Following delivery of the fetal head, a inger is passed across the fetal neck to determine whether it is encircled by one or more umbilical cord loops. he nuchal cord incidence increases with gestational age and is found in nearly 25 percent of deliveries at term (Larson, 1997; Ogueh, 2006). If an umbilical cord coil is felt, it is slipped over the head if loose enough. If applied too tightly, the loop is cut between two clamps. Tight nuchal cords complicate approximately 6 percent of all deliveries but are not associated with worse neonatal outcome than those without a cord loop (Henry, 2013).
Following its delivery, the fetal head falls posteriorly, bringing the face almost into contact with the maternal anus. he occiput promptly turns toward one of the maternal thighs, and the head assumes a transverse position. This external rotation indicates that the bisacromial diameter, which is the distance between the shoulders, has rotated into the anteroposterior diameter of the pelvis.
Most often, the shoulders appear at the vulva just after external rotation and are born spontaneously. If delayed, extraction aids controlled delivery. The sides of the head are grasped with two hands, and genle downward traction is applied until the anterior shoulder appears under the pubic arch (Fig. 27-4). Next, by an upward movement, the posterior shoulder is delivered. During delivery, abrupt or powerful force is avoided to avert fetal brachial plexus injury.
he rest of the body almost always follows the shoulders without diiculty. With prolonged delay, however, its birth may be hastened by moderate outward traction on the head and moderate pressre on the uterine fundus. Hooking the fingers in the axillae is avoided. This can injure upper extremity nerves and produce a transient or possibly permanent paralysis. Immediately after delivery of the newborn, a gush of amnionic luid that is often blood-tinged but not grossly bloody usually follows.
Previously, immediate nasopharyngeal bulb suctioning of the newborn was routine to remove secretions. It was found, however, that suctioning of the nasopharynx may lead to neonatal bradycardia (Gungor, 2006). he current American Heart Association neonatal resuscitation recommendations eschew most suctioning immediately following birth-even with meconium present (Chap. 33, p. 620). And with meconium-stained luid, routine intubation for tracheal suction is not recommended for vigorous or for nonvigorous neonates. Suctioning is reserved for neonates who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation (Wyckof, 2015). For suctioning, options are bulb syringe or suction catheter aspiration and may include intubation and suctioning if the airway is obstructed.
FIGURE 27-4 Delivery of the shoulders. A. Gentle downward traction to effect descent of the anterior shoulder. B. Delivery of the anterior shoulder completed. Gentle upward traction to deliver the posterior shoulder.
The umbilical cord is cut between two clamps placed 6 to 8 cm from the fetal abdomen, and later an umbilical cord clamp is applied 2 to 3 cm from its insertion into the fetal abdomen.
For term neonates, the timing of umbilical cord clamping remains debatable. Delayed umbilical cord clamping transfers a greater volume of blood to the newborn. A delay for up to 60 seconds may increase total body iron stores, expand blood volume, and decrease anemia incidence in the neonate (Andersson, 2011; Yao, 1974). his practice may be particularly valuable in populations in which iron deficiency is prevalent (Kc, 2017; World Health Organization, 2014).