shoulder cord_presentation
DESCRIPTION
to download this file contact via [email protected]TRANSCRIPT
![Page 1: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/1.jpg)
Dr. S.K.S
![Page 2: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/2.jpg)
Shoulder presentation :- when the long axis of fetus lies transversely with long axis of maternal spine, as a result shoulder of fetus occupies the birth canal.
Incidence: 0.3%
![Page 3: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/3.jpg)
Position of fetusDorso-anterior- more common.Dorso-posterior.
![Page 4: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/4.jpg)
Mechanics of presentation:long axis of the fetus is perpendicular to
long axis of mother (ie occurs in transverse lie)
mostly the shoulder presents in a transverse lie, but alternative presentations are hand and arm (may be prolapsed into the vagina) cord nil (fetal back is down, and above the level of the
inlet)
![Page 5: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/5.jpg)
AETIOLOGYFetal
prematurity, multipleLiquor
polyhydramniosUterine
Anomaly esp. subseptate uterusPlacenta
praeviaPelvis
contraction, tumourParity
high maternal parity (80% of cases occur in women who are para3 or more)
![Page 6: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/6.jpg)
DIAGNOSISInspection:-Asymmetrical enlargement of uterus.Abdomen is transversely broad.Palpation Fundal ht.:- smaller than gestational age.Fundal grip:- absent.Lateral grip:- head of fetus in one side and
breech on other side.Pelvic grip:- empty.
![Page 7: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/7.jpg)
Auscultation :- FHS is heard at higher level and more distinct in dorso-anterior position
P/V examination:-During pregnancy:- high presenting part.During labour:- shoulder is identified by
palpating the following parts:- acromian process, scapula, clavicle and axilla.
After rupture of membrane- hand may be prolapsed.
![Page 8: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/8.jpg)
Investigation :- USG abdomen pelvis at antenatal period.
![Page 9: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/9.jpg)
![Page 10: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/10.jpg)
MANAGEMENTGeneral management:-I/V fluidBlood grouping, Rh typing & cross match at
least 1 pint blood.Parenteral antibiotics – ampicillin 1 gm,
metronidazole 500mg.
![Page 11: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/11.jpg)
Obstetric management :-A.Antenatal managementB.Labour management.
![Page 12: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/12.jpg)
A. Antenatal management
External cephalic version if not contraindicated at 32-34 wks.
If fail repeat after 1 week
Vertex presentation
NVD
If revert back to transverse lie
El. C/S.
![Page 13: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/13.jpg)
B. Labour management
Labour
Alive baby
C/S
Dead baby
Internal podalic version with breech extraction
Destructive operation
C/S
![Page 14: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/14.jpg)
Immediate C/S must be perform if:-1.Cord prolapse2.Early rupture of membrane3.ECV failed.4.Any delay in the progress of labour.
![Page 15: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/15.jpg)
Danger of transverse lieMaternal1.Prolong labour2.Obstructed labour3.Rupture of uterus4.Haemorrhage & shock5.Maternal death
Fetal 1.Cord prolapse2.Hand prolapse3.IUD4.Foetal distress5.Still birth
![Page 16: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/16.jpg)
![Page 17: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/17.jpg)
COMPOUND PRESENTATION
![Page 18: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/18.jpg)
COMPOUND PRESENTATIONWhen more than 1 presenting part enters birth canal at
a time or, When a fetal extremity prolapses alongside the presenting part, and both enter the maternal pelvis at the same time vertex-hand or cord breech-hand or cord vertex-arm-foot
Incidence: 0.1%Aetiology
Fetal multiple premature
Maternal Multiparity
![Page 19: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/19.jpg)
MANGEMENTExclude cord prolapse
occurs in up to 20% of cases
Otherwise expectantvertex-foot: try to gently reposition the lower
extremityif arm prolapses in vertex-hand - deliver by
CS
![Page 20: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/20.jpg)
CORD
PROLAPSE/PRESENTATION
![Page 21: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/21.jpg)
Def – when the umbilical cord descends along with the presenting part, it is called cord prolapse/presentation.
Clinically, it can be divided as – 1.Occult prolapse – cord remains by the side of the presenting part & is not felt .2. Cord presentation – cord is slipped down below the presenting part.3.Cord prolapse – cord is lying inside the vagina or outside the vulva following rupture of membranes
![Page 22: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/22.jpg)
![Page 23: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/23.jpg)
Incidence – 1 in 300 deliveries. Mostly found in parous women.
Etiology – following factors play a great role.1. Malpresentation.2. Contracted pelvis3. Pre maturity.4. Twins.5. Hydramnios 6. Long cord 7. Iatrogenic – low rupture of membrane,
rotation / version.
![Page 24: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/24.jpg)
Diagnosis – Occult prolapse – difficult to diagnose.Cord presentation – by feeling the pulsation of
cord.Cord prolapse – cord can be felt pulsating if
the fetus is alive.
Cord pulsation may cease during uterine contraction but returns soon after contraction passes off.
Fetus may be alive even in the absence of cord pulsation, hence USG helps determine cardiac movt.
![Page 25: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/25.jpg)
Management – 1. Once the diagnosis is made, try to
preserve the membranes & to expedite the delivery.
2. If immediate vaginal delivery is not possible or contraindicated, caesarean section is the best choice.
3. Management Aim is guided by – a. baby living or dead. b. maturity of the baby. c. dilatation of the cervix.
![Page 26: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/26.jpg)
Baby living – -i.v. fluids & oxygen by mask.-Bladder filling to be done to raise the presenting part, 400-750 ml of NS is used with a Foleys catheter, the balloon is inflated & catheter is clamped. Empty the bladder before CS. - lift the presenting part off the cord. - keep the pt. in sims position. - to replace the cord inside the vagina (to minimize vasospasm due to irritation). - caesarean section is the best treatment when the baby is viable.
![Page 27: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/27.jpg)
Immediate safe vaginal delivery is possible if the head is engaged. Immediate delivery to be completed by forceps.
If breech – by breech extraction.Baby dead – labour should be
allowed to proceed. No need of CS.
![Page 28: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/28.jpg)
Prognosis – Fetal – fetus is at greater risk of anoxia. The hazards to the fetus is more in vertex presentation.The perinatal mortality is about 50%.
Maternal – operative delivery risks of anesthesia, blood loss & infection.
![Page 29: Shoulder cord_presentation](https://reader038.vdocuments.us/reader038/viewer/2022102901/5564ab87d8b42afd4f8b586b/html5/thumbnails/29.jpg)