Shoulder dystocia ckk edit

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Shoulder dystocia CME

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Shoulder dystocia ckk edit

  1. 1. Prepared by Dr Chia Kok King Counterchecked by Dr Maziah SHOULDER DYSTOCIA
  2. 2. Introduction <ul><li>Shoulder dystocia </li></ul><ul><ul><li>Delivery that requires additional obstetric maneuvers to release the shoulders after gentle downward traction has failed. </li></ul></ul><ul><ul><li>Occurs when the fetal anterior shoulder or less commonly, posterior shoulder impacts against the maternal symphysis or sacral promontory following delivery of the vertex </li></ul></ul><ul><ul><li>An obstetric emergency and one of the most frightening event in labour room. </li></ul></ul><ul><ul><li>Unpredictable and unpreventable event. </li></ul></ul>
  3. 3. <ul><li>Calm and effective management of this emergency is possible with recognition of the impaction and institution of specified maneuvers. </li></ul><ul><li>Incidence : 0.2% to 3.0% of all vaginal deliveries </li></ul><ul><li>Conventional risk factors predicted only 16% of shoulder dystocia that resulted in infant morbidity hence risk assessments for the prediction of shoulder dystocia are insufficiently predictive to allow prevention of the large majority of cases . </li></ul><ul><li>Clinicians should be aware of existing risk factors but must always be alert to the possibility of shoulder dystocia with any delivery. </li></ul>
  4. 4. Risk factors and anticipation <ul><li>Only 25% of shoulder dystocias have at least 1 risk factor </li></ul><ul><li>Maternal </li></ul><ul><ul><li>Abnormal pelvic anatomy </li></ul></ul><ul><ul><li>Short stature mother </li></ul></ul><ul><ul><li>Gestational diabetes mellitus </li></ul></ul><ul><ul><li>Post-dates pregnancy </li></ul></ul><ul><ul><li>Previous history of shoulder dystocia </li></ul></ul><ul><ul><li>Maternal BMI >30 </li></ul></ul><ul><li>Fetal </li></ul><ul><ul><li>Suspected macrosomia (>4500g) </li></ul></ul><ul><li>Labor related </li></ul><ul><ul><li>Assisted vaginal delivery (forceps or vacuum) </li></ul></ul><ul><ul><li>IOL </li></ul></ul><ul><ul><li>Prolonged active phase of first-stage labor </li></ul></ul><ul><ul><li>Prolonged second-stage labor </li></ul></ul><ul><ul><li>Secondary arrest </li></ul></ul><ul><ul><li>Augmentation of labor </li></ul></ul>
  5. 5. <ul><ul><ul><ul><ul><li>Most of the prenatal and antenatal risk factors for shoulder </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>dystocia are interrelated with FETAL MACROSOMIA. </li></ul></ul></ul></ul></ul><ul><li>However large majority of infants with a birth weight of </li></ul><ul><li>≥ 4500g do not develop shoulder dystocia and 48% of </li></ul><ul><li>incidences of shoulder dystocia occur in infants with a birth </li></ul><ul><li>weight <4000g. </li></ul><ul><li>Clinical fetal weight estimation is unreliable and </li></ul><ul><li>third-trimester ultrasound scans </li></ul><ul><li>have at least a 10% margin for </li></ul><ul><li>error for actual birth weight and </li></ul><ul><li>a sensitivity of just 60% for </li></ul><ul><li>macrosomia (over 4.5 kg). </li></ul>
  6. 6. Case-control study <ul><li>Objective : To determine if shoulder dystocia can be predicted in babies born weighing 3.5kg or more. </li></ul><ul><li>A case–control study nested in a perinatal database of 899 mothers and their babies who weighed 3.5kg or more . All were term pregnancies and delivered vaginally . A case was defined as any baby that encountered shoulder dystocia at delivery. Controls were deliveries over the same period that were not complicated by shoulder dystocia. A logistic regression model was created with macrosomia, parity, previous delivery of more than 3.5kg, diabetes in pregnancy, prolonged labor, prolonged second stage and instrumental delivery as the independent variables. The adjusted odds ratio and the receiver operator characteristics (ROC) curves were used to see if these variables, both individually and as a model, were associated with or were discriminative enough to predict shoulder dystocia; an ROC curve of more than 0.7 showing good prediction. </li></ul>Asmah Mansor, Kulenthran Arumugam ,  Siti Zawiah Omar Department of Obstetrics & Gynaecology, University of Malaya Medical Centre, ( Eur J Obstet Gynecol Reprod Biol.  2010 Mar;149(1):44-6. Epub 2009 Dec 29.)
  7. 7. <ul><li>Result : There were 36 cases of shoulder dystocia during the study period, an incidence of 4%. Previous delivery of more than 3.5kg, prolonged labor and prolonged second stage were not associated with shoulder dystocia. Although diabetes and instrumental delivery were independently and significantly associated with shoulder dystocia their importance as a predictor became relevant only in the presence of macrosomia. </li></ul><ul><li>Conclusion : Macrosomia is the only reliable predictor of shoulder dystocia in babies weighing 3.5kg or more </li></ul>Asmah Mansor, Kulenthran Arumugam ,  Siti Zawiah Omar Department of Obstetrics & Gynaecology, University of Malaya Medical Centre, ( Eur J Obstet Gynecol Reprod Biol.  2010 Mar;149(1):44-6. Epub 2009 Dec 29.)
  8. 8. Prevention <ul><li>Induction of labour </li></ul><ul><ul><li>DM mother on insulin  reduce the risk of macrosomia and risk of shoulder dystocia but does not reduce maternal or neonatal morbidity </li></ul></ul><ul><ul><li>Women without DM at term with suspected macrosomic baby  </li></ul></ul><ul><ul><li>no evidence to support that shoulder dystocia can be prevented with IOL </li></ul></ul><ul><li>Caesarian section </li></ul><ul><ul><li>Mother with DM + suspected big baby should be considered for ELLSCS to reduce the potential morbidity </li></ul></ul><ul><ul><li>Not recommended in non-DM mother with suspected big baby </li></ul></ul><ul><ul><li>Mode of delivery for mother with previous history of shoulder dystocia  for mother/obstetrician to decide. </li></ul></ul><ul><ul><li>No requirement to advise ELLSCS routinely but below factors should all be considered when offering recommendations for the next delivery : </li></ul></ul><ul><ul><ul><li>the severity of any previous neonatal or maternal injury, </li></ul></ul></ul><ul><ul><ul><li>fetal size </li></ul></ul></ul><ul><ul><ul><li>maternal choice </li></ul></ul></ul>
  9. 9. Diagnosing in labor <ul><li>Difficulty with delivery of the face and chin </li></ul><ul><li>The head remaining tightly applied to the vulva or even retracting  ‘turtle sign’ </li></ul><ul><li>Failure of restitution of the fetal head </li></ul><ul><li>Failure of the shoulders to descend. </li></ul>Royal College of Obstetricians and Gynaecologists Clinical Guideline-Guideline No 42 Shoulder Dystocia, December 2005
  10. 10. <ul><li>Shoulder dystocia becomes obvious when the fetal head emerges and then retracts against the perineum, commonly referred to as the “turtle sign.” </li></ul>
  11. 11. <ul><li>The CESDI (Confidential Inquiry Into Stillbirth and </li></ul><ul><li>Death in Infancy) report on shoulder dystocia </li></ul><ul><li>identified that 47% of the babies died within 5 </li></ul><ul><li>minutes of the head being delivered. </li></ul><ul><li>Therefore it is important to manage the problem as </li></ul><ul><li>efficiently as possible but also carefully : </li></ul><ul><li>Efficiently so as to avoid hypoxia acidosis </li></ul><ul><li>Carefully so as to avoid unnecessary trauma </li></ul>
  12. 12. Intrapartum management <ul><li>MO/obstetrician to standby at second stage of labour when shoulder dystocia is anticipated. </li></ul><ul><li>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. </li></ul>
  13. 13. Adapted from Advanced Life Support in Obstetric
  14. 14. H e lp <ul><li>Senior midwives </li></ul><ul><li>MO </li></ul><ul><li>O&G specialist </li></ul><ul><li>Paediatric team </li></ul>
  15. 15. <ul><li>Episiotomy is not necessary for all cases. </li></ul><ul><li>Some authors have advocated that episiotomy is an essential part of the management in all cases. The authors of one study have concluded that episiotomy does not decrease the risk of brachial plexus injury with shoulder dystocia. </li></ul><ul><li>An episiotomy should therefore </li></ul><ul><li>be considered………. </li></ul><ul><li>but it is NOT MANDATORY! </li></ul>E valuate for E pisiotomy
  16. 16. L eg  The McRoberts Maneuver <ul><li>It straightens the lumbosacral angle, rotates the maternal pelvis cephalad and is associated with an increase in uterine pressure and amplitude of contractions. </li></ul><ul><li>The McRoberts’ maneuver is the single most effective intervention, with reported success rates as high as 90% with low rate of complication </li></ul>Royal College of Obstetricians and Gynaecologists Clinical Guideline-Guideline No 42 Shoulder Dystocia, December 2005
  17. 17. <ul><li>Fundal pressure should not be employed. </li></ul><ul><li>It is associated with an unacceptably high neonatal complication rate and may result in uterine rupture. </li></ul><ul><li>Maternal pushing should be discouraged , as this may lead to further impaction of the shoulders, thereby exacerbating the situation. </li></ul>
  18. 18. Suprapubic P ressure a.k.a Rubin I maneuver <ul><li>Apply with downward and lateral direction to push the posterior aspect of the anterior shoulder towards the fetal chest for 30sec (recommended time). </li></ul><ul><li>Either continuous pressure or ‘rocking’ movement </li></ul><ul><li>Reduces the bisacromial diameter and rotates the anterior shoulder into the oblique pelvic diameter. </li></ul>Gobbo R, Baxley EG. Shoulder dystocia. In: ALSO: advanced life support in obstetrics provider course syllabus. Leawood, Kan.: American Academy of Family Physicians, 2000.
  19. 19. E nter : Vaginal Access
  20. 20. Internal rotation maneuvers Mr. Kim Hinshaw, consultant obstetrician and gynecologist, Newcastle, England. In: ALSO ®: advanced life support in obstetrics instructor course syllabus. Leawood, Kan.: American Academy of Family Physicians, 2002:67.
  21. 21. R emoval of posterior arm <ul><li>Delivery of the posterior arm has a high complication rate (12% humeral fractures) but the neonatal trauma may be a reflection of the refractory nature of the case, rather than the procedure itself. </li></ul>
  22. 22. R oll the patients to her hands and knees (All Four Position) <ul><li>83% success rate in one case series </li></ul>
  23. 23. What measures should be taken if first and second-line maneuvers fail? <ul><li>Third-line maneuvers require careful consideration to avoid unnecessary maternal morbidity and mortality. </li></ul><ul><li>It is difficult to recommend a time limit for the management of shoulder dystocia, as there are no conclusive data available. </li></ul>
  24. 24. Last resort maneuvers!! <ul><li>Cleidotomy </li></ul><ul><li>Symphysiotomy </li></ul><ul><li>Zavanelli maneuver </li></ul>Royal College of Obstetricians and Gynaecologists Clinical Guideline-Guideline No 42 Shoulder Dystocia, December 2005
  25. 25. Symphysiotomy <ul><li>Has been suggested as a potentially useful procedure, both in the developing and developed world. </li></ul><ul><li>High incidence of serious maternal morbidity and poor neonatal outcome. </li></ul><ul><li>After delivery, the birth attendants should be alert to the possibility of postpartum haemorrhage and 3 rd /4 th degree perineal tears. </li></ul>
  26. 26. Zavanelli manoeuvre <ul><li>Cephalic replacement of the head, and delivery by Caesarean section has been described but success rates vary. </li></ul><ul><li>Zavanelli maneuver may be most appropriate for rare bilateral shoulder dystocia </li></ul><ul><li>The maternal safety of this procedure is unknown, however should be borne in mind, knowing that a high proportion of fetuses have irreversible hypoxia-acidosis by this stage. </li></ul>
  27. 28. Complications <ul><li>Maternal </li></ul><ul><ul><li>Postpartum hemorrhage (11%) </li></ul></ul><ul><ul><li>Third- or fourth-degree episiotomy or tear </li></ul></ul><ul><ul><li>(3.8%) </li></ul></ul><ul><ul><li>Uterine rupture </li></ul></ul><ul><ul><li>Symphyseal separation or diathesis, </li></ul></ul><ul><ul><li>with or without transient femoral neuropathy </li></ul></ul><ul><ul><li>Rectovaginal fistula </li></ul></ul><ul><li>Fetal </li></ul><ul><ul><li>Brachial plexus palsy (4-16%) </li></ul></ul><ul><ul><li>Clavicle fracture </li></ul></ul><ul><ul><li>Fracture of the humerus </li></ul></ul><ul><ul><li>Fetal hypoxia, with or without permanent </li></ul></ul><ul><ul><li>neurological damage </li></ul></ul><ul><ul><li>Fetal death </li></ul></ul>
  28. 29. <ul><li>Erb-Duchenne Palsy (80%) </li></ul><ul><ul><li>(C5-C6) </li></ul></ul><ul><li>Klumpke’s Palsy </li></ul><ul><ul><li>(C7-T1 ) </li></ul></ul><ul><li>Moro reflex is absent </li></ul><ul><li>Grasp of the hand is present. </li></ul><ul><li>Fingers and wrist have normal motion. </li></ul><ul><li>Impaired functions of deltoid, the external </li></ul><ul><li>rotators of the shoulder, elbow flexors and </li></ul><ul><li>wrist extensors (supraspinatus, infraspinatus </li></ul><ul><li>and teres minor, biceps brachii, brachialis, </li></ul><ul><li>supinator, and the brachioradialis). </li></ul><ul><li>Shoulder is adducted and internally rotated. </li></ul><ul><li>The elbow is extended and the forearm </li></ul><ul><li>pronated (the “waiter’s tip position”) </li></ul><ul><ul><li>Moro reflex present/absent, </li></ul></ul><ul><ul><li>Loss of grasp reflex. </li></ul></ul><ul><ul><li>Wrist flexors, long digital flexors, and the </li></ul></ul><ul><ul><li>intrinsic muscles of the hand are impaired, </li></ul></ul><ul><ul><li>Muscles controlling the shoulder and elbow </li></ul></ul><ul><ul><li>are usually spared. </li></ul></ul><ul><ul><li>The hand is supinated, the wrist extended, </li></ul></ul><ul><ul><li>and the fingers clawed </li></ul></ul>
  29. 30. Risk Factors for Permanent Brachial Plexus Injury <ul><li>Birth Weight >4500g - 41% </li></ul><ul><li>DM - 11% </li></ul><ul><li>Prolonged second stage (>2H) - 14% </li></ul><ul><li>Operative Vaginal Delivery - 21% </li></ul><ul><li>Shoulder Dystocia - 94% </li></ul><ul><li>Ouzounian, Korst, Phelan </li></ul>
  30. 31. <ul><li>Brachial plexus injuries are one of the most important fetal complications of shoulder dystocia, complicating 4–16% of such deliveries. </li></ul><ul><li>Most cases resolve without permanent disability, with fewer than 10% resulting in permanent brachial plexus dysfunction. </li></ul><ul><li>Neonatal brachial plexus injury is the single most common cause for litigation related to shoulder dystocia. </li></ul><ul><li>Not all injuries are due to excess traction by the accoucheur and there is now a significant body of evidence that maternal propulsive force may contribute to some of these injuries </li></ul><ul><li>Evidence from cadaver studies suggests that lateral and downward traction is more likely to cause nerve avulsion </li></ul>Brachial plexus injuries
  31. 32. Documentation <ul><li>It is important to record : </li></ul><ul><li>● time of delivery of the head </li></ul><ul><li>● direction the head is facing after restitution </li></ul><ul><li>● maneuvers performed, their timing and sequence </li></ul><ul><li>● time of delivery of the body </li></ul><ul><li>● staff in attendance and the time they arrived </li></ul><ul><li>● condition of the baby (Apgar score) </li></ul><ul><li>● umbilical cord blood acid-base measurements. </li></ul>Royal College of Obstetricians and Gynaecologists Clinical Guideline-Guideline No 42 Shoulder Dystocia, December 2005
  32. 33. References <ul><li>Royal College of Obstetricians and Gynaecologists.  Shoulder Dystocia . Green-top Guideline Number 42. December 2005. </li></ul><ul><li>American Academy of Family Physician, Shoulder Dystocia ELIZABETH G. BAXLEY, M.D., ROBERT W. GOBBO, M.D. http://www.aafp.org/afp/2004/0401/p1707.html </li></ul><ul><li>Asmah Mansor, Kulenthran Arumugam ,  Siti Zawiah Omar </li></ul><ul><li>Department of Obstetrics & Gynaecology, University of Malaya Medical Centre, </li></ul><ul><li>( Eur J Obstet Gynecol Reprod Biol.  2010 Mar;149(1):44-6. Epub 2009 Dec 29.) </li></ul>
  33. 34. Thank you for listening…

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