SHOULDER PRESENTATION

INTRODUCTION

A shoulder presentation refers to a malpresentation at childbirth where the baby is in a transverse lie, thus the leading part is an arm, shoulder, or the trunk. While a baby can be delivered vaginally when either the head or the feet/buttocks are the leading part, it usually cannot be expected to be delivered successfully with a shoulder presentation unless a cesarean section is performed.
DEFINITION: when the long axis of the fetus lies perpendicular to the maternal spine or centralized uterine

axis, it is called transverse lie. But more commonly the fetal axis is placed oblique to the maternal spine and is then called oblique lie. In either of the conditions, the shoulder usually presents over the cervical opening during labour & as such both are called shoulder presentation.
INCIDENCE: It is about 1 in 300 births. It is common in premature & macerated fetuses, 5 times more

common in multiparae than primigravidae. Transverse lie is found in twin pregnancy is found in 40% of the cases. 3-4% during the last quarter of pregnancy but 0.5% by the time labour commences.
ETIOLOGY: Before term transverse or oblique lie may be transitory, related to maternal position or

displacement of the presenting part by an overextended bladder prior to ultrasound examination. Factors that
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change the shape of pelvis, uterus or fetus, allow free mobility of the fetus or interfere with engagement as: o Maternal:  Contracted pelvis.  Lax abdominal wall & uterine muscles as in multigravidae  Uterine abnormality as bicornuate, subseptate and fibroid uterus.  Pelvic masses as ovarian tumours. o Foetal causes:  Multiple pregnancy.  Polyhydramnios: the distended uterus is globular & the fetus can move freely in the excessive liquor.  Placenta praevia: prevents the head from entering the pelvic brim.  Prematurity: the amount of amniotic fluid in relation to the fetus is greater allowing the fetus more mobility than at term.  Intrauterine foetal death.  Macerated fetus: lack of muscle tone causes the fetus to slump down into the lower pole of uterus.

POSITIONS

It is determined by the direction of the back which is the denominator. The scapula is the denominator. According to the position of the head, the fetal position is termed right or left, the left one being commoner than the right.
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Left scapulo-anterior. Right scapulo-anterior. Right scapulo-posterior. Left scapulo-posterior.

Scapulo-anterior are more common than scapulo-posterior as the concavity of the front of the foetus tends to fit with the convexity of the maternal spines.
DIAGNOSIS

During pregnancy
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Inspection: o The abdomen is broader from side to side. The uterus looks broader & often asymmetrical, not maintaining the pyriform shape. Palpation: o Fundal level: lower than that corresponds to the period of amenorrhea. o Fundal grip: The fundus feels empty. Fetal pole is not palpable. o Lateral grip/Umbilical grip: The head is felt on one side while the breech one the other. In transverse lie, they are at the same level, while in oblique lie one pole, usually the head as it is heavier, is in a lower level i.e. in the iliac fossa. The back is felt anteriorly across the long axis in dorso-anterior or the irregular small parts are felt anteriorly in dorso posterior. o Pelvic grip: Empty lower uterine segment, but during labor it may be occupied by the shoulder. Auscultation: FHS are best heard easily much below the umbilicus in dorso-anterior position. It is however located at a higher level & often indistinct in dorso- posterior position. Ultrasound or X-ray: o Confirms the diagnosis and may identify the cause as multiple pregnancy or placenta praevia.

During labour Vaginal Examination reveals: 
    

The presenting part is high. Elongated bag of membranes if it does not rupture prematurely. Premature rupture of membranes with prolapsed arm or cord is common. The shoulder can be identified by palpating the following parts- acromian process, scapula, clavicle & axilla. The landmarks are the feeling of the ribs & intercostals spaces. On occasion prolapsed arm is seen. It is confined not only to transverse lie but may also be associated with compound presentation. Determination of position: the thumb of the prolapsed hand when supinated, points towards the head, the palm corresponds to the ventral aspects. The angle of the scapula if felt indicates the position of the back. The side to which the prolapsed arm belongs, can be determined by shaking hands with the fetus. If the right hand is required for this the, prolapsed arm belongs to right side & viceversa.

MECHANISM OF LABOUR As a rule no mechanism of labour should be anticipated in transverse lie and labour is obstructed. If a patient is allowed to progress in labour with a neglected or unrecognized transverse lie, one of the following may occur: Unfavourable events (most common)
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Impaction/ Neglected shoulder: it means the series of complication that arise out of shoulder presentation when labor is left uncared for. o This is the usual and most common outcome. o Obstructed labor - the lower uterine segment thins and ultimately ruptures. o The fetus becomes hyperflexed, placental circulation is impaired, and cord is prolapsed and compressed leading to fetal asphyxia and death.

Clinical picture (impending rupture uterus) 
 

   

Exhaustion and distress of the mother. Dehydration & ketoacidosis may develop. Evidences of sepsis usually become apparent. Shock may develop. In primigravidae, in response to obstruction, the uterus becomes inert and features of exhaustion & sepsis are only visible. But in multiparae, the uterus reacts vigorously in response to obstruction and ultimately the lower segment gives way as a result of marked thickening of its wall. Shoulder is impacted may be with prolapsed arm and / or cord. Membranes are ruptured since a time. Liquor is drained. The uterus is tonically contracted. The fetus is severely distressed or dead.

Favorable events (very rare): these events are very rare & occur only when the fetus is premature or macerated
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Spontaneous rectification: o It usually occurs in early labor with good amount of liquor & the baby is small & movable. Rarely the fetal lie may be corrected by the splinting effect of the contracted uterine muscles so that the head presents. Thus the lie may be changed from oblique to longitudinal with vertex presentation, when it is called rectification. Spontaneous version: o Rarely, by similar process the breech may come to present. Spontaneous expulsion (conduplicato corpora): o Very rarely, if the fetus is very small or dead and macerated, the shoulder may be forced through the pelvis followed by the head and trunk. Fetus is expelled doubled up, with chest & abdomen apposed. Spontaneous evolution: o Very rarely, the head is retained above the pelvic brim, the neck greatly elongates, the breech descends followed by the trunk and the after -coming head, i.e. spontaneous version occurs in the pelvic cavity. It requires strong uterine contraction.

PROGNOSIS

In well supervised pregnancy and labor the maternal & fetal outcome is not much unfavorable. But in uncared pregnancy & labor maternal risks is more & fetal loss more because of cord prolapse.

Scheme of clinical course of labor in transverse lie left uncared for

Unfavorable Early rupture of the membranes Prolapse of hand/ or
Cord

Favorable Spontaneous Correction Early labor Small baby version breech rectification vertex Double up fashion Fetal Death Expulsion of breech & trunk followed by head
Baby small/ macerated Uterine contraction

Spontaneous Expulsion

Spontaneous Evolution

Fetal death Drainage of liquor Intrauterine infection Poor cervical dilation

Contraction of the upper segment Distension of the lower segment Formation of Bandl¶s ring

Appearance of dehydration & exhaustion Ketoacidosis, Sepsis Maternal death

Multigravida Rupture of uterus Maternal death

Primigravida Uterine exhaustion

MANAGEMENT

Antenatal : External cephalic version should be done in all cases beyond 35 weeks if the membranes are intact and vaginal delivery is feasible. If the version fails or is contraindicated The patient is to be admitted at 37 week, because risk of early rupture of membranes and cord prolapsed. Elective cesarean is preferred mode of delivery. Vaginal delivery may be allowed in dead or malformed fetus. Labor be allowed under full supervision till full cervical dilation, when the baby can be delivered by internal version or destructive operation.

Can be done in late pregnancy or even early in labour In early labour, if version succeeded apply abdominal binder and rupture the membranes as if there are uterine contractions. Early labor: external cephalic version when good amount of liquor amnii is present. Cesarean section is preferred. Late labor: Baby alive: if baby is mature & fetal condition is good cesarean is preferable. Internal version is done only in case of second twin. Baby dead: Cesarean section is preferred when obstetrician is not conversant with destructive operation. If destructive operation is done uterine cavity is to be explored to exclude rupture of uterus. Internal version should not be done.

Internal podalic version: It is mainly indicated in 2nd twin of transverse lie and followed by breech extraction. Prerequisites: General or epidural anaesthesia. Fully dilated cervix. Intact membranes or just ruptured.

Caesarean section
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It is the best and safest method of management in nearly all cases of persistent transverse or oblique lie even if the baby is dead. As rupture of membranes carries the risk of cord prolapse, an elective caesarean section should be planned before labour commences.

COMPOUND PRESENTATION

DEFINITION: Compound presentation is defined as presentation of a fetal extremity alongside the presenting part. It may involve one or more extremities (e.g. hand, arm, foot) with the vertex or the breech. The majority of compound presentations are represented by the fetal hand or arm presenting with the vertex.

When a cephalic presentation is complicated by the presence of one or both hands by the side of the breech, it is called compound presentation.
INCIDENCE: Compound presentation complicates from 1 in 700 to 1 in 1000 deliveries ETIOLOGY 

Conditions preventing engagement of head can result in slipping of either upper or lower limbs by the side of the head.  Prematurity  Contracted pelvis, pelvic tumors  Macerated fetus  It is more likely to occur when the pelvis is not fully occupied by the fetus because of low birth weight, multiple gestation, polyhydramnios, or a large pelvis .Rupture of membranes when the presenting part is still high also increases the risk of compound presentation, cord prolapse, or both.  External cephalic version .During the process of external version, a fetal limb (commonly the hand/arm, but occasionally the foot) can become "trapped" below the fetal head and thus become the presenting part when labor ensues.  Multiple gestations: a possible scenario involves the head of the first twin and an extremity of the second twin within the birth canal.
DIAGNOSIS 

When cervical os is sufficiently dilated to feel the limb by the side of presenting part.  Compound presentation may be noted on an antepartum obstetrical ultrasound examination  When palpated during a cervical examination, typically during early labor. The examiner will feel an irregular shape beside or in advance of the vertex or breech.  Compound presentation may not be diagnosed on admission to the labor unit if the cervix is long or closed, but will be discovered as labor progresses and the cervix becomes more dilated. The clinician should consider this condition when the head remains high or unengaged after rupture of membranes or when there is a delay in the active phase.  Cord prolapsed is to be excluded.
LABOR MANAGEMENT

Factors to be considered      Stage of labour Maturity of the fetus Singleton or twins Pelvic adequacy Associated cord prolapsed

Indication for caesarean section: mature singleton fetus associated with contracted pelvis or cord prolapsed with fetus alive should be safely delivered. Expectant treatment: elevation of the prolapsed limb with descent of the presenting part usually takes place spontaneously. Slight elevation of the prolapsed limb during uterine contraction is a favorable sign. For women with normal progressing labor, favor observation alone. Occasionally, the presenting part will simply push the extremity aside or the fetus will retract the extremity as labor progresses The management of compound presentation is debatable. Some experts recommend attempting to reposition the fetal extremity, while others discourage this practice. There is consensus that oxytocin should be avoided.
NURSING MANAGEMENT

Determine onset of true labor Evaluate the uterine contraction pattern every 30-60 mt for frequency, duration, intensity, tone. Assess cervical dilation, fetal position,station, status of presenting part. Evaluate labor progress with partogram Assess for signs of dehydration, electrolyte imbalance, hypoglycemia. Fetal surveillance, FHS monitoring. Encourage patient to try various position changes. Encourage rest between contractions.

NURSING DIAGNOSIS

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Acute pain related to an active labor pattern as evidenced by verbalization/ non verbal behavior. Use positional comfort interventions along with lower back counter pressure to assist the client. Reassess labor progress and FHR Consult the anesthesia service for regional or general anesthesia in vaginal or cesarean delivery.

2. Anxiety related to altered plans for childbirth experience and unfamiliarity with the management of shoulder presentation Provide psychological support Explain the situation and plan for management to the mother Stay with the mother 3. Risk for injury (maternal) related to operative procedure, as evidenced by postoperative infection, hemorrhage. Prepare for cesarean section. Catheterize the bladder and prepare parts Monitor for any post operative complications Administer drugs as prescribed 4. Risk for injury(fetal) related to possible umbilical cord prolapsed with spontaneous rupture of membranes, soft tissue injury , as evidenced by signs of acute cord compression or fetal trauma after operative or cesarean birth. Order & report USG result to physician Monitor Maternal vital signs & fetal tolerance to labor Instruct client to report any sensation of ruptured membranes & be alert for potential cord prolapsed.

CONCLUSION

As suggested, in most cases, these events need not greatly influence the plans already made for the route of management of the birth process. Simple stimuli designed to get the child to withdraw the abnormal part may succeed. Management of labor and delivery after discovery of the intrusive part should be conservative and compatible with otherwise traditional obstetric principles.
REFERENCE              Fraser DM, Cooper MA. Myles textbook for midwives. 14th edition. London: Churchill Livingstone; 2003 Dutta DC. Textbook of obstetrics. 6th edition. Kolkata: New Central Book Agency; 2004 Jacob Annamma . A Comprehensive Textbook of Midwifery . 2nd edition . New Delhi : Jaypee Brothers Medical Publishers Pvt Ltd ;2008 Littleton LY, EngebretsonCJ. Maternity nursing care.1st edition. Haryana: Delmar learning;2007 Arias F, Daftary SN, Bhide AG. High risk pregnancy & delivery. 3rd edition. Noida: Elsevier; 2008 Mudaliar AL, Menon MK. Clinical obstetrics.10th edition. Chennai: Orient Longman; 2005. Evans AT. Manual of Obstetrics. 7th edition. New Delhi: Wolter Kluwer Pvt Ltd; 2007 Ladewig PW, London ML, Olds SB. Maternal newborn nursing. California: Addison Wesley nursing; 2007 Gilbert ES. High risk pregnancy & delivery. 4th edition. Missouri: Mosby; 2007 Internal podalic version for neglected shoulder presentation with fetal demise.Mahajan NN. BJOG. 2009 Dec;116(13):1801-4. Epub 2009 Jul 27. http://emedicine.medscape.com/article/262444-overview http://www.ncbi.nlm.nih.gov/pubmed/19656146 http://www.gfmer.ch/Obstetrics_simplified/shoulder_presentation_and_unstab.htm

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