Objective To examine the association between head-to-body delivery interval (HBDI) and cord arterial pH and base excess (BE), and the risk of development of hypoxic ischaemic encephalopathy (HIE). Design Retrospective review.Setting A university hospital.Population Pregnancies complicated with shoulder dystocia during the period 1995-2009.Methods Cases were identified from a search of the hospital electronic delivery records. Cord arterial pH and BE, and the incidence of HIE and perinatal death, were retrieved from medical records and correlated with HBDI, birth weight, mode of delivery and presence of nonreassuring fetal heart rate pattern and maternal diabetes using univariate analysis, followed by multivariate analysis.Main outcome measures Any association between cord pH and HBDI.Results Of the 200 cases identified, the mean (standard deviation) HBDI was 2.5 minutes (1.5 minutes). Both HBDI and the presence of nonreassuring fetal heart rate pattern were independent factors for pH, and HBDI was the only significant factor for BE. Arterial pH dropped at a rate of 0.011 per minute [95% confidence interval (95% CI), 0.017-0.004; P = 0.002] with HBDI. The mode of delivery, birth weight and maternal diabetes did not affect blood gas levels. The respective risks of severe acidosis (pH < 7) and HIE with HBDI of <5 minutes were 0.5% and 0.5% versus 5.9% and 23.5% with HBDI ‡ 5 minutes.Conclusions Cord arterial pH drops with HBDI during shoulder dystocia, but the risk of acidosis or HIE is very low with HBDI < 5 minutes.Keywords Acidosis, base excess, head-to-body delivery interval, hypoxic ischaemic encephalopathy, shoulder dystocia, umbilical cord pH.

Objective To evaluate the different types and sequences of manoeuvres to overcome shoulder dystocia and the rates of associated fetal injury. Design Retrospective review.Setting A university hospital.Population Pregnancies complicated with shoulder dystocia from 1995 to 2009.Methods Cases were identified from the hospital electronic delivery records.Main outcome measures The success rate between McRoberts' manoeuvre, rotational methods and posterior arm delivery, and the incidences of brachial plexus injury (BPI), clavicular fracture (CF) and humeral fracture (HF) according to the types and sequences of manoeuvres applied to overcome shoulder dystocia.Results Among 205 cases identified, McRoberts' manoeuvre was successful initially in 25% of cases, of which 7.8% suffered from BPI and 3.9% suffered from CF, but none had HF. In the failed cases, subsequent rotational methods and posterior arm delivery were similarly successful (72.0 versus 63.6%), whereas the former was associated with less BPI (4.4 versus 21.4%) and HF (1.1 versus 7.1%) despite similar risk of CF (5.6 versus 7.1%). The rotational methods were not associated with a higher fetal injury risk compared with McRoberts' manoeuvre. The remaining cases were managed by applying the third yet untried manoeuvre, and posterior arm delivery and rotational methods had similar success (77.1 versus 62.5%). The cumulative success rates after the second and the third manoeuvres were 79.0 and 94.6%, respectively.Conclusion Following the failure of McRoberts' manoeuvre, subsequent application of rotational methods and posterior arm delivery have similarly high success rates but the former may be associated with less fetal injury.

IntroductionVernix Caseosa peritonitis is a rare post caesarean section complication with only 19 case reports in the literature to date. Vernix caseosa spilt at the time of caesarean section is thought to incite an inflammatory reaction, causing symptoms resembling an acute abdomen.Case PresentationWe discuss three Caucasian patients (aged 32 to 43 years) who presented in our health sector in Sydney with vernix caseosa peritonitis. Each had a protracted course with significant comorbidities requiring surgical and medical intervention. This contrasts with other reports suggesting that a rapid resolution can be expected.This cluster may be a consequence of the rising caesarean section rate, a heightened local awareness of the condition and possibly a result of leaving material in the paracolic gutters intraoperatively.ConclusionOur aim is to increase awareness among our obstetric and surgical colleagues of the characteristic clinical presentation and intra-operative findings of vernix caseosa peritonitis. We also point out that, in contrast to those presented here, not all patients require laparotomy.