Shoulder Dystocia District 1 ACOG Medical Student Education Module 2011 Definition Difficulty in delivery of fetal shoulders Failure to deliver fetal shoulder without utilizing facilitating maneuvers Prolonged head-to-body delivery time >60 seconds
Incidence: 0.2-3% of all live births; represents an obstetric emergency Pathophysiology Size discrepancy between fetal shoulders and maternal pelvic inlet Macrosomia Large chest:BPD Absence of truncal rotation Fetal shoulders remain A-P or descent simultaneously
Risk factors cont No evidence based data: Male AMA Short maternal stature Abnormal pelvic shape/size
Unpredictable 25-50% have no defined risk factor! 50% of cases occur in infants whose birth weight is <4000g 84% of patients did not have prenatal dx. of macrosomia by US 82%of infants with brachial plexus palsy did not have macrosomia Complications
Maternal Hemorrhage 4th degree laceration Fetal Fx of humerus or clavicle Brachial plexus injury (Erbs/Klumpkes palsy)
Asphyxia/cord compression Physician Litigation: 11% of all obstetrical suits Management Goal: Safe delivery before neontal asphyxia and/or cortical injury 7 minutes!!!
Episiotomy Suprapubic Pressure McRoberts Maneuver Woods or Rubin Maneuvers Zavenelli Push back the delivered fetal head into birth canal and perform an emergent c/s
McRoberts Maneuver 42% success rate + Suprapubic pressure = 54-58% Brings pelvic inlet and outlet into more vertical alignment Flattens sacrum Cephalad rotation of pubic symphysis Elevates anterior shoulder and flexes fetal spine Increases IUP by 97%
Increases amplitude of contractions +31N of pushing force Summary Cannot accurately predict BE PREPARED!
Consider risk factors Be prepared to perform various maneuvers Diagnose and treat quickly Obtain assistance from nursing staff and NICU HELPER Algorithm H: Call for Help; Shoulder dystocia is called if shoulders cannot be delivered with gentle traction E: Evaluate for Episiotomy: Not routinely
indicated; maybe needed when attempting intra-vaginal maneuver L: Legs (McRoberts): Hyperflexion and abduction of hipsinitial maneuver HELPER Algorithm cont. P (Suprapubic Pressure): No fundal pressure; combination of McRoberts and suprapubic pressure resolves most shoulder dystocias Enter (Internal Maneuvers): Woods: Insert hand into posterior vagina and rotate
posterior shoulder clockwise or counterclockwise Rubin: Push posterior or anterior shoulder toward fetal chest to adduct shoulders Remove: Delivery posterior arm Prophylactic Cesarean? Not recommended by ACOG Exceptions: Consider if >5000g in mother without DM
>4500g in mother with DM Prolog Question #1 A 25 year-old healthy woman has a normal labor and a spontaneous delivery of the fetal head. On expulsion of the head, a shoulder dystocia is recognized. Before instituting maneuvers the next step is to:
A) Tell the patient not to push B) Apply fundal pressure C) Increase or initiate Oxytocin administration D) Cut a large episiotomy Answer A) Tell the patient not to push The training and experience of clinician should dictate sequence of maneuvers that
will be used; however, initially it is best to do nothing that will further impact the anterior shoulder above the pubic symphysis. The simplest way to avoid further impaction is to ask the patient to stop pushing.
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