Shoulder Dystocia And A Compressed Umbilical Cord
When you see an ultrasound of a pregnant woman at 24 weeks gestation, what do you think about? Do you wonder if there are any abnormalities that could present problems in delivery or later on? If so, you’re not alone; most people probably don’t even consider it until they get to the hospital and have their first glimpse of the infant. But when you look closer at some of these images, like this one posted by Dr. Michael Gabbett on Twitter, you may notice something else besides just the usual stuff – like the heart beating away inside your tiny bundle of joy. You might start wondering what exactly is going on here.
Let’s take a closer look. This particular image shows what appears to be a typical scan picture. In other words, everything looks pretty normal. The only thing out of the ordinary is the heart. It’s beating away as though it were still back in the womb, but its position is causing concern because it isn’t where it should be. Normally, the heart would be situated near the middle of the chest cavity, which means it would be positioned below the left breast, right above the liver. However, in this case, the heart has moved up into the upper abdomen. What does that mean?
Well, it means that the heart is compressed by the weight of the newborn’s head. As a result, the blood vessels running from the heart to the brain aren’t getting enough oxygenated blood to nourish them properly. This causes brain damage and death.
This scenario is called “umbilical cord compression” (or UCC). Most often, it happens during birth when the top half of the infant’s body doesn’t break through the pelvis after all of the other parts have been delivered. Instead, the bottom part of the body gets stuck behind the pubic symphysis. The baby’s legs end up wrapped around the mother’s thighs while her feet dangle down toward her pelvis. With nowhere else to go, the rest of the body ends up pushing upward against the uterine wall. Meanwhile, the shoulders haven’t yet broken through either. As a result, the body becomes wedged between the fetal skull and the mother’s pelvic bone.
In order to relieve the pressure, the doctor needs to perform maneuvers such as turning the baby over, pulling the child forward, rotating his or her torso, or lifting the uterus using forceps or vacuum extraction. These actions increase the risk of injury to the baby, however. They also put more strain on the obstetrician who will need to bear the full weight of the baby and deliver him or her quickly.
If the baby’s head is big and heavy, it can cause severe trauma to the neck and throat area. That’s why doctors try to avoid having large babies born early. While it makes sense to wait until the baby weighs at least 8 pounds before being born, researchers have found that delaying the delivery of twins past 32 weeks results in fewer complications than delivering them earlier.
So how does UCC affect outcomes? Well, according to the American Pregnancy Association, the rate of cerebral palsy among children who had UCC was three times higher than among those who didn’t experience it. Another study showed that infants who experienced UCC were four times more likely to die within their first year than others. Still another study showed that infants who suffered UCC were twice as likely to develop chronic lung disease, and those with pneumonia were almost five times more likely to suffer from it.
As if that wasn’t bad enough, a 2011 review published in the Journal of Obstetrics & Gynecology found that women whose fetuses turned sideways were at greater risk for having a caesarean section. Babies’ heads tilted to one side can cause the lower portion of the body to compress the bladder, leading to difficult urination and necessitating a catheterization procedure.
But perhaps the worst outcome of UCC is when it leads to shoulder dystocia. Read on to find out what that is.
According to WebMD, shoulder dystocia refers to a situation in which the baby’s head cannot fit through the vagina. Shoulder dystocia is a type of obstruction of labor that usually presents itself in two forms – anterior and posterior. Anterior shoulder dystocia is characterized by difficulty passing the fetus through the pelvic outlet. Posterior shoulder dystocia involves the baby’s shoulders becoming stuck behind the pubic symphysis. Both types require prompt action to prevent potentially catastrophic consequences.
With anterior shoulder dystocia, the baby’s arms become crossed due to compression of the brachial plexus. This prevents proper development of the muscles needed to extend the elbows. Because of this, the hands typically remain flexed, preventing the fingers from reaching the outside world. Without the ability to grasp onto anything, the baby relies entirely upon passive stretching of the umbilical cord to survive.
Posterior shoulder dystocia is caused by the fact that the baby’s buttocks are pushed up into the pelvis, blocking the passage of the rest of the body. As a result, the legs are forced to cross each other. To compensate, the baby kicks his or her heels downward, stretching the tendons and ligaments connecting the bones of the leg and foot. Eventually, the heel slips off the ground completely, resulting in loss of muscle control and possible fracture.
What happens next depends largely upon how long the impaction lasts. If the baby remains in place, he or she could lose consciousness and stop breathing. Once the baby begins breathing again, however, he or she could begin crying loudly or whimpering. This could lead to further delays in making a decision about whether to continue trying to pass the baby through the pelvis or call for emergency services.
Once the baby emerges, it’s time for the doctor to check him or her thoroughly. A pediatrician uses a stethoscope to listen to the heart and lungs, looking for signs of apnea, cyanosis (when the skin turns blue), tachycardia (a fast heartbeat), or bradycardia (a slow heartbeat). He or she then checks reflexes, temperature, pulse, color, capillary refill, mucous membranes, and movement. Any problem that goes unnoticed could worsen rapidly, putting the baby at risk of developing hypoxia (lack of oxygen) or shock.
The medical staff will want to know if the baby is healthy and able to breathe without assistance. If he or she is, the caregiver will move the baby carefully to minimize stress on the fragile neck. Some caregivers use specialized techniques, including chin lifts, suction-assisted deliveries, and rotational forces to help turn the baby from one side to the other. Others simply rotate the baby manually. All of these methods can compromise the integrity of the airway or make intubation necessary. Intubation requires inserting a tube through the mouth and into the trachea, allowing the physician to keep tabs on the vital signs of the baby.
For many years, physicians considered shoulder dystocia a life-threatening condition. Nowadays, thanks to improved training and better technology, the odds of survival are much better. According to the National Center for Health Statistics, in 2008, 98 percent of infants born weighing less than 12 pounds survived. Of those, 92 percent survived beyond their first day of life. But that still means that eight out of every 100 infants under 12 pounds dies each year.
One way to improve the chances of survival is by performing cesareans prior to giving birth. In 2001, the number of births via C-section ranged from 19% in New York state to 40% in South Carolina and 48% nationwide. Yet today, the rate of C-sections in the United States is nearly 30%.
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