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 with the 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 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 (category 1 if pathological fetal heart pattern or category 2 if normal fetal heart pattern).

Shoulder Dystocia is defined as a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the 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 .

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

(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 L = Legs (McRoberts Maneuver) P = Pressure (suprapubic) E = Enter the – 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 – 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

McRoberts combined with • NO FUNDAL PRESSURE! 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” – – , 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 has been clamped and cut