1. OUR NIGHTMARE: SHOULDER
DYSTOCIA
Dr. Alik Riasadesa Zakaria
M.B.,B.S(Malaya), M.Obsgyn (Malaya)
Department of Obstetrics & Gynaecology
International Islamic University Malaysia
2. NIGHTMARE
• It is a leading cause of obstetric malpractice claims
• Methods of prediction: not sensitive or specific enough
• Preventive measures: not effective clinically and economically
3. DEFINITION AND INCIDENCE
• Definition:
– A prolonged head to body delivery time ( i.e. >60 seconds)and/or
the necessitated use of ancillary obstetric manoeuvres
• Incidence:
– 0.2-2%
5. MECHANISM
• Fetopelvic relationships
– In the term fetus the bisacromial diameter is larger than its
biparietal diameter
– In spontaneous labour the head passes through the pelvic inlet
8. MECHANISM
• Fetopelvic relationships
– Usually the posterior shoulder will descend below the sacral
promontory and it is the anterior shoulder that becomes impacted
behind the pubic symphysis: unilateral shoulder dystocia
– On very rare occasions the posterior shoulder fails to descend
below the sacral promontory, so that both the anterior and posterior
shoulders are arrested above the pelvic brim: bilateral shoulder
dystocia
10. PREDISPOSING FACTORS
• There are number of predisposing factors, but there are not
sensitive or specific
1. Antepartum
2. Intrapartum
11. PREDISPOSING FACTORS: ANTEPARTUM
1. MACROSOMIA
• Is the most important risk factor
• The risk of shoulder dystocia increases with rising birth weight
2. INFANTS OF DIABETIC MOTHERS
• Hyperglycaemia and hyperinsulinaemia cause excessive growth
of shoulder girth
• Therefore they are at a greater risk of shoulder dystocia in
comparison to nondiabetic infants of the same weight
12. PREDISPOSING FACTORS: ANTEPARTUM
3. POST DATE PREGNANCY
• In the later weeks of pregnancy the biparietal diameter growth
slows but the fetal chest and shoulders continue to grow steadily
• This causes shoulder to be bigger than the head, thus increases
the risk of shoulder dystocia
4. MATERNAL OBESITY
• It has been shown in number of studies to be associated with
increased incidence of shoulder dystocia
• There is 8-fold increased in the risk of shoulder dystocia in
women weighing less than 90kg compare to those weighing more
than 113kg
14. PREDISPOSING FACTORS:INTRAPARTUM
• MOST CASES OF SHOULDER DYSTOCIA HAVE A
NORMAL PROGRESSION IN LABOUR
• HOWEVER , THERE ARE CERTAIN PATTERNS OF
LABOUR DO INCREASE THE LIKELIHOOD OF SHOULDER
DYSTOCIA:
1. Prolonged active phase of labour
2. Poor descent in the second stage of labour
3. Assisted mid-pelvis delivery
18. PREVENTION:
MANAGEMENT OF ANTEPARTUM RISK FACTORS
1. OBESITY
• BMI determination offers more precise quantification of obesity
• Advise on adequate but not excessive prenatal weight gain and
recommended weight gain based on BMI should be documented
2. EXCESSIVE WEIGHT GAIN
• Women with excessive weight gain should be referred to dietician
and should received counselling about activity
• They may benefit from increased support during prenatal visits at
more frequent interval
19. PREVENTION:
MANAGEMENT OF ANTEPARTUM RISK FACTORS
3. DIABETES
• Women should be referred to dietician for proper dietary advice
• Insulin therapy should be started early if the blood sugars are
poor controlled with diet modification
• Diet and/or insulin therapy reduces both macrosomia and the
incidence of shoulder dystocia
20. PREVENTION:
MANAGEMENT OF ANTEPARTUM RISK FACTORS
4. POST DATE PREGNANCY
• Some cilinicians plans an early induction of labour to prevent
macrosomia and thus avoiding shoulder dystocia
• But does it works?
• Study shows that the above approached does reduced the
incidence of macrosomia but does not reduced the incidence of
shoulder dystocia
• ACOG recommended that there is no indication for early
induction of labour if the ultrasound estimation of fetal weight
ranges from 4000-4500g at term
21. PREVENTION:
MANAGEMENT OF ANTEPARTUM RISK FACTORS
5. MACROSOMIA
• Guidelines published by ACOG do not support elective
Caesarean for all women suspected macrosomia
• But in patient with a history of shoulder dystocia, maternal
glucose intolerence and severe prior neonatal injury, risks and
benefits of Caesarean delivery should be discussed with the
patient
• Planned Caesarean delivery to prevent shoulder dystocia may be
considered for suspected fetal macrosomia with estimated fetal
weight exceedinf 5000g in women without diabetes and 4500g in
women with diabetes
22. MANAGEMENT
• DIAGNOSIS:
– When the head delivers, either spontaneously or assisted, but
does not undergo external rotation and recoils tightly back against
the perineum; often called the “turtle sign”
24. MANAGEMENT
• STOPSTOP THE TRACTION
• RED ALERTRED ALERT; DO NOT PANIC AND CALL FOR HELP
• GENEROUS EPISIOTOMY...PLEASE!!!GENEROUS EPISIOTOMY...PLEASE!!!
25. MANAGEMENT
1.1. MC ROBERTS’ MANOEUVRE;MC ROBERTS’ MANOEUVRE; APPLY FIRM FLEXION AND
ABDUCTION OF THE MATERNAL THIGHS TO INCREASED
THE PELVIC INLET
• APPLY SUPRAPUBICAPPLY SUPRAPUBIC (NOT FUNDAL) TO THE ANTERIOR
SHOULDER TO TO ROTATE TO THE OBLIQUE DIAMETER
AND UNDER THE SYMPHYSIS PUBIS
29. MANAGEMENT
QuickTime™ and aTIFF (Uncompressed) decompressare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressare needed to see this picture.
30. MANAGEMENT
• Mc Robert manoeuvre alone freed the shoulder in 41% of cases
• Mc Robert manoeuvre combined with suprapubic pressure freed
another 40%
• Thank God!!!Thank God!!! 80% of the time we can stop here...
• But if we have to go on......what is next......But if we have to go on......what is next......
31. MANAGEMENT
22. ROTATE THE FETAL SHOULDERS TO THE OBLIQUEROTATE THE FETAL SHOULDERS TO THE OBLIQUE
DIAMETER OF THE PELVIC BRIM;DIAMETER OF THE PELVIC BRIM; OBLIQUE DIAMETER
OF THE PELVIS IS WIDER!!!
• Push the infant’s posterior shoulder off the midline to the
oblique diameter
• If this FAILS@*%##@FAILS@*%##@
32. MANAGEMENT
• Am I SCREWED YET???SCREWED YET???
3.3. I GUESS NOT..WOODS’ CORKSCREW MANOEUVRE!!!I GUESS NOT..WOODS’ CORKSCREW MANOEUVRE!!!
• Continue rotating the infant’s posterior shoulder; (R) hand if
infant’s back was on the mother’s (R), and exerting the
pressure to rotate the fetus 1800
34. MANAGEMENT
• In doing so;
– The posterior shoulder, which is below the pelvic brim, remains at
that level and is rotated to become the anterior shoulder below the
sub-pubic arch, whence it can be delivered
– The former anterior shoulder, which was above the pelvic brim, has
been corkscrewed below the level of the pelvic brim and become
the posterior shoulder
• What if this still failed to deliver the shoulder....What if this still failed to deliver the shoulder....
35. MANAGEMENT
4.4. DELIVER THE POSTERIOR SHOULDER.....DELIVER THE POSTERIOR SHOULDER.....
– Pass the hand deep into the vagina and sacral hollow, identify
the fetal humerus and follow it to the elbow
36. MANAGEMENT
• DELIVER THE POSTERIOR SHOULDER.....
– The elbow is flexed and the forearm grasped and swept across the
fetal chest
37. MANAGEMENT
• DELIVER THE POSTERIOR SHOULDER.....
– After delivery of the posterior arm, the anterior shoulder
should be able to be delivered
– If not, support the fetal head and trunk and rotate though
180o
which served to bring the anterior shoulder below the
pelvic brim into the sacrum where it will be accessible
38. MANAGEMENT
• HOW DOES DELIVERY OF THE POSTERIOR SHOULDER
HELP ??....
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
39. MANAGEMENT
• DELIVER THE POSTERIOR SHOULDER.....
• BUT IT DOESN’T HELP AT ALL..!!!!! WHAT TO DO NEXT???BUT IT DOESN’T HELP AT ALL..!!!!! WHAT TO DO NEXT???
41. MANAGEMENT
• ALL-FOURS MANOEUVRE...
– Basis: The flexibility of the sacro-iliac joint which allows 1-2cm
increased in the antero-posterior diameter of the pelvic inlet
– In lithotomy: the posterior mobility of the sacrum is limited
– The gravity: Helps push the posterior forward and over the sacral
promontory
43. MANAGEMENT
• STILL SHOULDER NOT DELIVERED....STILL SHOULDER NOT DELIVERED....
• ZAVANELLI MANOEUVRE:
– Grasps the fetal head, flexed it and pushed it into the vagina
– Arrange for Caesarean delivery
• SYMPHYSIOTOMY
44. MANAGEMENT
• DOCUMENTATION:DOCUMENTATION:
– It is important that the delivery and manoeuvres required to
deliver the baby carefully recorded by all present
– This will help planning future delivery and provide sound medico
legal defence
– Umbilical cord blood gas analysis should be obtained
– Damage suffered by the infant should be recorded as it reflects
the severity of the shoulder dystocia
45. COMPLICATIONS
• FETAL:
1. Fracture of the clavicle: 15%
2. Brachial plexus injury;
– 5-15%
– The vast majority are of the Erb-Duchenne type (C5&C6 nerve roots)
– The majority of cases of brachial plexus injury resolve with time
– Less than 10% long term disability
47. COMPLICATIONS
• MATERNAL:
1. Lower genital tract lacerations;
– Due to the generous episiotomy &
– Distension of the vagina by the manoeuvre
2. Post-partum haemorrhage:
– Episiotomy and lacerations
– Uterine atony
– Rarely uterine rupture
3. In rare cases of Zavanelli manoeuvre:
– Haemorrhage
– Blood transfusion
– Hysterectomy
48. QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
