15.2 Complicated Deliveries: Breech, Prolapsed Cord, Nuchal Cord & Postpartum Hemorrhage

15.2 Complicated Deliveries: Breech, Prolapsed Cord, Nuchal Cord & Postpartum Hemorrhage

Nuchal Cord: Pathophysiology and Emergency Field Management

A nuchal cord occurs when the umbilical cord wraps 360° around the fetal neck, an occurrence documented in approximately 20% to 30% of all deliveries. While frequently loose and benign, a tight or multi-looped nuchal cord can become severely compressed as the fetal torso advances into the birth canal, occluding umbilical vein and artery blood flow and inducing acute fetal asphyxia, bradycardia, and cerebral ischemia.

Clinical Management Protocol

1. Palpation: Immediately upon the delivery of the fetal head, the paramedic gently slides a gloved index finger around the infant's neck.
2. Loose Nuchal Cord: If the cord is loose, gently slip the loop forward over the newborn's head. If there is sufficient slack, the loop may alternatively be guided downward over the emerging shoulders and body as delivery progresses.
3. Tight Nuchal Cord: If the cord is wrapped tightly around the neck and cannot be mobilized over the head or shoulders, delivery cannot proceed without risk of cord tearing or fetal strangulation:
   • Immediately place two umbilical clamps side-by-side directly onto the cord encircling the neck.
   • Cut the cord cleanly between the two clamps with sterile scissors.
   • Rapidly uncoil the cord from around the neck.
   • Immediately proceed with delivery of the shoulders and torso without delay, recognizing that the neonate is now completely disconnected from placental oxygen supply.

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Shoulder Dystocia: Recognition and Prehospital Rescue Maneuvers

Shoulder dystocia is an unpredictable, time-critical obstetrical emergency in which the anterior fetal shoulder becomes mechanically impacted behind the maternal symphysis pubis after the delivery of the head. Once the head delivers, the infant's chest cannot expand, and the umbilical cord is compressed between the fetal body and the maternal pelvic brim. Without immediate relief, fetal hypoxia, severe acidemia, irreversible neurological injury, or death occurs within 4 to 6 minutes.

Recognition: The "Turtle Sign"

• The fetal head delivers over the perineum and then immediately retracts tightly against the maternal perineum, with the chin depressing the fourchette.
• External restitution (rotation of the head) fails to occur.
• Gentle downward axial traction on the head fails to deliver the anterior shoulder.

Stepwise Prehospital Rescue Protocol

[Turtle Sign Observed / Shoulder Dystocia]
       │
       ▼
[Stop Maternal Pushing Immediately]
       │
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[McRoberts Maneuver (Hyperflex & Abduct Hips)]
       │
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[Suprapubic Pressure (Directional Downward/Lateral)]
       │
       ├──> [Shoulder Released] ──> Proceed with Delivery
       │
       ▼ (If Impaction Persists)
[Gaskin All-Fours Maneuver]
       │
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[Emergency ALS Intercept & Rapid Transport]

1. Stop Maternal Pushing: Instruct the mother to immediately stop pushing. Involuntary or voluntary maternal bearing-down forces drive the anterior shoulder more firmly against the pubic bone, compounding the impaction.
2. McRoberts Maneuver (First-Line):
   • Position two rescuers (or family members) on either side of the mother.
   • Hyperflex the mother's thighs sharply back against her abdomen while abducting the hips (knees brought tightly to the patient's shoulders).
   • Biomechanical Rationale: This maneuver flattens the maternal lumbosacral angle, rotates the symphysis pubis cephalad, and directs the posterior pelvic inlet backward, freeing up to 1 to 2 cm of vital pelvic clearance.
3. Suprapubic Pressure (Simultaneous with McRoberts):
   • An assistant places the heel of a gloved hand directly over the maternal lower abdomen, immediately above the symphysis pubis.
   • Apply firm, continuous or rocking downward and lateral pressure toward the fetal chest.
   • Biomechanical Rationale: Suprapubic pressure directly pushes the anterior shoulder downward and inward, adducting the shoulder girdle and rotating it into the wider oblique pelvic diameter.
4. Gaskin All-Fours Maneuver (Alternative):
   • If McRoberts and suprapubic pressure fail, roll the mother onto her hands and knees ("all-fours"). Gravitational and positional changes often dislodge the impacted shoulder.

[!CAUTION] Strict Contraindication: FUNDAL PRESSURE IS PROHIBITED: Paramedics must NEVER apply fundal pressure during a shoulder dystocia. Pushing on the top of the uterus rams the impacted anterior shoulder more tightly into the pubic symphysis, guarantees complete avulsion of the fetal brachial plexus (Erb's palsy), causes clavicular and humeral fractures, and carries an extreme risk of catastrophic maternal uterine rupture.

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Breech Presentation: Classifications & Delivery Management

In a breech presentation, the fetal buttocks or lower extremities present first at the pelvic inlet (occurring in approximately 3% to 4% of term deliveries). Breech deliveries carry exceptionally high prehospital risks: the soft buttocks and legs fail to dilate the maternal cervix as effectively as the hard fetal skull, predisposing to cord prolapse and entrapment of the aftercoming head by a partially dilated cervix.

Classifications of Breech Presentation

• Frank Breech (50–70%): Hips are flexed, and knees are extended with the feet touching the fetal face/head. The buttocks present alone at the introitus.
• Complete Breech (10%): Both hips and knees are flexed. The infant sits cross-legged with buttocks and feet presenting together.
• Footling / Incomplete Breech (10–25%): One or both hips and knees are extended, with one or both feet protruding into the vagina. This carry an exceptionally high risk of umbilical cord prolapse.

General Prehospital Principles

• If a breech presentation is identified early in labor, initiate immediate rapid transport to an obstetrical center; do not attempt delivery in the field unless the buttocks are crowning and delivery is unavoidable.
• THE GOLDEN RULE OF BREECH DELIVERY: NEVER PULL ON THE BABY. Applying traction or pulling on the breech fetus causes the infant's arms to extend over the head (nuchal arms) and causes the fetal head to hyperextend, trapping the chin behind the symphysis pubis and making delivery virtually impossible.

Assisting Spontaneous Breech Delivery

1. Allow the buttocks and lower limbs to deliver spontaneously through maternal pushing.
2. As the legs deliver, grasp the infant's pelvis and bony hips wrapped in a warm, sterile towel. Do NOT compress or squeeze the infant's soft abdomen, which can lacerate the liver, spleen, or kidneys.
3. Support the infant's torso as it rotates. Allow the arms to emerge spontaneously; if an arm is delayed, gently sweep a finger over the infant's shoulder to flex the arm at the elbow and sweep it across the chest.

Emergency Management of the Delayed Aftercoming Head

Once the body has delivered, the umbilical cord is compressed between the baby's head and the maternal pelvis. The head must deliver within 3 minutes to prevent fatal asphyxiation. If the head does not deliver spontaneously:

1. Mauriceau-Smellie-Veit Maneuver

• Lay the infant face down (prone) along the paramedic's forearm, supporting the infant's chest with the palm.
• Insert the index and middle fingers of that hand into the vagina and place them on the infant's maxilla (malar bones) on either side of the nose. Do NOT pull on the infant's mandible, as this fractures the jaw and tears the tongue.
• Place the index and middle fingers of your other hand over the infant's shoulders/occiput.
• Apply gentle downward flexion on the malar bones to flex the fetal chin down onto the chest, maintaining the smallest cephalic diameter.
• Apply gentle, steady downward traction until the subocciput pivots under the maternal symphysis pubis, then lift the infant upward toward the mother's abdomen to deliver the face and skull.

2. Gloved V-Shaped Finger Airway Creation

• If the aftercoming head remains entrapped and cannot be delivered despite the Mauriceau maneuver, the infant will asphyxiate as the compressed cord halts all oxygen delivery.
• Emergency Airway Procedure: The paramedic immediately inserts two sterile gloved fingers into the vagina, forming a "V" on either side of the infant's nose.
• Push the maternal vaginal wall firmly away from the infant's face and nose to create an artificial pocket of air.
• This physical airway allows the trapped infant to breathe ambient room air inside the birth canal.
• Maintain this hand position continuously while emergency transport is executed under priority conditions to the nearest obstetrical surgical suite.

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Umbilical Cord Prolapse: Emergency Interventions

Umbilical cord prolapse occurs when the umbilical cord slips ahead of or alongside the presenting fetal part and protrudes through the open cervix into the vagina or past the vulva. When the fetal presenting part descends during contractions or membrane rupture, it directly crushes the umbilical cord against the maternal bony pelvis, completely cutting off umbilical blood flow. This causes immediate, profound fetal bradycardia, catastrophic asphyxia, and fetal death within minutes.

Identification & Risk Factors

• Visible umbilical cord protruding from the vaginal introitus, or palpable pulsating/non-pulsating loop of cord felt during vaginal assessment.
• Common risk factors: Premature rupture of membranes (PROM), footling breech or transverse lie, polyhydramnios, unengaged presenting part, multiparity, multiple gestation.

Stepwise Prehospital Emergency Protocol

1. Immediate Manual Elevation of Presenting Part:
   • The paramedic immediately inserts a sterile, gloved hand into the vagina.
   • Locate the presenting fetal part (head or buttocks) and apply gentle, steady, continuous upward pressure to lift the fetus off the umbilical cord.
   • Maintain this upward pressure continuously to relieve cord compression.
2. CONTINUOUS HAND PLACEMENT (DO NOT REMOVE HAND):
   • The paramedic's hand must remain inside the vagina holding the fetus off the cord throughout the entire packaging, transfer, ambulance transport, and hospital handover until the obstetrician delivers the baby in the operating room.
3. Maternal Positioning:
   • Place the mother in the knee-chest position (patient rests on knees and elbows/chest with buttocks elevated in the air) or exaggerated Trendelenburg position (stretcher tilted 30° head-down with pillows beneath the hips).
   • Rationale: Gravity causes the fetus to slide toward the maternal diaphragm, relieving gravitational pressure on the cord.
4. Cord Protection:
   • Wrap any externally exposed portion of the cord gently with warm, sterile saline-moistened dressings to prevent dessication and cold-induced arterial vasospasm.
   • NEVER ATTEMPT TO PUSH THE PROLAPSED CORD BACK INTO THE UTERUS. Mechanical manipulation of the cord triggers severe, irreversible umbilical arterial vasospasm, terminating all remaining perfusion.
5. Supportive Care & Transport:
   • Administer high-flow oxygen (15 L/min NRB) to the mother to maximize maternal PaO2.
   • Establish large-bore IV access.
   • Transport immediately under Code 3 (lights and sirens) conditions with early pre-arrival notification for an emergent stat Cesarean section.

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Postpartum Hemorrhage (PPH)

Postpartum Hemorrhage (PPH) is traditionally defined as blood loss exceeding 500 mL following a normal vaginal delivery (or >1000 mL following Cesarean delivery), or any volume of blood loss resulting in maternal hemodynamic compromise (hypotension, tachycardia, diaphoresis, altered mental status).

Etiologies: The "4 T's"

• Tone (Uterine Atony): Responsible for 70% to 80% of all PPH cases. After placental separation, the interlacing smooth muscle fibers of the myometrium ("living ligatures") normally contract firmly, constricting the torn maternal spiral arteries. When the uterus fails to contract, massive arterial hemorrhage ensues.
• Trauma (20%): Unrepaired lacerations of the cervix, vagina, or perineum; uterine rupture; hematomas.
• Tissue (10%): Retained placental fragments, cotyledons, or succenturiate lobes preventing effective myometrial contraction.
• Thrombin (<1%): Pre-existing or acquired maternal coagulopathies (e.g., DIC secondary to placental abruption or amniotic fluid embolism).

Systematic Prehospital Management of Uterine Atony

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Clinical Scenario: Emergency Shoulder Dystocia Rescue in the Field

Paramedics arrive at a home for a 34-year-old Gravida 4, Para 3 patient at 40 weeks gestation in active second-stage labor. The patient has a history of delivering large-for-gestational-age infants.

1. Recognition: The fetal head delivers over the perineum but immediately retracts firmly against the maternal vulva, pulling the chin tightly into the fourchette (Turtle sign). The head fails to rotate, and gentle downward guidance fails to release the anterior shoulder. Paramedic 1 recognizes acute shoulder dystocia and immediately calls out: "Shoulder dystocia, stop pushing now!"
2. McRoberts Maneuver: Paramedic 1 instructs the partner and the patient's spouse to grasp the patient's legs, sharply hyperflexing her thighs back against her abdomen with hips widely abducted. Paramedic 1 verifies that the patient's hips are completely flexed toward her armpits.
3. Suprapubic Pressure: While the McRoberts maneuver is maintained, Paramedic 2 places the heel of a gloved hand directly above the patient's pubic symphysis and applies firm, directional downward and lateral pressure toward the fetal chest.
4. Release & Delivery: With the anterior shoulder displaced into the oblique diameter, Paramedic 1 applies gentle, steady downward guidance on the fetal head. The anterior shoulder smoothly clears the symphysis pubis, followed immediately by the posterior shoulder and the rest of the body. Total dystocia duration was 85 seconds.
5. Post-Delivery Care: The newborn is vigorous and cries immediately. Paramedic 1 inspects the newborn's clavicles and upper extremities: symmetric arm movement is observed without evidence of brachial plexus injury. The infant is placed skin-to-skin and mother and baby are transported safely to the obstetrical center.

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Exam Pitfalls & High-Yield Dystocia & Hemorrhage Pearls

• Applying Fundal Pressure in Shoulder Dystocia: Fundal pressure is strictly prohibited. It impacts the shoulder deeper, fractures fetal bones, avulses the brachial plexus, and ruptures the uterus.
• Pulling on a Breech Infant: Never pull on a breech delivery. Pulling extends the arms and head, trapping the chin behind the symphysis pubis.
• Removing the Hand in Cord Prolapse: Never withdraw your hand from the vagina after elevating the presenting part in cord prolapse. The hand must remain in place until the infant is delivered surgically.
• Packing the Vagina in Postpartum Hemorrhage: Never pack gauze or pads into the vagina. It conceals active internal blood loss.
• Pushing Prolapsed Cord Back into Vagina: Never attempt to reduce or push a prolapsed cord back into the uterus; doing so provokes catastrophic umbilical arterial vasospasm.