Background

Umbilical cord prolapse may be defined as the

descent of the umbilical cord through the cervix

alongside or past the presenting part in the

presence of ruptured membranes .

It is estimated to occur in 0.1–0.6% of

pregnancies with the perinatal mortality rate

estimated at 91 per 1,000.

these factors predispose to cord prolapse by preventing

close application of the presenting part to the lower part

of the uterus and/or pelvic brim.

50% of cases is preceded by obstetric manipulation.

Prevention:

1-with transverse, oblique or unstable lie, elective

admission to hospital after 37+0 weeks’ gestation allows

for quick delivery should membranes rupture.

2-Women with non-cephalic prelabour preterm rupture of

membranes should be managed as inpatients.

3-Avoid artificial induction of labour when the presenting

part is non-stable and/or mobile.

4-When performing vaginal examination avoid upward

pressure on the presenting part.

When should cord prolapse be suspected?

Cord presentation and prolapse may occur without signs

and with a normal fetal heart rate pattern.

The cord should be examined for:

1. at every vaginal examination in labour

2. after SROM if risk factors are present

3. if cardiotocographic abnormalities commence soon after

SROM .

Management

1-When suspected, perform speculum or digital

examination immediately as early detection is crucial for

timely delivery and in the prevention of fetal morbidity

and mortality (reported as high as 25–50% of cases).

2-When diagnosed, summon senior help and prepare

operating theatre for emergency delivery.

.

3-Attempt to prevent further cord compression by

elevating the presenting part or filling the bladder.

4-Avoid handling the cord as this causes cord spasm.

5-Place mother in knee to chest or left lateral position,

ideally with head slightly declined.

6-Confirm fetal viability by auscultation of the fetal

heart using CTG

7- Delivery is generally performed by emergency

caesarean section (category 1 if pathological fetal heart

pattern or category 2 if normal fetal heart pattern).

Shoulder Dystocia Shoulder dystocia is defined as a vaginal cephalic

delivery that requires additional obstetric

manoeuvres to deliver the fetus after the head has

delivered and gentle traction has been

unsuccessful in delivering the shoulders

. It is associated with significant morbidity both

for the mother and fetus.

Prevention:

1. diagnosis and optimal control of gestational and

insulin-dependent diabetics,

2. reduction of maternal obesity.

3. Careful plan for mode of delivery in women with

previous shoulder dystocia delivery (recurrence

rate 10–15%).

Warning signs:

1. failure of restitution of head following delivery of the

head,

2. retraction of the fetal head against the perineum

(analogous to a turtle withdrawing into its shell).

Complications of Shoulder Dystocia

Maternal complications include

1- increased perineal trauma (third- and fourth degretear)

2-postpartum haemorrhage

3-psychological trauma.

Fetal complications include

brachial plexus injury (2–7% at birth reducing to 1–3% at

12 months of age), fractured clavicle or humerus (1–2%)

and hypoxic brain injury.

Management HELPERR Mnemonic

H = Help (call for additional assistance)

E = Evaluate for Episiotomy

L = Legs (McRoberts Maneuver)

P = Pressure (suprapubic)

E = Enter the vagina – rotatory maneuvers

R = Remove the posterior arm

R = Roll the patient (to hands and knees)

Perform secondary maneuvers (repeat internal maneuvers

and consider other options)

H = Help

• Activate institutional protocol

– Appropriate notification

– Additional nursing staff

– Additional back‐up

• Neonatal resuscitation personnel

• Obstetrical/surgical backup

• Anesthesia

E = Evaluate for Episiotomy

• Shoulder dystocia is not a soft‐tissue dystocia

• Consider when additional room for the clinician’s hands is

needed to perform internal maneuvers

• Decision based on clinical judgment and response to initial

maneuvers

Bring the mother buttock to the edge of the bed

L = Legs

• McRoberts Maneuver

– Flex maternal hips so that thighs are just touching the

sides of abdomen

• Effect

– Straightens the lumbosacral lordosis

– Increases AP diameter of pelvis

– Flexes the fetal spine decrease the biacromial diameter

–this facilitate delivery in about 90%

P = Pressure

• Suprapubic pressure by

assistant

– CPR‐style hand position

– Force should act to adduct

anterior shoulder

– Initially continuous, but can

involve a rocking motion

– Attempt for 30 to 60 seconds

• NO FUNDAL PRESSURE! McRoberts combined with suprapubic pressure

E = Enter Maneuvers

• Rubin II maneuver

• Approach anterior fetal shoulder by placing index and middle

finger into introitus

– Sweep fingers to a position behind the anterior shoulder

– Exert pressure to adduct most accessible shoulder and rotate

to oblique position

– Continue McRoberts maneuver

E = Enter, continued

• Reverse Woods screw maneuver

– Remove fingers that are in front of the posterior

shoulder

– Sweep fingers that are behind the anterior shoulder

to a position behind the posterior shoulder***

– Rotate fetus in the opposite direction from Woods

screw maneuver

R = Remove the Posterior Arm

• Confirm position of infant

• Make entering hand small!

• Enter birth canal ‐ introduce appropriate hand into

introitus at 6 o'clock

• Follow along anterior aspect of infant’s chest to find

forearm or hand

• If not found, arm will be behind back, so change hands

R = Roll the Patient (Gaskin Maneuver)

• Roll patient to “all‐fours” position

• Increases pelvic diameters

• Movement and gravity may also contribute to dislodging

the impaction

• Deliver posterior shoulder with gentle downward traction

Secondary Maneuvers

• Second attempt at all of the previously mentioned

internal maneuvers

• Posterior sling maneuver

• The “methods of last resort”

– Zavanelli maneuver

– Symphysiotomy, cleidotomy

– Abdominal rescue (cesarean)

Zavanelli Maneuver: Cephalic Replacement

• Flex fetal head to replace

• Cephalic replacement followed by emergency

cesarean delivery

• Requires anesthesia, operative team, tocolysis

• Not an option if nuchal cord has been clamped

and cut