Shoulder Dystocia 1

8/10/2019 Shoulder Dystocia 1

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Shoulder Dystocia


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OBJECTIVES:

Definition .

Incidence .

Consequences .

Risk factors .

Management.


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Why is it important?

An obstetric emergency.

Increased maternal morbidity.

Increased fetal morbidity & mortality .


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Definition

A head-to-body delivery time > 60 seconds due toimpaction of the shoulder ( anterior ) against thesymphsis pubis.

(Williams Ob)

Use of any of the obstetric maneuvers to release theshoulder after gentle downward traction has failed.

(RCOG ,2005)


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Mean time of normal delivery24 sec.

Mean time of delivery with dystocia 79 sec.


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Shoulder dystocia

Shoulder dystocia can be one of the most frighteningemergencies in the delivery room

Although many factors have been associated withshoulder dystocia, most cases occur with no warning

Defined as a delivery in which additional maneuvers arerequired to deliver the fetus after normal gentledownward traction has failed

Shoulder dystocia occurs when the fetal anterior shoulderimpacts against the maternal symphysis


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Epidemiology

The overall incidence of shoulder dystocia varies basedon fetal weight 0.6-1.4%: 2500g(5lb,8oz) to 4000g(8lb,13oz)

5-9%: 4000g to 4500g(9lb,14oz), born to mothers withoutdiabetes

3969g (8lb,12oz)our patient

Shoulder dystocia occurs with equal frequency inprimigravid and multigravid women More common in infants born to women with diabetes

However, most cases occur in fetuses of normal birth

weight and are unanticipated, limiting the clinicalusefulness of risk-factor identification


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Risk Factors for Shoulder

Dystocia Maternal

Abnormal pelvic anatomy

Gestational diabetes

Post-dates pregnancy

Previous shoulder dystocia Short stature

Fetal

Suspected macrosomia

Labor related

Assisted vaginal delivery

(forceps or vacuum) Prolonged active phase of

first-stage labor

Prolonged second-stagelabor


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Complications of Shoulder

Dystocia* Maternal

Postpartum hemorrhage(11%)

Rectovaginal fistula Symphyseal separation

With or without transientfemoral neuropathy

3rdor 4thdegree (3.8%)episiotomy or tear

Uterine rupture

Fetal Brachial plexus palsy (4-

15%) Clavicle fracture Fetal hypoxia

With or withoutpermanent neurologic

damage Fracture of the humerus Fetal death

Nearly all palsies resolve within sixto 12 months, with fewer than10% resulting in permanent injury

*These rates remain constant, independent of operator experience


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Management

H

E

L

P

E

R

R


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Each step 30-60 Sec

For a total 3- 5 minutes (All Maneuvers)

Noindication thatany of these maneuvers is superior, they

represent a valuable tool to help clinicians take effective steps

to relieve impacted shoulder ( Category C )

ACOG..October 1997


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Benefits

1. Increase the size of the bony pelvis

2. Decrease bisacromial diameter

3. Change the relation of bisacromial diameter within the bony

pelvis .


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How to recognize SD?

Prolonged 1st& 2ndstage of labor.

Head bobbing , then retracting back in the birth canal.

Minimal downward traction does not affect delivery.


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Once recognized

Do NOT ask the patient to push.

Do NOTapply fundal pressure. ( Grade C )

DoNOT panic !!

RCOG guidelines..December,2005


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HELPERR

Although there is no indication that any one ofthese techniques is superior to another, togetherthey effectively relieve the impacted shoulder

The order of the steps is not as important as the

fact that they each be employed efficiently andappropriately

Persistence in any one ineffective maneuvershould be avoided

Clinical judgment always should guide theprogression of procedures used


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H - Help

This refers to activating the pre-arrangedprotocol or requesting the appropriate personnelto respond with necessary equipment to thelabor and delivery unit

If standard levels of traction do not relieve theshoulder dystocia, the physician must movequickly to other maneuvers while asking for helpand notifying the family

A critical step in addressing the emergencymanagement of shoulder dystocia is ensuringthat all involved hospital personnel are familiarwith their roles and responsibilities


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E - Evaluate for episotomy

Episiotomy should be considered when ashoulder dystocia is encountered, althoughbecause the primary problem is a bonyimpaction, episiotomy by itself will not release

the impaction

Episiotomy does provide additional room for thephysician's hand when internal rotationmaneuvers are required

Given the success of the McRoberts maneuverand suprapubic pressure in relieving a largepercentage of cases of shoulder dystocia,performing an episiotomy can wait until later inthe sequence


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L Legs (McRoberts

maneuver) The simplicity of the McRoberts maneuver and its

proven effectiveness make it an ideal first step in themanagement of shoulder dystocia

This procedure results in a cephalad rotation of thesymphysis pubis and a flattening of the sacral

promontory These motions push the posterior shoulder over the sacral

promontory, allowing it to fall into the hollow of the sacrum, androtate the symphysis over the impacted shoulder

When this maneuver is successful, the fetus should be

delivered with normal traction The McRoberts maneuver alone is believed to relieve

more than 40% of all shoulder dystocias and, whencombined with suprapubic pressure, resolves more than50% of shoulder dystocias


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P Pressure (suprapubic)

When applying suprapubic pressure, an assistant's handshould be placed on top of the mother's abdomen overthe fetal anterior shoulder, applying pressure in acompression/relaxation cycle analogous tocardiopulmonary resuscitation, so that the shoulder will

adduct and pass under the symphysis Pressure should be applied from the side of the mother,

with the heel of the assistant's hand moving in adownward and lateral motion on the posterior aspect ofthe fetal impacted shoulder

Initially, the pressure can be continuous, but if delivery isnot accomplished, a rocking motion is recommended todislodge the shoulder from behind the pubic symphysis

Fundal pressure is never appropriate and only serves toworsen the impaction, potentially injuring the fetus or

mother


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E Enter maneuvers

Rotation maneuvers may require episiotomy to gainposterior vaginal space for the physicians hand

The Rubin II maneuver consists of inserting the fingers ofone hand vaginally behind the posterior aspect of the

anterior shoulder of the fetus and rotating the shouldertoward the fetal chest

This motion will adduct the fetal shoulder girdle,reducing its diameter

The McRoberts maneuver also can be applied during this

maneuver and may facilitate its success


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E Enter maneuvers (cont.)

If the Rubin II maneuver is unsuccessful, the Woodscorkscrew maneuver may be attempted

The physician places at least two fingers on the anterioraspect of the fetal posterior shoulder, applying gentleupward pressure around the circumference of the arc in

the same direction as with the Rubin II maneuver The Rubin II and Woods corkscrew maneuvers may be

combined to increase torque forces by using two fingersbehind the fetal anterior shoulder and two fingers infront of the fetal posterior shoulder

Procedurally, this step often is difficult because of limitedspace for the physician's hand

Downward traction should be continued during theserotational maneuvers, simulating the rotation of a screwbeing removed


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E Enter maneuvers (cont.)

If the Rubin II or Woods corkscrew maneuversfail, the reverse Woods corkscrew maneuver maybe tried

In this maneuver, the physician's fingers areplaced on the back of the posterior shoulder ofthe fetus, and the fetus is rotated in the oppositedirection as in the Woods corkscrew or Rubin IImaneuvers

This maneuver adducts the fetal posteriorshoulder in an attempt to rotate the shouldersout of the impacted position and into an obliqueplane for delivery


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Rubin II

At vaginal examination apply pressure

as indicated. If shoulders move into the

oblique diameter, attempt delivery

Rubin II + Woods corkscrew

maneuver

If unsuccessful, add the Woods

corkscrew maneuver and continue

rotation in the same direction. Use both

hands and apply pressure as indicated.If shoulders now move into the oblique,

attempt delivery. If this is unsuccessful,

continue rotation 180 degrees and

deliver

Reverse Woods corkscrew maneuverIf the last maneuver is unsuccessful,

change to reverse Woods corkscrew

maneuver. Slide fingers down to back of

posterior shoulder and attempt 180-

degree rotation in the opposite direction


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R Remove the posterior arm

Removal of the posterior arm involves placing thephysician's hand in the vagina and locating the fetal arm,which sometimes is displaced behind the fetus and mustbe nudged anteriorly The physician's hand, wrist, and forearm may need to enter the

vagina, necessitating an episiotomy or extension The fetal elbow is then flexed, and the forearm is

delivered in a sweeping motion over the anterior chestwall of the fetus

The upper arm should never be grasped and pulled

directly, because this step may result in a fracture of thehumerus

The posterior hand, followed by the arm and shoulder,will be reduced, facilitating delivery of the infant

The anterior shoulder will then fall under the symphysis

and deliver


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RRoll the patient

Rolling the patient onto her hands and knees, known asthe all-fours or Gaskin maneuver, is a safe, rapid, andeffective technique for the reduction of shoulderdystocia

Once the patient is repositioned, the physician provides

gentle downward traction to deliver the posteriorshoulder with the aid of gravity

The all-fours position is compatible with all intravaginalmanipulations for shoulder dystocia, which can then bereattempted in this new position

All-fours positioning may be disorienting to physicianswho are unfamiliar with attending a delivery in thisposition

Performing a few normal deliveries in this positionbefore encountering a case of shoulder dystocia may

prepare physicians for more emergent situations


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Maneuvers of last resort

If the maneuvers described in HELPERR are

unsuccessful, several techniques have been

described as last-resort maneuvers

Once the infant is delivered, quick assessmentand employment of resuscitation efforts, if

necessary, are vital


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Maneuvers of last resort (cont.)

Deliberate clavicle fracture Direct upward pressure on the mid-portion of the fetal

clavicle; reduces the shoulder-to-shoulder distance

Zavanelli maneuver

Cephalic replacement followed by cesarean delivery;involves rotating the fetal head into a direct occiputanterior position, then flexing and pushing the vertexback into the birth canal, while holding continuousupward pressure until cesarean delivery isaccomplished

An operating team, anesthesiologist, and physicianscapable of performing a cesarean delivery must bepresent, and this maneuver should never beattempted if a nuchal cord previously has beenclamped and cut


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General anesthesia Musculoskeletal or uterine relaxation with halothane

(Fluothane) or another general anesthetic may bringabout enough uterine relaxation to affect delivery

Oral or intravenous nitroglycerin may be used as analternative to general anesthesia

Abdominal surgery with hysterotomy General anesthesia is induced and cesarean incision

performed, after which the surgeon rotates the infant

transabdominally through the hysterotomy incision,allowing the shoulders to rotate, much like a Woodscorkscrew maneuver

Vaginal extraction is then accomplished by anotherphysician


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Symphysiotomy

Intentional division of the fibrous cartilage of

the symphysis pubis under local anesthesia has

been used more widely in developingcountries than in North America

It should be used only when all other

maneuvers have failed and capability of

cesarean delivery is unavailable


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Documentation

Documentation of the management of shoulder dystociashould concentrate on the maneuvers performed andthe duration of the event

Terms such as mild, moderate, or severe shoulderdystocia offer little information about the situation or

care encountered Other team members assisting the delivery should be

listed, as well as cord pH, if obtained

Specific notation regarding which arm was impactedagainst the pubis should be made in the event that

subsequent nerve palsy develops The delivery should be reviewed with the parents, and

the management and prognosis for any infant palsyshould be explained

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Shoulder Dystocia 1