Aboubakr Elnashar
Benha University Hospital,Egypt
Email:elnashar53@hotmail.com
Aboubakr Elnashar
unanticipated, unpredictable nightmare of the
obstetrician
(Langer et al,1991)
INCIDENCE
0.2-2%
Depend on definition & fet...
DEFINITION
Failure of the shoulders to spontaneously traverse
the pelvic brim after delivery of the head
(Benedetti,1989)...
DEGREES
(O, leary,1992; Pearson,1996)
1. Severe= Bilateral:
both the posterior & the anterior shoulders do not
cross the p...
2. Mild= Unilateral:
The posterior shoulder enters the pelvic cavity, while
the anterior shoulder hooked behind the S. pub...
CAUSE
Not simply increase in F. wt
increase in body size in relation to head size.
increased shoulder/ head circumferen...
RISK FACTORS
The majority: No risk factors.
S. dystochia cannot be predicted from clinical
characteristics or labor abno...
A. Antepartum:
DOPE
1. D.M (Tissues of the shoulders are insulin sensitive
& the brain is not & is not affected by D.M.)
2...
B. Intrapartum
1. 1st stage labor abnormalities.
2. Prolonged 2nd stage.
3. Oxytocin augmentation.
4. Mid pelvic ventouse ...
The predictive factors
(Dildy & Clark,2000)
1. D.M. with EFW >4250 g
2. Macrosomia & 2nd stage arrest with midpelvic
vento...
PREDICTION OF FETAL
MACROSOMIA
A. Clinical
Sensitivity is only 20%
(Park & Ziel,1978)
The diagnosis of f macrosomia is i...
B. U/S
1. EFW: 10-15 % error (Hadlock or Shepard)
2. Femur SC tissue
3. Cheek to cheek D.
4. Chest D - BPD > 1.4 cm
5. Che...
CLINICAL PICTURE
(Rubin, 1969)
Early
1. Slow crowing.
2. It is necessary to press the perineum back to
deliver the face.
3...
Late
1. Usual down traction of the head does not result in
appearance of the anterior shoulder
2. Vascular congestion of t...
PREVENTION
A. Ante partum
1. Identification of risk factors & proper management.
2. IOL at 38 W:
 History of S dystocia
(...
 DM treated with insulin:
Dec risk of macrosomia
Small dec in s dystocia
No dec in maternal or neonatal morbidity
(Cochra...
3. C.S:
Cumulative risk factors
(Basket, 2001).
Previous history of S dystocia:
Either CS or vaginal delivery is appropr...
 EFW:
 In DM:
>4250 g in DM
(Dildy & Clark, 2000)
>4,500 g (ACOG, 2003)
 Non diabetic
 > 5,000 g (ACOG, 2003)
Planned ...
B. Intrapartum
Management of macrosomic F. during labor
(Louca & Johanson,1998)
1. Manage as far as CS during labor:
NPO, ...
MANAGEMENT
I. Effective plan
1. Call for help
2. Clear infant mouse & nose.
3. Avoid 5 P:
Panic,
pulling,
pushing,
pressur...
II. Improve pelvic dimensions
1. Episiotomy or extend it.
{facilitate manoeuvres such as delivery of the posterior
arm or ...
III. Disimpact F. shoulders
1. Suprapupic pressure
2. Rotation of the shoulders:
Wood,s maneuver, Rubin M.
3. All-fours ma...
IV. If all else fail
3rd -line methods
1. Cleidotomy
(bending the clavicle with a finger or surgical division),
2. Symphys...
McRoberts maneuver:
The first step (RCOG, 2005).
The most successful
risk-free
easily applied.
Aboubakr Elnashar
Increase IU pressure by 97%
Increase U. contraction amplitude by 25%
Applied additional 31 Newtons pushing
force (Buhimsch...
McRoberts manoeuvre: X ray pelvimetry study
(Gherman et al, 2000)
No increase in pelvic dimensions.
Decrease in the angle ...
Suprapubic pressure:
Mazzanti:
directed posterioly to dislodge the ant shoulder &
push it beneath S.P.
Rubin:
directed lat...
Aboubakr Elnashar
Aboubakr Elnashar
.
The Mc Roberts manoeuvre can
be applied with Suprapubic
pressure to increase success
rate
(ACOG , 1991; RCOG, 2005)
Abou...
Rotation of the F. shoulders:
Woods screw M.:
Pressure on the anterior surface of the posterior shoulder:
±increase should...
Rubin M.
Pressure on the posterior surface of the posterior
shoulder.: decrease shoulder to shoulder D.
It is preferred by...
All-fours M.:
The woman is placed on her hands & knees.
Gravity pushes the posterior shoulder anteriorly.
The flexibility ...
• It allows rotational movement of the sacroiliac
joints: 1-2 cm increase in the sagittal diameter of the
pelvic outlet.
•...
•Success rate: 83%
• Maternal complications: 1.2%
•Neonatal complications: 4.9%,
•Time for complete delivery: 2 to 3 ms.
•...
Delivery of the posterior arm:
± difficult to insert the hand in the vagina.
Fracture of the humerus is common.
{No advant...
By inserting a hand into
the posterior vagina and
ventrally rotating the arm
at the shoulder
Delivery over the
perineumAbo...
Cephalic replacement & C.S.
(Zavanelli) :
Early indicated in bilateral S. dystochia.
If replacement is done within 4 min: ...
Zavanelli
2.Flexion of the head,
Returning it to the vagina with
upward constant firm
pressure, followed by CS
1.The head ...
Abdominal rescue:
If cephalic replacement is failed.
C.S
direct disimpaction of the shoulder
vaginal delivery.
Aboubakr El...
•Bilateral Shoulder dystocia
All- Fours Maneuver
Used at all circumstances
except if the patient has received
epidural an...
The HELPERR mnemonic
H Call for help
E Evaluate for episiotomy
L Legs (the McRoberts’ manoeuvre)
P Suprapubic pressure
E E...
Aboubakr Elnashar
COMPLICATIONS
A. Fetal
1. Death:
{asphyxia}.
8% of all intrapartum F. death.
(Baskett,2001)
Head –shoulder interval
 4-6 ...
2. Injuries:
Cerebral hge.
Brachial plexus palsy
10%
Determine whether the affected shoulder was
anterior or posterior a...
3. Remote:
Mental retardation
Speech defects.
Aboubakr Elnashar
Aboubakr Elnashar
B. Maternal
25% (Gherman et al,1997)
1. Injuries:
Perineal (4%), vaginal (19%), cervical (2%)
2. Postpartum hge (11%).
3. ...
Benha University Hospital,Egypt
Email:elnashar53@hotmail.com
Aboubakr Elnashar
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Shoulder dystocia

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Shoulder dystocia

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Shoulder dystocia

  1. 1. Aboubakr Elnashar Benha University Hospital,Egypt Email:elnashar53@hotmail.com Aboubakr Elnashar
  2. 2. unanticipated, unpredictable nightmare of the obstetrician (Langer et al,1991) INCIDENCE 0.2-2% Depend on definition & fetal size (1/2: >4Kg) Increased in the past 2 decades Aboubakr Elnashar
  3. 3. DEFINITION Failure of the shoulders to spontaneously traverse the pelvic brim after delivery of the head (Benedetti,1989) Special maneuvers to deliver the shoulders (Resnik,1980) Prolonged head to body delivery time > 60 sec (Spong et al,1995). Aboubakr Elnashar
  4. 4. DEGREES (O, leary,1992; Pearson,1996) 1. Severe= Bilateral: both the posterior & the anterior shoulders do not cross the pelvic brim. Aboubakr Elnashar
  5. 5. 2. Mild= Unilateral: The posterior shoulder enters the pelvic cavity, while the anterior shoulder hooked behind the S. pubis. Aboubakr Elnashar
  6. 6. CAUSE Not simply increase in F. wt increase in body size in relation to head size. increased shoulder/ head circumference (Baskett,200). Aboubakr Elnashar
  7. 7. RISK FACTORS The majority: No risk factors. S. dystochia cannot be predicted from clinical characteristics or labor abnormalities (Basket,200) Aboubakr Elnashar
  8. 8. A. Antepartum: DOPE 1. D.M (Tissues of the shoulders are insulin sensitive & the brain is not & is not affected by D.M.) 2. Obesity: (90 kg before pregnancy or 110 kg at delivery) 3. Postterm pregnancy. 4. Past history of S. dystocia. 5. Excessive f wt (>4.5 kg) or maternal wt gain (>20 kg) Aboubakr Elnashar
  9. 9. B. Intrapartum 1. 1st stage labor abnormalities. 2. Prolonged 2nd stage. 3. Oxytocin augmentation. 4. Mid pelvic ventouse or forceps. Aboubakr Elnashar
  10. 10. The predictive factors (Dildy & Clark,2000) 1. D.M. with EFW >4250 g 2. Macrosomia & 2nd stage arrest with midpelvic ventouse or forceps Aboubakr Elnashar
  11. 11. PREDICTION OF FETAL MACROSOMIA A. Clinical Sensitivity is only 20% (Park & Ziel,1978) The diagnosis of f macrosomia is imprecise. Accuracy of EFW using US is no better than that obtained with cl palpation (Leopold's maneuver). ACOG Guidelines, 2000 (Level :A) Aboubakr Elnashar
  12. 12. B. U/S 1. EFW: 10-15 % error (Hadlock or Shepard) 2. Femur SC tissue 3. Cheek to cheek D. 4. Chest D - BPD > 1.4 cm 5. Chest C. - HC. > 1.6 cm. 6. Shoulder C. - HC > 4.8 cm. Aboubakr Elnashar
  13. 13. CLINICAL PICTURE (Rubin, 1969) Early 1. Slow crowing. 2. It is necessary to press the perineum back to deliver the face. 3. Fatty cheeks. 4. Turtle sign (head is drawn tight against the perineum). 5. Restitution is slow or does not occur. Aboubakr Elnashar
  14. 14. Late 1. Usual down traction of the head does not result in appearance of the anterior shoulder 2. Vascular congestion of the face. 3. Vaginal ex is difficult Aboubakr Elnashar
  15. 15. PREVENTION A. Ante partum 1. Identification of risk factors & proper management. 2. IOL at 38 W:  History of S dystocia (Kjos et al,1993).  Suspected f macrosomia: increased CS without improving perinatal outcomes (ACOG Issues Guideline 2000 (Level B) (Sanchez-Ramos, Systematic Review, 2002) Aboubakr Elnashar
  16. 16.  DM treated with insulin: Dec risk of macrosomia Small dec in s dystocia No dec in maternal or neonatal morbidity (Cochrane review). Aboubakr Elnashar
  17. 17. 3. C.S: Cumulative risk factors (Basket, 2001). Previous history of S dystocia: Either CS or vaginal delivery is appropriate The decision should be made by the woman and her careers (RCOG, 2005). Aboubakr Elnashar
  18. 18.  EFW:  In DM: >4250 g in DM (Dildy & Clark, 2000) >4,500 g (ACOG, 2003)  Non diabetic  > 5,000 g (ACOG, 2003) Planned CS on the basis of suspected macrosomia in the general population is not a reasonable strategy {1. Number & cost of additional CS required to prevent one permanent injury is excessive To prevent one Erb,s palsy an additional 500 CS are done 2. 3% of brachial plexus injury are associated with C.S . Aboubakr Elnashar
  19. 19. B. Intrapartum Management of macrosomic F. during labor (Louca & Johanson,1998) 1. Manage as far as CS during labor: NPO, IVF, decrease stomach acidity 2. Close observation of the fetus & mother. 3. Experienced obstetrician, anesthetist & neonatologist. 4. Prophylactic Mc Roberts maneuver if risk factors. Position can be maintained by the woman herself. 5. Generous episiotomy 6. Early detection of S. dystocia. Aboubakr Elnashar
  20. 20. MANAGEMENT I. Effective plan 1. Call for help 2. Clear infant mouse & nose. 3. Avoid 5 P: Panic, pulling, pushing, pressure on the fundus {an unacceptably high neonatal complication rate and may result in uterine rupture} pivoting Aboubakr Elnashar
  21. 21. II. Improve pelvic dimensions 1. Episiotomy or extend it. {facilitate manoeuvres such as delivery of the posterior arm or internal rotation of the shoulders}. Episiotomy is not mandatory (RCOG, 2005). 2. Mc Roberts maneuver Aboubakr Elnashar
  22. 22. III. Disimpact F. shoulders 1. Suprapupic pressure 2. Rotation of the shoulders: Wood,s maneuver, Rubin M. 3. All-fours maneuver 4. Delivery of the posterior arm. Aboubakr Elnashar
  23. 23. IV. If all else fail 3rd -line methods 1. Cleidotomy (bending the clavicle with a finger or surgical division), 2. Symphysiotomy (dividing the symphyseal ligament) 3. Zavanelli maneuver. 4. Abdominal rescue Aboubakr Elnashar
  24. 24. McRoberts maneuver: The first step (RCOG, 2005). The most successful risk-free easily applied. Aboubakr Elnashar
  25. 25. Increase IU pressure by 97% Increase U. contraction amplitude by 25% Applied additional 31 Newtons pushing force (Buhimschi et al, 2001)Aboubakr Elnashar
  26. 26. McRoberts manoeuvre: X ray pelvimetry study (Gherman et al, 2000) No increase in pelvic dimensions. Decrease in the angle of pelvic inclination Straightening of the sacrum Tends to free the impacted anterior shoulder Aboubakr Elnashar
  27. 27. Suprapubic pressure: Mazzanti: directed posterioly to dislodge the ant shoulder & push it beneath S.P. Rubin: directed laterally, with pressure applied to the posterior surface of the anterior shoulder. Apply for 30 seconds. No difference in efficacy between continuous pressure or ‘rocking’ movement. Aboubakr Elnashar
  28. 28. Aboubakr Elnashar
  29. 29. Aboubakr Elnashar
  30. 30. . The Mc Roberts manoeuvre can be applied with Suprapubic pressure to increase success rate (ACOG , 1991; RCOG, 2005) Aboubakr Elnashar
  31. 31. Rotation of the F. shoulders: Woods screw M.: Pressure on the anterior surface of the posterior shoulder: ±increase shoulder to shoulder D. Aboubakr Elnashar
  32. 32. Rubin M. Pressure on the posterior surface of the posterior shoulder.: decrease shoulder to shoulder D. It is preferred by many obstetrician Aboubakr Elnashar
  33. 33. All-fours M.: The woman is placed on her hands & knees. Gravity pushes the posterior shoulder anteriorly. The flexibility of the sacro-iliac joints increases the saggital D of the pelvic inlet. The posterior shoulder is delivered first. Aboubakr Elnashar
  34. 34. • It allows rotational movement of the sacroiliac joints: 1-2 cm increase in the sagittal diameter of the pelvic outlet. • It disimpacts the shoulders, and allowing it to slide over the sacral promontory. Aboubakr Elnashar
  35. 35. •Success rate: 83% • Maternal complications: 1.2% •Neonatal complications: 4.9%, •Time for complete delivery: 2 to 3 ms. •Effective also for bilateral Sh. D. (Drummond et al; 1998) Aboubakr Elnashar
  36. 36. Delivery of the posterior arm: ± difficult to insert the hand in the vagina. Fracture of the humerus is common. {No advantage between delivery of the posterior arm and internal rotation maneuvers}: clinical judgment and experience can be used to decide their order. Aboubakr Elnashar
  37. 37. By inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder Delivery over the perineumAboubakr Elnashar
  38. 38. Cephalic replacement & C.S. (Zavanelli) : Early indicated in bilateral S. dystochia. If replacement is done within 4 min: good Apgar. Aboubakr Elnashar
  39. 39. Zavanelli 2.Flexion of the head, Returning it to the vagina with upward constant firm pressure, followed by CS 1.The head first manually rotated to the occipito anterior (Pre-restitution) position Reversing the mechanism of delivery of the vertex under tocolytic Aboubakr Elnashar
  40. 40. Abdominal rescue: If cephalic replacement is failed. C.S direct disimpaction of the shoulder vaginal delivery. Aboubakr Elnashar
  41. 41. •Bilateral Shoulder dystocia All- Fours Maneuver Used at all circumstances except if the patient has received epidural analgesia, heavy analgesia or anesthesia Zavanelli Maneuver Used if the patient has received epidural analgesia or heavy analgesia with obstetric facilities for emergency CS Aboubakr Elnashar
  42. 42. The HELPERR mnemonic H Call for help E Evaluate for episiotomy L Legs (the McRoberts’ manoeuvre) P Suprapubic pressure E Enter maneuvers (internal rotation) R Remove the posterior arm R Roll the patient Aboubakr Elnashar
  43. 43. Aboubakr Elnashar
  44. 44. COMPLICATIONS A. Fetal 1. Death: {asphyxia}. 8% of all intrapartum F. death. (Baskett,2001) Head –shoulder interval  4-6 min: No permanent hypoxic damage  >7 min: permanent hypoxic damage  With hypoxic fetus it is much shorter (Quzounian et al, 1998) Aboubakr Elnashar
  45. 45. 2. Injuries: Cerebral hge. Brachial plexus palsy 10% Determine whether the affected shoulder was anterior or posterior at the time of delivery {damage to the plexus of the posterior shoulder is considered not due to action by the accoucheur}. Fracture clavicle (the most common) or humerus. Traction combined with fundal pressure: high rate of brachial plexus injuries and fractures (ACOG , 1997) Aboubakr Elnashar
  46. 46. 3. Remote: Mental retardation Speech defects. Aboubakr Elnashar
  47. 47. Aboubakr Elnashar
  48. 48. B. Maternal 25% (Gherman et al,1997) 1. Injuries: Perineal (4%), vaginal (19%), cervical (2%) 2. Postpartum hge (11%). 3. Infection Aboubakr Elnashar
  49. 49. Benha University Hospital,Egypt Email:elnashar53@hotmail.com Aboubakr Elnashar
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