Shoulder Presentation – Everything You Should Be Aware Of

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Vaginal delivery is the best way to bring your baby out, but it is not always an easy option. The position of the fetus is crucial as any deviation in this can lead to complications.

Shoulder presentation is a rare but a complicated instance when normal delivery becomes almost impossible. Read below to know more about this phenomenon, its diagnosis and the options you have when you face this situation.

What Is Shoulder Presentation:

Shoulder presentation happens when that part of the fetus pushes out of the mother’s body first. This may occur when the fetus is positioned transversely across the uterus.

In a shoulder presentation, a baby cannot be delivered through the natural way but only through Caesarean section because vaginal delivery is possible only if the baby’s head or feet/buttock are at the bottom. If the baby is facing downwards, its hand may appear through the cervix, and if it is facing upwards, its back may be visible.

[ Read: Brow Presentation And Its Complications ]

What Is Transverse Lie:

When the long axis of the fetus lies perpendicular to the maternal spine or uterine axis, it is called a transverse lie. When the fetal axis is slanted to the maternal spine, it is known as an oblique lie. In both the conditions, the shoulder presents over the cervical opening during labor.

Frequency Of Shoulder Representation:

Shoulder presentation is a rare condition and occurs among one in 300 births. It is common in macerated and premature fetuses and five times more frequent in multiparae than in primigravidae.

Causes Of Shoulder Presentation:

Shoulder presentation can be the result of various fetal or maternal factors.

The fetal factors include:

  • Multiple pregnancies
  • Preterm labor
  • Polyhydramnios, a condition in which the fetus can move freely in excessive water
  • Placenta previa, which prevents the head from entering the pelvic brim
  • Intrauterine fetal death
  • Macerated fetus, the lack of muscle tone, which causes the fetus to fall into the lower portion of the uterus.

[ Read: How To Push During Delivery ]

The maternal factors include:

  • Uterine abnormality such as sub-septate and fibroid uterus and bicornuate
  • Pelvic masses as ovarian tumors
  • Lax uterine and abdominal muscles. It usually occurs in the case of multiple pregnancies.
  • Contracted or abnormally narrow pelvis

What Are the Complications Of Shoulder Presentation?

  • Trauma to a prolapsed arm
  • Cord prolapse
  • Ruptured uterus and obstructed labor
  • Fetal hypoxia or even death

Diagnosis Of Shoulder Presentation:

  • The most common diagnosis of shoulder presentation is the uterus becoming broader on abdominal palpation.
  • The height of the fundus reduces because it is occupied by neither the buttock nor baby’s head.
  • The expectant mother can feel the head on one side of her abdomen.
  • On vaginal examination, especially during early labor, the presenting part may not be felt by the mother, but when it progresses, she can feel the baby’s ribs.
  • If the shoulder enters the pelvic brim, the arm may become visible outside the vagina because of arms prolapse.

Management Of Shoulder Presentation:

Traverse lie can be versed in a longitudinal line before labor, but once the uterus starts contracting, it will not allow for any such procedures. Here are the different ways to manage shoulder presentation.

1. External cephalic version:

  • The external cephalic version of shoulder presentation should be done in cases beyond 35 weeks, and only if the membranes are intact, and the vaginal delivery is feasible.
  • The patient has to be admitted at 37 weeks when the risk of membranes and cord rupture prolapse. In such a case, Caesarean section is the preferred mode of delivery.
  • Vaginal delivery can be allowed in the malformed or dead fetus. Labor must be permitted under full supervision, by destructive operation or internal version.

External cephalic version is done both during early and late labor.

Early Labor:

  • External cephalic version can be done during early labor when a good amount of amnii is present. Doctors suggest a Caesarean section in early labor.

Late Labor:

  • In the case of late labor, if the fetal condition is good and the baby is mature, Caesarean section is preferred. The internal version should be done only in the event of the second twin.
  • For stillborn babies, Caesarean-section is preferred. If destruction operation needs to be done, the uterine cavity should be explored to avoid the rupture of the uterus.

[ Read: Natural Pain Relief During Labor ]

2. Internal Podalic Version:

Internal Podalic Version is indicated in case of the second twin of a transverse lie, followed by breech extraction.

The prerequisites for internal podalic version include:

  • Dilated Cervix
  • Just ruptured or intact cervix
  • Epidural or general anesthesia

3. Caesarean Section:

  • Caesarean section is the safest management method in nearly all the cases of persistent transverse or oblique lie.
  • Rupture of membranes can lead to cord prolapse. Elective Caesarean section should be planned before the commencement of labor.
  • Remember, in shoulder presentation, the baby cannot be born through the vagina. So if you detect this anomaly, consult a specialist immediately.

Did anyone you know experience shoulder presentation? Share some tips and inputs with us by commenting below.

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