Dr. S.K.S

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%

Position of fetusDorso-anterior- more common.Dorso-posterior.

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)

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)

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.

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.

Investigation :- USG abdomen pelvis at antenatal period.

MANAGEMENTGeneral management:-I/V fluidBlood grouping, Rh typing & cross match at

least 1 pint blood.Parenteral antibiotics – ampicillin 1 gm,

metronidazole 500mg.

Obstetric management :-A.Antenatal managementB.Labour management.

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.

B. Labour management

Labour

Alive baby

C/S

Dead baby

Internal podalic version with breech extraction

Destructive operation

C/S

Immediate C/S must be perform if:-1.Cord prolapse2.Early rupture of membrane3.ECV failed.4.Any delay in the progress of labour.

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

COMPOUND PRESENTATION

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

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

CORD

PROLAPSE/PRESENTATION

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

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.

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.

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.

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.

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.

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.