SHOULDER DYSTOCIA &

UMBILICAL CORD
PROLAPSE
Nur Haizum Binti Mohamed Aris

O&G CME, Aug 2 2012

SHOULDER DYSTOCIA

Definition
Prevalance
Risk factors
HELPERR
Complication
Prevention
Simulation

DEFINITION

Vaginal cephalic delivery that requires additional

obstetric maneuvers to deliver the fetus after the
head has delivered and gentle traction has failed.
An objective diagnosis of a prolongation of headto-body delivery time of more than 60 seconds
Occurs in 1% of births (normal birth weight) and
up to 10% of births of infants of higher birth
weight (>4500g)
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PREVALANCE
Studies involving the largest number of vaginal
deliveries (34 800 to 267 228) report incidences
between 0.58% and 0.70%
Macrosomia shows the strongest correlation with
shoulder dystocia

Occurs

more often with gestational diabetes and

twice as often in postdate pregnancies
In women without diabetes, labor induction for
suspected fetal macrosomia does not lower the rates
of shoulder dystocia or cesarean delivery

There is a relationship between fetal size and

shoulder dystocia but it is not a good predictor:
partly

because fetal size is difficult to determine

accurately
large majority of infants with a birth weight of
4500g do not develop shoulder dystocia.

Equally important, 48% of births complicated by

shoulder dystocia occur with infants who weigh
less than 4000g

RISK FACTORS FOR SHOULDER

DYSTOCIA

WARNING SIGNS
Failure of restitution
Turtle Neck Sign

SHOULDER DYSTOCIA
H Call for help
E Evaluate for episiotomy
L Legs (The McRoberts Maneuver)
P Suprapubic (not fundal) pressure to disengage
the anterior shoulder
E Enter maneuvers
R Remove posterior arm
R Roll the patient over

* Make sure to note start time of dystocia and delivery time

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MCROBERTS AND SUPRAPUBIC

PRESSURE

McRoberts maneuver - flex the legs toward the

patient's chest to open the anterior posterior
diameter of the pelvis

Figure 1. The McRoberts' maneuvre

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SUPRAPUBIC PRESSURE (RUBIN I)

Suprapubic pressure apply a rolling pressure

over the fetal anterior shoulder on mothers lower
abdomen so that the shoulder will adduct and
pass under the symphysis

Figure 2 Suprapubic pressure

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RUBIN II MANEUVER
Hand is inserted into the vagina
Digital pressure is applied to the posterior aspect
of the anterior shoulder
Push towards the fetal chest, rotating the
shoulders forward into an oblique diameter.

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WOODS SCREW MANEUVER

While maintaining pressure as above in the
Rubin II maneuver, a second hand locates the
anterior aspect of the posterior shoulder.
Apply pressure to rotate the posterior shoulder.
Attempt delivery once the shoulders move into
the oblique diameter.
If unsuccessful continue rotation through 180
and attempt deliver

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REVERSE WOODS SCREW

MANEUVER
Apply pressure to the posterior aspect of the
posterior shoulder
Attempt to rotate it through 180 in the opposite
direction to that described in the Wood Screw
maneuver

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POSTERIOR ARM
Pass hand into the vagina over the chest of the
fetus to identify the posterior arm and elbow.
Apply pressure to the antecubital fossa to flex the
elbow in front of the body, and/or grasp the
posterior hand to sweep the arm across the chest
and deliver the arm.
Rotate the fetus into the oblique diameter of the
pelvis, or through 180, bringing the anterior
shoulder under the symphysis pubis

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Figure 3 Delivery of the posterior arm

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SHOULDER DYSTOCIA
Do not persist in any one maneuver if it is not
immediately successful. Try another maneuver.
NEVER apply fundal pressure - this can
further engage the anterior shoulder under the
pubic bone.
Uterine relaxants (nitroglycerin or general
anesthesia with halothane) may be needed to
overcome the expulsive forces of the uterus.
Rotation of the patient onto all fours may also
facilitate delivery by increasing the pelvic
diameters and allowing better access to the
posterior shoulder.

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In extreme situations try:

Intentional clavicle fracture
Symphysiotomy
Zavanelli Maneuver

Rarely

Document severity of shoulder dystocia and

maneuvers, management and timing

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DONT 3 Ps:
Pushing (on the head)
Pulling (on the fundus)
Pivoting (sharply angulating the head, using
the coccyx as a fulcrum)
Some add the 4th P:
Dont Panic

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COMPLICATIONS
Maternal

Fetal

Postpartum hemorrhage

Brachial plexus palsy

Clavicle fracture
Fetal death
Fetal hypoxia, with or
without permanent
neurologic damage
Fracture of the humerus

Rectovaginal fistula
Symphyseal separation
or diathesis
Third or fourth degree
episiotomy or tear
Uterine rupture
Psychological trauma

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PREVENTION
Control maternal weight gain
Optimize glycemic control in diabetics
If concern for LGA offer C-section if efw>5000 gm
in non-diabetics, if efw>4500 gm in diabetics
In high risk patients, the head and shoulder
maneuver can be used (delivery of head and
shoulders in one move without suctioning the
nasopharynx after delivery of the head)
Be prepared - call for help

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Shoulder dystocia simulation video

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CORD PROLAPSE
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Definition
Types
Risk
Diagnosis
Management
Prevention

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DEFINITION

Cord prolapsed: descent of the umbilical cord

through the cervix alongside (occult) or past the
presenting part (overt) in the presence of
ruptured membranes
Cord presentation : presence of the umbilical cord
between the fetal presenting part and the cervix,
with or without membrane rupture

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TYPES

Occult prolapse: the prolapsed cord is contained

within the uterus usually by the side of the
presenting part unnoticed
Overt prolapse: the cord protrude into the vagina

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RISK FACTORS

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DIAGNOSIS

Appearance of loop of umbilical cord

Pulsation of cord on V/E

Suspect in unexplained fetal distress

Variable

decelerations
Prolonged bradycardia

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DELIVERY- IS BABY VIABLE?

IUD - Aim for vaginal delivery
Alive - aim for most expedient delivery method
Instrumental delivery only if os full and
expecting a relatively easy and fast delivery
Otherwise crash Caesarean section
emergency CS, regardless of indications,
should be performed within 30 minutes
from the time decision was made

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MANAGEMENT
Call for help
Give explanations to the woman and her birth
partner
Move the woman into the knee-chest or
exaggerated Sims position (see Appendix A)
If syntocinon augmentation is in progress,
discontinue immediately
Elevate the presenting part digitally or by
bladder filling

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Avoid excessive handling of umbilical cord.

If cord is presenting outside of vagina, it can be
replaced gently or wrapped in warmed salinesoaked gauze to prevent reactive
vasoconstriction.
Continue to assess fetal heart rate
Expedite the birth of the baby
Transport the woman to the operating theatre, if
required

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RELIEVE CORD COMPRESSION

Replace cord gently into vagina
Place hand in vagina, cord cradled in palm
Tips of fingers elevating presenting part
Mother in trendelenburg or knee-chest position
Fill bladder (16 Foley catheter, 500-800ml of
saline)

Several

studies have shown reduced perinatal

mortality with elevation of the presenting part by
bladder filling.
Allow time for anaesthesia & transfer of the woman
to the secondary or tertiary unit from other settings.

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Continuation of relieving of cord compression

during
Induction

of anaesthesia
Placement of sterile sheet
LSCS

Remove hands only when the surgeon tells you!

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Trendelenberg position

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PREVENTION

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REFERENCES

RCOG

Green-top

guideline No. 42 / 2nd edition/ March 2012/

Shoulder Dystocia
http://www.rcog.org.uk/files/rcog-corp/GTG42_150713.pdf

Green-top

Guideline No. 50/ April 2008/ Umbilical

Cord Prolapse
http://www.rcog.org.uk/files/rcog-corp/uploaded
files/GT50UmbilicalCordProlapse2008.pdf

http://www.networks.nhs.uk/nhs-networks/staffordshireshropshire-and-black-country/documents/Umbilical
%20Cord%20Prolapse.pdf

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