2. Distocia de hombros
 Describir la historia clínica típica de la paciente y examen físico
apropiado e identificar los principales hallazgos clínicos
anormales
 Etiología y Causas y signos clínicos de la distocia de hombros
 Técnicas y Maniobras eutosicas para la atención de la distocia de
hombros
 Técnicas y Maniobras distosicas para la atención de la distocia
de hombros
 Complicaciones y morbi-mortalidad materna y neonatal de la
distocia de hombros

3. Fuentes
 RCOG Guideline
December 2005
 Cochrane Library
 Medline

4. Falta de expulsión de la cintura escapular a
pesar de maniobras obstétricas sistémicas
después del nacimiento de la cabeza.
Se presenta en 0.23 a 2.9% de los partos
vaginales.
Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

5. Background
 There can be a high perinatal mortality
and morbidity associated with the
condition, even when it is managed
appropriately.
 Maternal morbidity is also increased,
particularly postpartum haemorrhage
(11%) and fourth-degree perineal tears
(3.8%).

6.  Nacimiento del hombro posterior, no obstante
hombro anterior se impacta detrás de la
sínfisis del pubis e impedir descenso.
Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

7. Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

10.  Los factores de riesgo para la
prediccion de distocia de hombros son
insuficientes para permitir la
prevencion en la mayoria de casos
con factores de riesgo.
Grade B

11. Prediction
 A number of antenatal and intrapartum
characteristics have been reported to be
associated with shoulder dystocia .
 There is a relationship between fetal size
and shoulder dystocia but it is not a good
predictor.
Evidence level III

12. Maternos:
Parto precipitado
Dilatación mayor de 5cms/hora en Multíparas
Dilatación mayor de 3cms/hora en Nulíparas
Estructura pélvica diferente a la ginecoide
(antropoide/androide)
Obesidad
Diabetes sacarina
Embarazo prolongado
Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

13. Pelvis
Pelvis Pelvis
Ginecoide
Androide Antrop
oide
Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

14. Fetal
Macrosomia
peso fetal al nacimiento mayor de 4000 gr
peso fetal estimado mayor de 4500 gr
50 a 90% de las distocias son fetos normales.
1.2 a 1.7% de fetos macrosomicos hacen distocia de
hombros
Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

15. Prediction
 Conventional risk factors predicted only
16% of shoulder dystocia that resulted in
infant morbidity.
 The large majority of cases occur in the
children of women with no risk factors.
 Shoulderdystocia is, therefore, a largely
unpredictable and unpreventable event.
Evidence level III

16. Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

17. Solicitar ayuda!!!!!!
Evitar tracción excesiva y comprensión de
fondo uterino
• Aumento de la impactación de hombro
anterior
• Ruptura uterina por compresión fúndica
desordenada
Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

18. Fundal pressure
 Fundal pressure should not be employed.
Grade C
 Fundal pressure should not be used for the
treatment of shoulder dystocia.
 It is associated with an unacceptably high
neonatal complication rate and may result in
uterine rupture.
Evidence level IV

19. Intrapartum
 An experienced obstetrician, should be available
on the labour ward for the second stage of labour
when shoulder dystocia is anticipated.
 However, it is recognized that not all cases can be
anticipated and therefore all birth attendants
should be ready with the techniques required to
facilitate delivery complicated by shoulder
dystocia.
Evidence level IV

20. Parto
 El uso de la maniobra de
McRoberts’comparado con la posicion de
litotomia antes del diagnostico de distocia de
hombros, no reduce la traccion de la cabeza
fetal durante el parto vaginal en multiparas
 NO puede ser usada para prevenir la
distocia de hombros
Evidence level Ib

21. McRoberts manoeuvre: X ray pelvimetry study
No increase in pelvic dimensions.
Decrease in the angle of pelvic inclination P=0.001
Straightening of the sacrum P= 0.04%
Tends to free the impacted anterior shoulder
Gherman et al Obstet Gynecol 95:43 ,2000

22. McRoberts’ manoeuvre
 The McRoberts’ manoeuvre is the
single most effective intervention,
with reported success rates as high
as 90%.
 Ithas a low rate of complication and
therefore should be employed first.
Grade B

23. Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

24. Episiotomy
 Episiotomy is not necessary for all cases.
Grade B
 Some authors have advocated that episiotomy is
an essential part of the management in all cases
but others suggest that it does not affect the
outcome of shoulder dystocia.
 The authors of one study have concluded that
episiotomy does not decrease the risk of brachial
plexus injury with shoulder dystocia.
 An episiotomy should therefore be considered but
it is not mandatory.
Evidence level III

25. Suprapubic pressure
 Suprapubic pressure is useful.
Grade C
 Suprapubic pressure can be employed together with
McRoberts’ manoeuvre to improve success rates.
 Suprapubic pressure reduces the bisacromial
diameter and rotates the anterior shoulder into the
oblique pelvic diameter.
 The shoulder is then free to slip underneath the
symphysis pubis with the aid of routine traction.
Evidence level IV

26. Maniobra de McRoberts y Rubin
combinadas
.

27. Maniobra de Gaskin

28. Advanced manoeuvres should be used if the
McRoberts’ manoeuvre and suprapubic pressure fail.
 If these simple measures fail, then there is a
choice to be made between the all-fours-position
and internal manipulation.
 Traditionally, internal manipulations are used at
this point but the-all-fours position has been
described, with an 83% success rate in one case
series.
 The individual circumstances should guide the
accoucheur.
Evidence level III

30. Maniobras internas
 No existe ventaja entre:
1. El Nacimiento del hombro posterior (jaquemiere)
2. Maniobras de rotación interna (Maniobra de
Woods ) y
 Así que el juicio clínico y la experiencia pueden
decidir el orden de estas maniobras

31. Si Mc Roberts falla:
Maniobra de Woods :
•La mano es posicionada
Detras del hombro
Posterior del feto.
•El hombro se rota
Progresivamente 180 grados en forma de sacacorcho,
de manera que el hombro anterior sea liberado.
.

32. Maniobra de Jaquemiere.
Insertando la mano
en la parte posterior
de la vagina y
rotando el brazo
hacia el hombro.
Se realiza
el parto
sobre el
periné

33. Delivery of the posterior arm
 Delivery of the posterior arm has a high
complication rate: 12% humeral fractures
in one series.
 Some authors favour delivery of the
posterior arm, particularly where the
mother is large.
Evidence level III

35.  Varios metodos de tercera linea han sido
descritos para los casos en los que ha resistencia
a las medidas simples
 Estos incluyen:
1. Cleidotomia (fractura de la clavicula con la mano
o tijera quirurgica),
2. Sinfisiotomia (division de las fibras de los huesos
pubianos)
3. Maniobra de Zavanelli.

36. Zavanelli manoeuvre
 The maternal safety of this procedure is
unknown, however, and this should be borne
in mind, knowing that a high proportion of
fetuses have irreversible hypoxia-acidosis by
this stage.
Evidence level III

37. Symphysiotomy
 Has been suggested as a potentially useful
procedure, both in the Developing and
developed world.
 There is a high incidence of serious maternal
morbidity and poor neonatal outcome.
 After delivery, the birth attendants should be
alert to the possibility of postpartum
haemorrhage and third- and fourth-degree
perineal tears.
Evidence level III

39. Fetales
Parálisis del plexo braquial.
Parálisis de Erb
Parálisis de Kumpke
Acidosis fetal por compresión del cordón
umbilical.
Maternos
Hemorragia post parto
Rasgadura grado 4

41. Fetal Complications of Sh D
Brachial plexus injuries,
Fractures of the humerus, and
Fractures of the clavicle
are the most commonly reported
injuries associated with shoulder
dystocia
ACOG practice 1997 (A: II-2)

42. Brachial plexus injuries
 Brachial plexus injuries are one of the most
important fetal complications of shoulder
dystocia, complicating 4–16% of such
deliveries.
 This appears to be independent of operator
experience.
 Most cases resolve without permanent
disability, with fewer than 10% resulting in
permanent brachial plexus dysfunction.

43. Brachial plexus injuries
 In the UK, the incidence of brachial
plexus injuries is 1/2300 live births.
 Neonatal brachial plexus injury is the
single most common cause for
litigation related to shoulder
dystocia.