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Shoulder
Dystocia


   ( ACOG Medical Student Education Module 2011)
Definition

  Difficulty in delivery of fetal shoulders
  Failure to deliver fetal shoulder without
   utilizing facilitating maneuvers
  Prolonged head-to-body delivery time
    >60 seconds
  Incidence: 0.2-3% of all live births;
   represents an obstetric emergency
Bilateral Shoulder
Dystocia
              The posterior
               shoulder is not in the
               hollow of the pelvis.

              This presentation
               often requires a
               cephalic
               replacement.
Unilateral Shoulder
Dystocia
              Unilateral shoulder
               dystocia is usually easily
               dealt with by standard
               techniques.
Pathophysiology

 Size discrepancy between fetal
  shoulders and maternal pelvic inlet
   Macrosomia
   Large chest:BPD
   Absence of truncal rotation
      Fetal shoulders remain A-P or descent
       simultaneously
Risk Factors
 Antepartum
     Macrosomia (>4500g ACOG)
     GDM (increases overall risk by 70%)
     Multiparity
 Intrapartum
     Prolonged deceleration phase of labor
     Prolonged 2nd stage
     Protracted descent
     Operative delivery (vacuum>forceps)
   D - Diabetes
   O- Obesity
   P- Post term pregnancy, prior large baby
   E- Excessive weight gain during
    pregnancy

 No evidence based data:
     Male
     Short maternal stature
     Abnormal pelvic shape/size
Unpredictable
 25-50% have no defined risk factor!

 50% of cases occur in infants whose birth
  weight is <4000g

 TURTLE SIGN: represented by the
  retraction of the fetal head after expulsion,
  may herald shoulder dystocia, shoulder
  dystocia is not diagnosed until the usual
  attempts at the delivery of the head fail.
Complications
 Maternal
   Hemorrhage
   4th degree laceration
 Fetal
   Fx of humerus or clavicle
   Brachial plexus injury (Erb’s/Klumpke’s
    palsy)
   Asphyxia/cord compression
 Physician
   Litigation: 11% of all obstetrical suits
Management
 Goal: Safe delivery before neontal
  asphyxia and/or cortical injury
      7 minutes!!!
     Episiotomy
     Suprapubic Pressure
     McRoberts Maneuver
     Woods or Rubin Maneuvers
     Zavenelli
       Push back the delivered fetal head into birth
        canal and perform an emergent c/s
HELPERR Algorithm
 H: Call for Help; Shoulder dystocia is
  called if shoulders cannot be delivered
  with gentle traction
 E: Evaluate for Episiotomy: Not routinely
  indicated; maybe needed when
  attempting intra-vaginal maneuver
 L: Legs (McRoberts): Hyperflexion and
  abduction of hips—initial maneuver
 P (Suprapubic Pressure): No fundal pressure; combination of
  McRoberts and suprapubic pressure resolves most shoulder dystocias

 Enter (Internal Maneuvers): oblique diameter rotational maneuvers
    Woods screw (1943): Insert two fingers into posterior vagina and
     apply pressure to the anterior aspect (clavicular) of the posterior
     shoulder and abduct and rotate that shoulder, the posterior
     shoulder could be rotated 180° degrees to the anterior, and this
     would disimpact the obstructed anterior shoulder. The subsequent
     addition of gentle downward traction with a contraction would then
     result in delivery.

     Rubin(1964): either the anterior or posterior shoulder, which ever
      was more accessible, be adducted and brought toward the fetal
      chest. Insert two fingers on the posterior aspect (scapular) of the
      anterior or posterior shoulder and also rotate the baby 180° to
      reduce the obstruction.

 Remove: Delivery posterior arm

 Roll the patient: Gaskin maneuver or all four positions
McRoberts Maneuver
 42% success rate
      + Suprapubic pressure = 54-58%
   Brings pelvic inlet and outlet into more vertical
    alignment
   Flattens sacrum
   Cephalad rotation of pubic symphysis
   Elevates anterior shoulder and flexes fetal spine
   Increases IUP by 97%
   Increases amplitude of contractions
   +31N of pushing force
Preliminary Measures:

                   Gentle        pressure on the fetal
                     vertex in a dorsal direction will move
                     the posterior fetal shoulder deeper
                     into the maternal pelvic hollow,
                     usually resulting in easy delivery of
                     the anterior shoulder.
                   Excession angulation (>45
                    degrees) is to be avoided.


        (Gabbe, et al., Obstetrics: Normal and Problem
        Pregnancies, Churchill Livingstone, New York, 1986)
The McRoberts manoeuvre
Suprapubic Pressure
 Moderate suprapubic pressure is often the
  only additional maneuver necessary to disimpact
  the anterior fetal shoulder. Stronger pressure can
  only be exerted by an assistant.




                                           (Gabbe, et al., 1986)
Oblique Diameter
Rotational Maneuver
          Delivery may be facilitated by
           counterclockwise
           rotation of the anterior
           shoulder to the more
           favorable oblique pelvic
           diameter, or clockwise
           rotation of the posterior
           shoulder.
          During these maneuvers,
           expulsive efforts should
           be stopped and the head
           is never grasped !!
Delivery of the
Posterior Arm

                                       To bring the fetal wrist
                                        within reach, exert
                                        pressure with the index
                                        finger at the antecubital
                                        junction.




   (E. Sandberg. American Journal of Obstetrics and Gynecology, 1985; 152: 481.)
Delivery of the
Posterior Arm
                   Sweep the
                    fetal
                    forearm
                    down over
                    the front of
                    the chest.
Delivery of the
Posterior Arm
              If less invasive
               maneuvers fail to affect
               this impaction, delivery
               should be facilitated by
               manipulative delivery of
               the posterior arm by
               inserting a hand into the
               posterior vagina and
               ventrally rotating the arm
               at the shoulder with
               delivery over the
               perineum.
All- Fours
Manoeuver
It consists of placing the patient onto
         her hands and knees
The Chavis Maneuver

 Described in 1979.
 A “shoulder horn” consisting of a
  concave blade with a narrow handle is
  slipped between the symphysis and the
  impacted anterior shoulder.
 This used like a shoe-horn as a lever
  where the symphysis is the fulcrum.
The Hibbard Maneuver
           Release of the anerior shoulder
            is initiated by firm pressure
            against the infant's jaw and neck
            in a posterior and upward
            direction. An assistant is poised,
            ready to apply fundal pressure
            after proper suprapublic
            pressure
           As the anterior shoulder slips
            free, fundal pressure is applied,
            and pressure against the neck is
            shifted slightly toward the
            rectum.
            Proper suprapubic pressure is
            continued.
The Hibbard Maneuver

             Continued fundal and
              suprapublic pressure
              results in an upward-
              inward rotation of the
              newly freed anterior
              shoulder and a further
              descent in a position
              beneath the pubic
              symphysis.
The Hibbard Maneuver
 As a result of the previous maneuvers,
  the transverse diameter of the shoulders
  is reduced.
 Lateral (upward) flexion of the head
  releases the posterior shoulder into the
  hollow of the sacrum.
Fracture of the
Clavicle
  The anterior clavicle is pressed against
   the ramis of the pubis.
  Care should be taken to avoid puncturing
    the lung by angling the fracture
   anteriorly.
  Theoretically, a fracture of the clavicle is
   less serious than a brachial nerve injury
   and often heals rapidly.
The Zavanelli
Maneuver
  First described in 1988
  Consists of cephalic replacement and
   then cesarean delivery.
  Mixed reviews in the literature.
Summary

 Cannot accurately predict
     BE PREPARED!
     Consider risk factors
     Be prepared to perform various maneuvers
     Diagnose and treat quickly
     Obtain assistance from nursing staff and
      NICU
Prophylactic
Cesarean?
  Not recommended by ACOG
  Exceptions:
    Consider if…
      >5000g in mother without DM

      >4500g in mother with DM
 Shoulder dystocia is well suited for
  simulation training.
 The obstetric birth simulator NOELLE
  (Gammard Scientific, FL, USA) is one
  such model.
Shldr dystocia acog

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Shldr dystocia acog

  • 1. Shoulder Dystocia ( ACOG Medical Student Education Module 2011)
  • 2. Definition  Difficulty in delivery of fetal shoulders  Failure to deliver fetal shoulder without utilizing facilitating maneuvers  Prolonged head-to-body delivery time  >60 seconds  Incidence: 0.2-3% of all live births; represents an obstetric emergency
  • 3.
  • 4. Bilateral Shoulder Dystocia  The posterior shoulder is not in the hollow of the pelvis.  This presentation often requires a cephalic replacement.
  • 5. Unilateral Shoulder Dystocia  Unilateral shoulder dystocia is usually easily dealt with by standard techniques.
  • 6. Pathophysiology  Size discrepancy between fetal shoulders and maternal pelvic inlet  Macrosomia  Large chest:BPD  Absence of truncal rotation  Fetal shoulders remain A-P or descent simultaneously
  • 7. Risk Factors  Antepartum  Macrosomia (>4500g ACOG)  GDM (increases overall risk by 70%)  Multiparity  Intrapartum  Prolonged deceleration phase of labor  Prolonged 2nd stage  Protracted descent  Operative delivery (vacuum>forceps)
  • 8. D - Diabetes  O- Obesity  P- Post term pregnancy, prior large baby  E- Excessive weight gain during pregnancy  No evidence based data:  Male  Short maternal stature  Abnormal pelvic shape/size
  • 9. Unpredictable  25-50% have no defined risk factor!  50% of cases occur in infants whose birth weight is <4000g  TURTLE SIGN: represented by the retraction of the fetal head after expulsion, may herald shoulder dystocia, shoulder dystocia is not diagnosed until the usual attempts at the delivery of the head fail.
  • 10. Complications  Maternal  Hemorrhage  4th degree laceration  Fetal  Fx of humerus or clavicle  Brachial plexus injury (Erb’s/Klumpke’s palsy)  Asphyxia/cord compression  Physician  Litigation: 11% of all obstetrical suits
  • 11.
  • 12. Management  Goal: Safe delivery before neontal asphyxia and/or cortical injury  7 minutes!!!  Episiotomy  Suprapubic Pressure  McRoberts Maneuver  Woods or Rubin Maneuvers  Zavenelli  Push back the delivered fetal head into birth canal and perform an emergent c/s
  • 13. HELPERR Algorithm  H: Call for Help; Shoulder dystocia is called if shoulders cannot be delivered with gentle traction  E: Evaluate for Episiotomy: Not routinely indicated; maybe needed when attempting intra-vaginal maneuver  L: Legs (McRoberts): Hyperflexion and abduction of hips—initial maneuver
  • 14.  P (Suprapubic Pressure): No fundal pressure; combination of McRoberts and suprapubic pressure resolves most shoulder dystocias  Enter (Internal Maneuvers): oblique diameter rotational maneuvers  Woods screw (1943): Insert two fingers into posterior vagina and apply pressure to the anterior aspect (clavicular) of the posterior shoulder and abduct and rotate that shoulder, the posterior shoulder could be rotated 180° degrees to the anterior, and this would disimpact the obstructed anterior shoulder. The subsequent addition of gentle downward traction with a contraction would then result in delivery.  Rubin(1964): either the anterior or posterior shoulder, which ever was more accessible, be adducted and brought toward the fetal chest. Insert two fingers on the posterior aspect (scapular) of the anterior or posterior shoulder and also rotate the baby 180° to reduce the obstruction.  Remove: Delivery posterior arm  Roll the patient: Gaskin maneuver or all four positions
  • 15. McRoberts Maneuver  42% success rate  + Suprapubic pressure = 54-58%  Brings pelvic inlet and outlet into more vertical alignment  Flattens sacrum  Cephalad rotation of pubic symphysis  Elevates anterior shoulder and flexes fetal spine  Increases IUP by 97%  Increases amplitude of contractions  +31N of pushing force
  • 16. Preliminary Measures:  Gentle pressure on the fetal vertex in a dorsal direction will move the posterior fetal shoulder deeper into the maternal pelvic hollow, usually resulting in easy delivery of the anterior shoulder.  Excession angulation (>45 degrees) is to be avoided. (Gabbe, et al., Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986)
  • 18. Suprapubic Pressure  Moderate suprapubic pressure is often the only additional maneuver necessary to disimpact the anterior fetal shoulder. Stronger pressure can only be exerted by an assistant. (Gabbe, et al., 1986)
  • 19. Oblique Diameter Rotational Maneuver  Delivery may be facilitated by counterclockwise rotation of the anterior shoulder to the more favorable oblique pelvic diameter, or clockwise rotation of the posterior shoulder.  During these maneuvers, expulsive efforts should be stopped and the head is never grasped !!
  • 20. Delivery of the Posterior Arm  To bring the fetal wrist within reach, exert pressure with the index finger at the antecubital junction. (E. Sandberg. American Journal of Obstetrics and Gynecology, 1985; 152: 481.)
  • 21. Delivery of the Posterior Arm  Sweep the fetal forearm down over the front of the chest.
  • 22. Delivery of the Posterior Arm  If less invasive maneuvers fail to affect this impaction, delivery should be facilitated by manipulative delivery of the posterior arm by inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder with delivery over the perineum.
  • 23. All- Fours Manoeuver It consists of placing the patient onto her hands and knees
  • 24. The Chavis Maneuver  Described in 1979.  A “shoulder horn” consisting of a concave blade with a narrow handle is slipped between the symphysis and the impacted anterior shoulder.  This used like a shoe-horn as a lever where the symphysis is the fulcrum.
  • 25. The Hibbard Maneuver  Release of the anerior shoulder is initiated by firm pressure against the infant's jaw and neck in a posterior and upward direction. An assistant is poised, ready to apply fundal pressure after proper suprapublic pressure  As the anterior shoulder slips free, fundal pressure is applied, and pressure against the neck is shifted slightly toward the rectum. Proper suprapubic pressure is continued.
  • 26. The Hibbard Maneuver  Continued fundal and suprapublic pressure results in an upward- inward rotation of the newly freed anterior shoulder and a further descent in a position beneath the pubic symphysis.
  • 27. The Hibbard Maneuver  As a result of the previous maneuvers, the transverse diameter of the shoulders is reduced.  Lateral (upward) flexion of the head releases the posterior shoulder into the hollow of the sacrum.
  • 28. Fracture of the Clavicle  The anterior clavicle is pressed against the ramis of the pubis.  Care should be taken to avoid puncturing the lung by angling the fracture anteriorly.  Theoretically, a fracture of the clavicle is less serious than a brachial nerve injury and often heals rapidly.
  • 29. The Zavanelli Maneuver  First described in 1988  Consists of cephalic replacement and then cesarean delivery.  Mixed reviews in the literature.
  • 30. Summary  Cannot accurately predict  BE PREPARED!  Consider risk factors  Be prepared to perform various maneuvers  Diagnose and treat quickly  Obtain assistance from nursing staff and NICU
  • 31. Prophylactic Cesarean?  Not recommended by ACOG  Exceptions:  Consider if…  >5000g in mother without DM  >4500g in mother with DM
  • 32.  Shoulder dystocia is well suited for simulation training.  The obstetric birth simulator NOELLE (Gammard Scientific, FL, USA) is one such model.