compression on the cord. lie on her left side, with a wedge or pillow elevating her hips (exaggerated Sims' position)

bladder filling may also be an effective technique for managing cord prolapse -A self-retaining 16G Foley catheter is used to instill approximately 500–700 ml of sterile saline into the bladder. -The full bladder can relieve compression of the cord by elevating the presenting part about 2 cm above the ischial spines until birth by caesarean section. The bladder would be drained in theatre immediately before the caesarean section

Knee–chest position. Pressure on the umbilical cord is relieved as the fetus gravitates towards the fundus.

Exaggerated Sims' position Exaggerated Sims' position. Pillows or wedges are used to elevate the woman's buttocks to relieve pressure on the umbilical cord.

-Birth must be possible speed to reduce the mortality and morbidity Caesarean section is the treatment of choice a cord prolapse is diagnosed in the second stage of labour, with a multigravida, the midwife may perform an episiotomy to expedite the birth.

the presentation is cephalic, assisted birth may be achieved through ventouse or forceps Senior obstetric and anesthetic staff paediatrician should be available to resuscitate the baby

Shoulder dystocia failure of the shoulders to traverse the pelvis spontaneously requiring additional manoeuvres after the birth of the head -The anterior shoulder behind or on the symphysis pubis, while the posterior shoulder in the hollow of the sacrum or high above the sacral promontory

a bony dystocia, and traction at this point will further impact the anterior shoulder, impeding attempts to assist the baby's birth.

Shoulder dystocia

Risk factors Antenatal risk factors include diabetes, post-term pregnancy, high parity, maternal age over 35 and maternal obesity (weight over 90 kg). -Fetal macrosomia (birth weight over 4000 g) the incidence increasing as birth weight increases ,Ultrasound scanning for prediction of macrosomia to

ultrasound detection of macrosomia can be improved -Maternal diabetes and gestational diabetes have been identified as important risk factors In diabetic women, a previous birth complicated by shoulder dystocia increases the risk of recurrence

-In labour risk factor oxytocin augmentation prolonged labour prolonged second stage of labour operative births

Warning signs and diagnosis -the head may have advanced slowly, with the chin having difficulty in sweeping over the perineum. Once the head is born, it may look as if it is trying to return into the vagina (the turtle sign). Shoulder dystocia is diagnosed when manoeuvres such as gentle downward axial traction* on the head, that may normally be used by the midwife, fail to complete the birth The woman should be discouraged from pushing and any further traction must be avoided.

Management and manoeuvres -The HELPERR Mnemonic Help Episiotomy need assessed Legs in McRoberts position Pressure suprapubically Enter vagina (internal rotation) Remove posterior arm Roll the woman over and try again

-Shoulder dystocia is a frightening experience for the woman, for her partner and for the midwife.

The purpose of all these manoeuvres - to disimpact the shoulders. - The midwife will need to make an accurate and detailed record of the time help was summoned and those who attended, the type of manoeuvre(s) used and the time taken, the amount of force used and the outcome of each manoeuvre attempted

Non-invasive procedures Change in maternal position -may be useful to help release the fetal shoulders as shoulder dystocia is a bony, mechanical obstruction.

The McRoberts manoeuvre assisting the woman to lie completely flat (pillows removed) with her buttocks at the edge of the bed and hyperflexing her hips to bring her knees up to her chest as far as possible

The McRoberts manoeuvre position.

-This manoeuvre will rotate the angle of the symphysis pubis superiorly and use the weight of the woman's legs to create gentle pressure on her abdomen, releasing the impaction of the anterior shoulder

Suprapubic pressure -exerted on the side of the fetal back and towards the fetal chest. help to adduct the shoulders and push the anterior shoulder away from the symphysis pubis into the larger oblique or transverse diameter - Suprapubic pressure can be employed together with the McRoberts manoeuvre to improve success rates

Correct application of suprapubic pressure for shoulder dystocia Correct application of suprapubic pressure for shoulder dystocia. After Pauerstein C (ed), Clinical obstetrics. Churchill Livingstone, New York, 1987, with permission.

All-fours position Gaskin manoeuvre) is achieved by assisting the woman onto her hands and knees. The act of the woman turning may be the most useful aspect of this manoeuvre In shoulder dystocia, the impaction is at the pelvic inlet and the force of gravity will keep the fetus against the anterior aspect of the mother's uterus and pelvis.

helpful if the posterior shoulder is impacted behind the sacral promontory Manipulative manoeuvres can be performed while the woman is on all fours ,but clear verbal communication is needed as eye contact is difficult. Where non-invasive procedures have not been successful, direct manipulation of the fetus must be attempted, requiring the midwife to insert a whole hand into the vagina.

-The McRoberts position can be used, or the woman could be placed in the lithotomy position with her buttocks well over the end of the bed so that there is no restriction on the sacrum. Episiotomy -The problem facing the midwife is an obstruction at the pelvic inlet which is a bony dystocia, not an obstruction caused by soft tissue. Episiotomy will not help to release the shoulders, it will avoid tearing the perineum and vaginal walls

Rotational maneuvers The Rubin manoeuvre suprapubic rocking to dislodge the anterior shoulder. If rocking alone proved unsuccessful, vaginal examination (inserting the whole hand) was suggested to identify the most accessible shoulder (usually the posterior shoulder), and push that shoulder in the direction of the fetal chest. This process adducts the shoulders and allows rotation away from the symphysis pubis. The manoeuvre reduces the 12 cm bisacromial diameter

The Rubin manoeuvre.

The Woods manoeuvre the midwife to insert a whole hand into the vagina and identify the fetal chest. exerting pressure on to the posterior fetal shoulder, rotation is achieved. abduct the shoulders, it will rotate the shoulders into a more favourable diameter and enable the midwife to complete the birth

The Woods manoeuvre. After Sweet B R, Tiran D, Mayes' midwifery The Woods manoeuvre. After Sweet B R, Tiran D, Mayes' midwifery. Baillière Tindall, London, 1996: p 664, with permission.

Birth of the posterior arm The midwife has to insert a hand into the vagina, making use of the space created by the hollow of the sacrum, Then two fingers grasp the wrist of the posterior arm to flex the elbow and sweep the forearm over the chest for the hand to be born, If the rest of the birth is not then accomplished, the birth of the second arm is assisted following rotation of the shoulder using either the Woods or Rubin manoeuvre or by reversing the Løvset manoeuvre

Birth of the posterior arm

Zavanelli manoeuvre Zavanelli manoeuvre as a last hope for birth of a live baby. The Zavanelli manoeuvre requires the reversal of the mechanisms of birth ,reinsertion of the fetal head into the vagina. The birth is then completed by caesarean section. -Method: The head is returned to its pre-restitution position ,Pressure is then exerted onto the occiput and the head is returned to the vagina ,Prompt birth of the baby by caesarean section is then required.

The Zavanelli manoeuvre The Zavanelli manoeuvre. (A) Head being returned to direct anteroposterior (pre- restitution) position. (B) Head being returned to the vagina. After Sandberg 1985, with permission.

Symphysiotomy is the surgical separation of the symphysis pubis and is used to enlarge the pelvis to enable the birth. It is usually performed in cases of cephalopelvic disproportion (CPD) and is used more routinely in the developing world. There are a few recorded cases where symphysiotomy has been used successfully to relieve shoulder dystocia ,but the procedure has usually been associated with a high level of maternal morbidity.

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