“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
Shoulder Dystocia“Making the Best of a Bad Situation” Sandesh Kamdi, M. Pharm
Incidence Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%. An increase in the incidence of shoulder dystocia has been recorded over the last 20 years Incidence appears to be increasing as birth weights increase. Ceska Gynekol 2010 ; 75(4):274-79
Although half of shoulder dystocias occur in infants weighing less than 4000 gms…. The incidence of shoulder dystocia is directly related to fetal size. Ceska Gynekol 2010 ; 75(4):274-79
Definition“Difficulty encountered in the deliveryof the fetal shoulders after delivery ofthe head.”It is the complication of vaginaldelivery that requires additionalobstetric manoeuvres to release theshoulders of the baby.Due to impaction of the fetal shoulderbehind the symphysis pubis. Ceska Gynekol 2010 ; 75(4):274-79
Bilateral Shoulder Dystocia A bilateral shoulder dystocia. The posterior shoulder is not in the hollow of the pelvis. This presentation oftern requires a cephalic replacement. Clinical Obstetrics, Churchill Livingstone, New York, 1987.)
Unilateral Shoulder Dystocia Unilateral shoulder dystocia is usually easily dealt with by standard techniques. Clinical Obstetrics and Gynecology, 1984l 27:106)
Diagnosis One often described feature is the turtle sign which involves the appearance and retraction of the fetal head (analogous to a turtle withdrawing into its shell) and the erythematous, red puffy face indicative of facial flushing. This occurs when the babys shoulder is impacted in the maternal pelvis Ceska Gynekol 2010 ; 75(4):274-79
Risk FactorsRemember, many cases of shoulder dystociaoccur with no readily identified risk factors!!!! ANTEPARTUM FACTORS INTRAPARTUM FACTORS Maternal Obesity Prolonged Second Stage Maternal Diabetes of Labor Mellitus Oxytocin Induction Post-term Pregnancy Midforceps and Vacuum Excessive Weight Gain Extraction
Risk factors Fetal macrosomia and maternal diabetes most strongly associated with shoulder dystocia No single risk factor or combination of risk factors are predictive for which infants will experience shoulder dystocia ACOG Practice Pattern No. 40 2002
Fetal Complications Fetal Fractures - • In 18 to 25% of cases Erb’s Palsy - • Although 80% will resolve by 18 months Perinatal Asphyxia – Uncommon Brachial plexus injury Neonatal Death - Rare
Management of Shoulder Dystocia Individuals who MUST be present in the room if shoulder dystocia is anticipated or encountered • Attending physician • Anesthesiologist • Pediatrician • Nursing Staff • “Extra Hands”
Who’s the Boss? It is important that the conduct of any shoulder dystocia be managed by the most experienced person in the room. This individual ( generally the attending physician) must have the ability to intervene at any time and should be the only one giving orders.
Preliminary Steps Call for help and have the team assembled Drain the bladder Perform a generous episiotomy TAKE YOUR TIME, THIS IN AN EMERGENCY, BUT IT IS NOT A RACE!!!
Preliminary Measures: Gentle pressure on the fetal vertex in a dorsal direction will move the posterior fetal shoulder deeper into the maternal pelvic hollow, usually resulting in easy delivery of the anterior shoulder. Excession angulation (>45 degrees) is to be avoided. (Gabbe, et al., Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986)
Key points Instruct the mother to stop pushing until suprapubic pressure has been applied Apply direct downward pressure above the maternal symphysis – Dislodges the anterior shoulder by pushing it under the maternal symphysis Do not use fundal pressure
Key points Move to the side of the bed opposite of the infant’s face Instruct the mother to stop pushing Apply firm pressure on the backside of the infant’s anterior shoulder and shove in the direction of the infant’s face – Decreases shoulder to shoulder diameter Note: Applying pressure in front of the anterior shoulder and shoving in the opposite direction of the infant’s face increases the shoulder to shoulder diameter up to 2 cm
Suprapubic Pressure Moderate suprapubic pressure is often the only additional maneuver necessary to disimpact the anterior fetal shoulder. Stronger pressure can only be exerted by an assistant. (Gabbe, et al., 1986)
Woods’ Corkscrew Maneuver Woods corkscrew maneuver. The shoulders must be rotated utilizing pressure on the scapula and clavicle. The head is never rotated.(B.Harris, Shoulder dystocia, Clinical Obstetrics and Gynecology, 1984; 27:106.)
Woods’ Corkscrew Maneuver Delivery may be facilitated by counterclockwise rotation of the anterior shoulder to the more favorable oblique pelvic diameter, or clockwise rotation of the posterior shoulder. During these maneuvers, expulsive efforts should be stopped and the head is never grasped !!
Delivery of the Posterior Arm To bring the fetal wrist within reach, exert pressure with the index finger at the antecubital junction. (E. Sandberg. American Journal of Obstetrics and Gynecology, 1985; 152: 481.)
Delivery of the Posterior Arm Sweep the fetal forearm down over the front of the chest.
Delivery of the Posterior Arm If less invasive maneuvers fail to affect this impaction, delivery should be facilitated by manipulative delivery of the posterior arm by inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder with delivery over the perineum.
When All Else Fails... The Rubin Maneuver The Chavis Maneuver The Hibbard Maneuver Fracture of the Clavicle / Cleidotomy The Zavanelli Maneuver Symphysiotomy
The Rubin Maneuver Step 1: The fetal shoulders are rocked from side to side by applying force to the maternal abdomen. Step 2: If step one is not successful, push the presenting fetal shoulder toward the chest. This will often cause abduction of both shoulders and create a smaller shoulder to shoulder diameter.
The Chavis Maneuver Described in 1979. A “shoulder horn” consisting of a concave blade with a narrow handle is slipped between the symphysis and the impacted anterior shoulder. This used like a shoe-horn as a lever where the symphysis is the fulcrum.
The Hibbard Maneuver Release of the anerior shoulder is initiated by firm pressure against the infants jaw and neck in a posterior and upward direction. An assistant is poised, ready to apply fundal pressure after proper suprapublic pressure As the anterior shoulder slips free, fundal pressure is applied, and pressure against the neck is shifted slightly toward the rectum. Proper suprapubic pressure is continued.
The Hibbard Maneuver Continued fundal and suprapublic pressure results in an upward- inward rotation of the newly freed anterior shoulder and a further descent in a position beneath the pubic symphysis.
The Hibbard ManeuverAs a result of the previous maneuvers, thetransverse diameter of the shoulders is reduced.Lateral (upward) flexion of the head releases theposterior shoulder into the hollow of the sacrum.
Fracture of the Clavicle The anterior clavicle is pressed against the ramis of the pubis. Care should be taken to avoid puncturing the lung by angling the fracture anteriorly. Theoretically, a fracture of the clavicle is less serious than a brachial nerve injury and often heals rapidly.
The Zavanelli Maneuver First described in 1988 Consists of cephalic replacement and then cesarean delivery. Mixed reviews in the literature.
... Don’t Even Think About It... Symphysiotomy is a dangerous procedure with substantial risk to maternal health and well being. It is difficult to justify this procedure for shoulder dystocia in modern medicine.
Complications Associated withSymphysiotomy Vesicovaginal Fistula Osteitis Pubis Retropubic Abscess Stress Incontinence Long Term Walking Disability / Pain
Although shoulder dystocia represents acatastrophic event in obstetrics, a well-reasoned plan of action with adequatesupport and skilled personnel can reducefetal morbidity.Proper patient selection and awareness ofrisk factors for shoulder dystocia can alsoreduce morbidity.
Can Cesarean Sections for Suspected Macrosomia Reduce the Rates of Shoulder Dystocia? No Sensitivity of clinical estimates of BW > 4500 gms is only 20% USG is not very accurate at extremes of EFW Most cases of shoulder dystocia occur in infants of average weight The incidence of birth trauma in large infants is not trivial • (2.5% with BW > 4500 gms)
Top Reasons for Successful Claims AgainstObstetricians in Cases of Shoulder Dystocia Inappropriate obstetrical delivery notes Absence of delivery notes Failure to document the dystocia Failure to document use of McRobert’s maneuver Lack of prenatal documentation or follow-up of • Abnormal or borderline GTT • Unexpected large maternal weight gain. Harvard Risk Management Foundation (1994) www.rmf.org
Things To Do After Dystocia Occurs Check for and treat reproductive tract injuries Pediatric neurology and neonatology consultation Document a detailed delivery note, including maneuvers used Explain the occurrence of dystocia to the parents of the infant Do not finger-point Be truthful, but avoid discrepancies in notes by doctors, midwives and nurses. Harvard Risk Management Foundation (1994) www.rmf.org