Breech delivery (Cord around the neck)

Limes

Limes

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So let's say that the baby's head is out, but you can see the umbilical cord around the neck.

My exam presented with two possible options:

A) gently slip my finger(s) under the cord and bring it around the head
B) Ask the mom to go head down butt up while putting pressure on the baby's head.

I picked A, but is there specifc time when you ask the mom to go head down and butt up? And why? And when should you put pressure on the head?

Thanks!
 
Limes said:
I picked A, but is there specifc time when you ask the mom to go head down and butt up? And why? And when should you put pressure on the head?
Click to expand...
Legs up.
https://en.wikipedia.org/wiki/McRoberts_maneuver

shoulder-dystocia-yellow.jpg
 
DEmedic said:
I have a very specific time when I ask that, but there's usually not a nuchal cord involved.
Click to expand...
Doing that is what caused this whole issue
 
Elevating the hips does have its advantages, but be careful with how they word things.
First, breech birth is when a part other than the head is delivered first. (butt, leg, arm, etc.)
Nuchal cord is what this situation would be called. You never want to put pressure on the baby's head, however in the case of cord prolapse (when the cord comes out first) that's when you insert two fingers to create an airway in the event the baby starts spontaneously breathing.
 
BassoonEMT said:
You never want to put pressure on the baby's head, however in the case of cord prolapse (when the cord comes out first) that's when you insert two fingers to create an airway in the event the baby starts spontaneously breathing.
Click to expand...

So in the event of a proplapsed umbilical cord, should delivery be stalled for as long as you can until you reach the hospital? As for the two fingers you mentioned, are you creating a small opening for the baby until it's head is out of the vagina?
 
Limes said:
So in the event of a proplapsed umbilical cord, should delivery be stalled for as long as you can until you reach the hospital? As for the two fingers you mentioned, are you creating a small opening for the baby until it's head is out of the vagina?
Click to expand...

Yes inserting the fingers serves two purposes. Mainly to allow perfusion if the cord. If there is pressure on it, it stops blood flow to the baby cutting off oxygen supply. You should be able to feel pulsations in the cord as you would feel an arterial pulse on anyone, if you can't it's probably being compressed. I've also heard it can help the baby to get oxygen in the event he/she/it starts breathing on their own, but everything else I've heard told me that doesn't happen. :confused:

So you do want to haul *** to the er. You do want to avoid having mom push, but sometimes the baby is will come so let it come, but be very careful about the cord, as if it is prolapsed it could also be nuchal, could also be a breech delivery, etc. a saline soaked sterile dressing is also good to keep the cord from drying out. The "knee-chest" position and hip elevation is one of those things they say is useful, but some studies say "eh".

The usual solution is a c-section, so rapid transport that sucker.
 
Limes said:
So in the event of a proplapsed umbilical cord, should delivery be stalled for as long as you can until you reach the hospital? As for the two fingers you mentioned, are you creating a small opening for the baby until it's head is out of the vagina?
Click to expand...

You cannot stall delivery. It has been happening for thousands of years and will happen no matter what you do. For a cord prolapse, you want to haul *** to a hospital that has OB. This pt should never end up in an ER. They need an emergency c-section. You also want to keep the baby off the cord as that is their only way of getting oxygen. This often requires that you push the baby off the cord. You can try to use your hand to create a path for air to get to the baby. You will not find any adequate studies on this because this is not a situation that is amenable to developing a study for. It is probably one of the few times that L&S are truly justified.

As for a nuchal cord, where the cord has wrapped around the baby's neck, that is not a big deal usually. Gently lift the cord over the babies head.
 
Try to unwrap the cord, if the cord is too tightly wrapped, clamp and cut immediately. Continue the delivery.


Primum non Nocere
 
Y'all are getting your terms confused. You really need to know the difference.

A nuchal cord, which is quite common, is when the cord is wrapped around the babies neck at delivery. At delivery, unwrap the cord - problem solved.

An umbilical cord prolapse, where the cord presents before the fetus, is far different and a BIG problem. If delivery is not immediate, whether vaginal or by C-section, fetal morbidity/mortality is very high. These are the types of cases where we run to the OR with the patient on the bed, move them to the OR table, induce, intubate, and cut.

Pre-hospital, it's a much bigger problem. Rather than go through all the steps, here's an excellent article which includes in-house and pre-hospital scenarios.

http://contemporaryobgyn.modernmedi...holbrook-md/umbilical-cord-prolapse?page=full
 
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