obgyn

1. SHOULDERSHOULDER
DYSTOCIADYSTOCIA
An Evidence BasedAn Evidence Based
ApproachApproach
Mansour Khalifa,M.D.
Assuit university

2. SHOULDER DYSTOCIA
Evidence Based Sources:
PubMed
Cochrean library
ACOG Issues Guidelines
National Guideline Clearinghouse

3. Definition:
Shoulder dystocia (Sh. D) is the
inability to deliver the fetal
shoulders after delivery of the
head, without the aid of
specific maneuvers (ie. other
than gentle downward traction
on the head) .
Spong et al. 1995; Beal et al 1998 ; Bruner 1998

4. DefinitionDefinition
Objective definition :Objective definition :
Mean head-to-body
delivery time > 60 seconds
Spong et al. 1995; Beal et al 1998 ; Bruner 1998

5. As operative vaginal delivery of
malposition and malpreresntation
has declined, Sh.D has emerged as
one of the more important clinical
and medico-legal complications of
vaginal delivery
Baskett, 2001

6. Shoulder
dystocia
will still the
obstetric
nightmare

7. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Shoulder dystocia results from
a size discrepancy between the
fetal shoulders and the pelvic inlet
when:
1. The bisacromial diameter is large
relative to the biparietal diameter
2. Pelvic prim is flat rather
than gynecoid
.

8. Types of ShoulderTypes of Shoulder
DystociaDystocia
Types of ShoulderTypes of Shoulder
DystociaDystocia
1- High Shoulder Dystocia1- High Shoulder Dystocia
2-Low Shoulder Dystocia2-Low Shoulder Dystocia
1- High Shoulder Dystocia1- High Shoulder Dystocia
2-Low Shoulder Dystocia2-Low Shoulder Dystocia

9. • Both shoulders fail to
engage
(Bilateral Sh.D). (Rare)
• More common with mid
-pelvic assisted delivery
• This presentation often
requires a cephalic
replacement.
(The most
difficult)
11--HighHigh Shoulder DystociaShoulder Dystocia

10. A)A) Failure ofFailure of
engagement of theengagement of the
anterior shoulderanterior shoulder
(Unilateral Sh.D).(Unilateral Sh.D).
,The commonest:
Usually easily dealt
with by Standard
techniques
2-Low Shoulder Dystocia

11. IncidenceIncidence
Varies according to:
1. Criteria for diagnosis.
2. Prophylactic manoeuvre done
Subjective: 0.6-1.6%
Objective: Much lower
ACOG Bulletin,22, Novamber2000

12. Release techniques
1.Maternal
2.Fetal
Complications of Sh DComplications of Sh D

13. 1. Postpartum hemorrhage 11%
2. Vaginal laceration 19%
3. Perineal tears 2nd
&3rd
4%
4. Cervical laceration 2%
Maternal ComplicationsMaternal Complications (25%)(25%)
The largest study (285 cases)
Gherman et al Am J Obstet Gynecol176:656, 1997

14. Release techniquesFetal Complications of Sh DFetal Complications of Sh D

15. Injuries are a common outcome
associated with shoulder
dystocia and may occur despite
use of proper standard obstetric
manoeuvers
ACOG practice 1997 (B: II-2)
Fetal Complications of Sh DFetal Complications of Sh D

16. 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)
Fetal Complications of Sh DFetal Complications of Sh D

17. Traction combined with
fundal pressure has been
associated with a high rate
of brachial plexus injuries
and fractures
ACOG practice 1997 (B: II-2)
Fetal Complications of Sh DFetal Complications of Sh D

18. Fewer than 10% of
deliveries complicated by
shoulder dystocia will result
in brachial
plexus injury.
ACOG practice 1997(A: II-2)
Fetal Complications of Sh DFetal Complications of Sh D
a persistenta persistent

19. Release techniques
Head –shoulder interval > 7min.
Brain injuryBrain injury
• With hypoxic fetus it is much shorter
Fetal ComplicationsFetal Complications
Quzounian et al Am J Obstet Gynecol 178;S76, 1998
(sensitivity & specificity :70 %)

20. Can shoulder
dystocia be
predicted?

21. RISK FACTORS FOR SHOULDERRISK FACTORS FOR SHOULDER
DYSTOCIADYSTOCIA
PRECONCEPTIONAL:
1. Maternal birth weight
2. Prior shoulder dystocia 12%
3. Prior macrosomia
4. Pre-existing diabetes
5. Obesity
6. Multiparity
7. Prior gestational diabetes
8. Advanced maternal age
O'Leary &, Leonetti; 1990

22. RISK FACTORS FOR SHOULDERRISK FACTORS FOR SHOULDER
DYSTOCIADYSTOCIA
Antenatal:Antenatal:
• Excessive maternal weight gain
• Macrosomia
• G. diabetes
• Short stature
• Post term
O'Leary &, Leonetti; 1990

23. RISK FACTORS FOR SHOULDER
DYSTOCIA
Intrapartum:Intrapartum:
1. Protracted or arrested active phase
2. Protracted or failure of descent of
head
3. Need for midpelvic assisted delivery
Hopwood,1982 ; Baskett &,Allen, 1995

24. RISK FACTORS FOR SHOULDER
DYSTOCIA
Most of the prenatal and antenatal risk
factor are interrelated with fetal
macrosomia. So the main risk factor is:
Fetal
Macrosomia

25. MacrosomiaMacrosomia
Acker et al, Obst. Gynecol 66:762, 1985
Baskett &Allen Obstet Gynecol 86:14, 1995
Although macrosomia
is clearly the main risk
factor,
50-60 % of Shoulder
Dystocia are of < 4 Kg !!

26. PredictionPrediction
Most cases of shoulder dystociaMost cases of shoulder dystocia
becausebecause
accurate methods for identifyingaccurate methods for identifying
which fetuses will experiencewhich fetuses will experience
ACOG Practice 1997 (B: II-2).
cannot be predictedcannot be predicted

27. Fetal body configuration may be more
important than macrosomia per se
MacrosomiaMacrosomia
Greater shoulder /head circumference:
1.Infant of diabetic mother
2.Post term (21% at 42 weeks)

28. Non Diabetic+
vacuum . Diabetic or
forceps
DiabeticWight (Kg)
4 : 4.25 5.2% 8.4% 12.2%
4.25: 4.5 9.1% 12.3% 16.7%
4.5 : 4.75 14.3% 19.9% 27.3%
4.75: 5 21.1% 23.5% 34.8%
Nesbitt et al, Am J Obstet Gynecol 179;476, 1998
Macrosomia And Shoulder Dystocia

29. UnfortunatelyUnfortunately
• The diagnosis of fetal macrosomia is
imprecise.
• For suspected fetal macrosomia, the
accuracy of estimated fetal weight
using ultrasound biometry is no better
than that obtained with clinical
palpation (Leopold's manoeuver).
ACOG Issues Guidelines on Fetal Macrosomia 2000ACOG Issues Guidelines on Fetal Macrosomia 2000(Level :A)

30. Can shoulder
dystocia be
Prevented ?

31. Macrosomia
There are 2 controversial
prophylactic measures
1-Prophylactic labor
induction
2-Elective CS

32. Induction of Labor
Suspected fetal macrosomia is
not an indication for induction
of labor, because induction
does not improve maternal or
fetal outcomes.
.
ACOG Issues Guidelines on Fetal Macrosomia 2000ACOG Issues Guidelines on Fetal Macrosomia 2000(Level B):

33. Labor induction for suspected fetal
macrosomia results in an
increased CS delivery rate
without improving perinatal
outcomes.
.
Sanchez-Ramos Obstet Gynecol Systemic Review
November 2002:100:997-1002
Induction of Labor

34. There is very little evidence to support
either elective delivery or expectant
management at term.
A single randomized controlled trialA single randomized controlled trial
suggest that induction of labor in GDMsuggest that induction of labor in GDM
treated with insulin reduces the risk oftreated with insulin reduces the risk of
macrosomia.macrosomia.
Boulvain et al:Cochrane Review,2001. In: The Cochrane
Library, Issue 2 2003. Oxford: Update Software.
Induction For Gestational DiabetesInduction For Gestational Diabetes

35. Planned cesarean delivery on the basis of
suspected macrosomia in the general
population is not a reasonable strategy
because the number and cost of
additional cesarean deliveries required to
prevent one permanent injury is
excessive
ACOG 1997 (B: II-2).
Prevention of Sh. D. :Prevention of Sh. D. : c.sc.s..

36. Furthermore 3%Furthermore 3% ofof
brachial plexus injurybrachial plexus injury
are associated withare associated with C.S.C.S.

37. When isWhen is CSCS
recommended inrecommended in
macrosomiamacrosomia?

38. ACOG Issues Guidelines on FetalACOG Issues Guidelines on Fetal
MacrosomiaMacrosomia 20002000
Prophylactic CS may be considered
for suspected fetal macrosomia
with estimated fetal weights of:
.
(Level :C)
<5,000g in non diabetic women
<4,500g in diabetic women

39. ACOG Issues Guidelines on FetalACOG Issues Guidelines on Fetal
MacrosomiaMacrosomia 20002000
With an estimated fetal weight more
than 4,500 g, with :
• A prolonged second stage of labor
or
• Arrest of descent in the second stage
It is an indication forIt is an indication for CSCS delivery.delivery.
.
Level B

40. MANAGEMENT
.
(Within5- 7 minutes)

41. ManagementManagement
1-Suprapubic pressure
2-McRobert manoeuver
3- Woods corkscrew .
4-Rubens manoeuver
5-Delivery of P. shoulder
6-Zavanelli
7-All fours
8-Cleidotomy
9-symphysiotomy

42. ACOG Issues GuidelinesACOG Issues Guidelines
Recommendation 1991Recommendation 1991
1-Call for help: assistants,
anesthesiologist
2-Initial gentle attempt of
traction.
3-Generous episiotomy.
4-Suprapubic pressure.

43. ACOG Issues GuidelinesACOG Issues Guidelines
Recommendation 1991Recommendation 1991
.
5-The Mc Roberts
manoeuvre
(Exaggerated hyper
flexion of the thighs
upon the abdomen.)
&
Suprapubic pressure
in the direction of the
Foetal face

44. 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
McRoberts manoeuvre: X ray pelvimetry study

45. IU pressure by 97% (P<0.0001)
U. contraction amplitude by 25% (P<0. 001)
Applied additional 31 Newtons pushing force
Buhimschi et al Lancet 358:470 ,2001
Mc Roberts manoeuvre

46. ACOG Issues GuidelinesACOG Issues Guidelines
Recommendation 1991Recommendation 1991
.
If Mc Roberts failed:If Mc Roberts failed:
6-Woods manoeuvre6-Woods manoeuvre::
•The hand is placed
behind the posterior
shoulder of the fetus.
•The shoulder is
rotated progressively 180 d in a corkscrew manner so
that the impacted anterior shoulder is released.

47. ACOG Issues GuidelinesACOG Issues Guidelines
Recommendation 1991Recommendation 1991
.
7-Delivery of the
posterior arm :

48. By inserting a hand
into the posterior
vagina and ventrally
rotating the arm at
the shoulder
delivery
over the
perineum

49. ACOG Issues GuidelinesACOG Issues Guidelines
Recommendation 1991Recommendation 1991
.
8-Other techniques
include:
1.Intentional fracture of the
clavicles or the humerus
Or
2.Zavanelli Maneuver.

50. The Zavanelli ManoeuverThe Zavanelli Manoeuver
Reversing the
mechanism of
delivery of the vertex
under tocolytic

51. 1. The head first manually rotated to
the occipito anterior
(Pre-restitution) position

52. 2.Flexion of the head, Returning it to
the vagina with upward constant
firm pressure, followed by CS

53. Zavanelli maneuver
• It would usually only be applicable in
those rare cases of bilateral Sh.D.
• It involves an emergency procedure
that is not without risks of its own .
• It has minimal applicability as it
needs
Immediate CS
The Zavanelli ManoeuverThe Zavanelli Manoeuver

54. Zavanelli maneuver
In an analysis of 92 cases of shoulder dystocia
managed by Zavanelli Maneuver:
• Success rate : 92 %
• Stillbirth: 7%
• Neonatal death : 9%.
• Brain damage : 11%
Maternal complication:
Rupture uterus ,vaginal rupture ,severe infection,
The Zavanelli Manoeuver
Sanberg; Obstet Gynecol.;93:312. 1999

55. All- Fours ManoeuverAll- Fours Manoeuver
It consists of placing the patient ontoIt consists of placing the patient onto
her hands and kneesher hands and knees

56. • It allows rotational movement of the
sacroiliac joints resulting in a l-cm to 2-
cm increase in the sagittal diameter of the
pelvic outlet.
• It disimpact the shoulders, and
allowing it to slide over the sacral
promontory.
•Effective also for bilateral Sh.D.
All- Four ManoeuverAll- Four Manoeuver

57. All- Fours ManoeuverAll- Fours Manoeuver
In an analysis of 82 cases of shoulder
dystocia managed by all-four manoeuver
:
• Success rate : 83%
• Maternal complications 1.2%
•Neonatal complications : 4.9%,
•Time for complete delivery : 2 to 3 Ms.
Drummond et al. J Reprod Med. ;43:439; 1998.

58. Release techniques
There is no evidence that any
one maneuver is superior to
another in releasing an
impacted shoulder or
reducing the chance of
injury.
)B: II-2(.
ACOG Issues Guidelines 1997ACOG Issues Guidelines 1997

59. Release techniques
However, the Mc Roberts
maneuver is easily facilitated
and has a high success rate
without an associated
increased risk of injury to the
newborn )B: II-2(.
ACOG Issues Guidelines 1997ACOG Issues Guidelines 1997

60. Bilateral Shoulder ImpactionsBilateral Shoulder Impactions
Zavanelli Manoeuver:
Used if the patient has received epidural
analgesia or heavy analgesia
with obstetric facilities for emergency CS
All- Fours Manoeuver:
Used at all circumstances except if the
patient has received epidural analgesia,
heavy analgesia or anesthesia

61. Prophylactic ProceduresProphylactic Procedures
When shoulder dystocia isWhen shoulder dystocia is
anticipated , prophylacticanticipated , prophylactic
McRobert positionMcRobert position isis
recommendedrecommended

62. Shoulder Dystocia Drill
Shoulder dystocia drill should be as
important as CPR for the mother
and neonate.
This should be taught and practiced
regularly, by all staff involved
with delivery

63. Thank You