2. Shoulder Dystocia A shoulder dystocia is defined as the impaction of the anterior fetal shoulder against the maternal pubic bone after delivery of the fetal head.
3. There are no warning signs for shoulder dystocia just several risk factors: Maternal -Gestational Diabetes -Post dates -History of previous shoulder dystocia -Short stature -Obesity -Abnormal pelvic anatomy
4. Risk Factors (continued) Fetal -Suspected macrosomia Intrapartum -Forceps or vacuum assisted delivery -Protracted active phase of first stage labor -Protracted second stage Labor
5. Signs of a Shoulder Dystocia Protracted Labor “Turtle Sign”
7. Management of a Shoulder DystociaLast resort maneuvers: Deliberate clavicle frature Zavanelli maneuver Symphysiotomy
8. Documentation In the event of a Shoulder Dystocia meticulous documentation is necessary: Charting instances of dystocia can be used for teaching and learning enhancement for all healthcare team members and is supportive evidence in medical-legal events.
Editor's Notes
A shoulder dystocia is considered a rare acute obstetrical emergency whereby injury to the infant and the woman can occur during vaginal delivery.The incidence of shoulder dystocia is estimated to be 0.5% to 1.5%.
Maternal diabetes in pregnancy has been closely related to shoulder dystocia. Gestational diabetes has a great correlation to macrosomia. Due to the complexity of diabetes the fetus is at risk for abnormal growth rates and storage of extra glucose. Additionally, the fetal growth is not evenly distributed throughout the body.Although fetal growth is much slower in the concluding weeks of pregnancy there is still growth. Therefore, the baby will continue to grow bigger the longer the pregnancy continues. This increases the risk of shoulder dystocia.A shoulder dystocia in a previous delivery indicates an increased chance of a repeat shoulder dystocia. A woman’s pelvic anatomy remains the same between pregnancies and further pregnancies have shown to result in bigger babies.The risk of shoulder dystocia is increased in women with a pre-pregnancy weight of 82 kilograms or greater. Larger babies have been known to be born to obese women.There are several different pelvic shapes. The dimensions of pelvic anatomy can determine the accommodation of the fetus.
Research supports macrosomia as having a strong correlation with shoulder dystocia.Macrosomia is considered fetal weights between 4500 grams and 5000 grams.The use of assistive instruments during delivery have shown to have a higher incidence rate of shoulder dystocia. This may be due to ineffective pushing by the mother.The Friedman’s Labor Curve is used to describe the progression of labor. A prolonged active phase of first stage labor and second stage labor have also been noted to increase the risk of shoulder dystocia due to slow descent.
The “turtle sign” can be noted when the head is delivered and continuously retracts against the perineum.
Refrain from applying force to the infant head or neck as well as fundal pressure. These maneuvers are more likely to cause injury to both mother and infant.The key to resolving a shoulder dystocia is to remain calm and to act swiftly. Remembering the mnemonic device HELPERR can assist in guiding appropriate actions to take.Once a dystocia is recognized it is important to call for nursing and medical personnel for assistance.A team effort is employed to manage the dystocia swiftly and safely.An Episiotomy can be cut to provide more room for the physicians hand for manipulation.Positioning the legs back have shown to resolve 50% of shoulder dystocias.Suprapubic pressure is carried out by exerting force slightly above the symphisis pubis to dislodge the anterior shoulder from under the pubic bone.Rotational maneuvers are conducted by the physician -Rubin- 2 fingers are placed behind the shoulder in an attempt to rotate the anterior shoulder towards the direction of the infants chest. If successful delivery may be attempted. -Woods corkscrew maneuver- 2 fingers are placed on the anterior portion of the posterior shoulder while gently attempting to rotate the shoulder in the same direction as the Rubin. -Reverse Woods corkscrew maneuver- 2 fingers are placed on the posterior portion of the posterior shoulder in an attempt to rotate the infant the opposite direction -Removing the posterior arm requires the physician to reach into the birth canal, hook the posterior arm and sweep it across the infants chest, the arm should be delivered by the sweep reducing the impaction of the opposite shoulder facilitating delivery of the infant.Rolling the patient is considered the Gaskin maneuver. The patient is safely and rapidly placed on all fours. This is said to change the position and dimensions of the pelvis which may help delivery of the infant.
Zavanelli Maneuver- A procedure whereby the infants head is replaced in its original position by turning and pushing it back into the birth canal. Continuous pressure must be held on the head until the cesarean section is performed.Symphysiotomy- Is a procedure in which the cartiliage of the pubic bone is surgically separated.
Documentation should include specific times during the event, the maneuvers implemented in order, length of time each maneuver was employed, an approximation of the amount traction forces, description of which shoulder was impacted, names of staff present to assist, episiotomy and time cut, time of delivery for the head then the body, estimated fetal weight and birth weight, and apgars.
