Shoulder dystocia is when the fetal shoulders become lodged at the maternal pelvis after delivery of the head, occurring in 0.2-2% of births. Risk factors include maternal diabetes, obesity, macrosomia, and prior shoulder dystocia. Management involves calling for help, applying suprapubic pressure and the McRoberts maneuver to widen the pelvis, and rotating the shoulders using maneuvers like Woods screw or Rubin. If unsuccessful, procedures include delivering the posterior arm or rarely symphysiotomy. Fetal risks are brachial plexus injury, fractures, and hypoxic brain injury. Maternal risks include perineal tears and postpartum hemorrhage. Prevention focuses
When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as shoulder dystocia.
The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as shoulder dystocia.
The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
This ppt is made by Mr. arkab khan pathan under guidance of Mrs. RAKHI GOAR. this ppt contain the detail and all the lecture notes of HEG.
THANK YOU.
Arkab khan
This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
Cord prolapse is a frightening and life-threatening event that occurs in labor. Rapid identification and immediate appropriate response may well save the life of a neonate. Therefore, clinicians should be knowledgeable in its recognition and management.
Malpresentations are all presentations of
fetus other than vertex. Face presentation, brow presentation, shoulder presentation and breech presentation are common malpresentations.
This ppt is made by Mr. arkab khan pathan under guidance of Mrs. RAKHI GOAR. this ppt contain the detail and all the lecture notes of HEG.
THANK YOU.
Arkab khan
This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
Cord prolapse is a frightening and life-threatening event that occurs in labor. Rapid identification and immediate appropriate response may well save the life of a neonate. Therefore, clinicians should be knowledgeable in its recognition and management.
Malpresentations are all presentations of
fetus other than vertex. Face presentation, brow presentation, shoulder presentation and breech presentation are common malpresentations.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. unanticipated, unpredictable nightmare of the
obstetrician
(Langer et al,1991)
INCIDENCE
0.2-2%
Depend on definition & fetal size (1/2: >4Kg)
Increased in the past 2 decades
Aboubakr Elnashar
3. DEFINITION
Failure of the shoulders to spontaneously traverse
the pelvic brim after delivery of the head
(Benedetti,1989)
Special maneuvers to deliver the shoulders
(Resnik,1980)
Prolonged head to body delivery time > 60 sec
(Spong et al,1995).
Aboubakr Elnashar
5. 2. Mild= Unilateral:
The posterior shoulder enters the pelvic cavity, while
the anterior shoulder hooked behind the S. pubis.
Aboubakr Elnashar
6. CAUSE
Not simply increase in F. wt
increase in body size in relation to head size.
increased shoulder/ head circumference
(Baskett,200).
Aboubakr Elnashar
7. RISK FACTORS
The majority: No risk factors.
S. dystochia cannot be predicted from clinical
characteristics or labor abnormalities
(Basket,200)
Aboubakr Elnashar
8. A. Antepartum:
DOPE
1. D.M (Tissues of the shoulders are insulin sensitive
& the brain is not & is not affected by D.M.)
2. Obesity: (90 kg before pregnancy or 110 kg at
delivery)
3. Postterm pregnancy.
4. Past history of S. dystocia.
5. Excessive f wt (>4.5 kg) or
maternal wt gain (>20 kg)
Aboubakr Elnashar
10. The predictive factors
(Dildy & Clark,2000)
1. D.M. with EFW >4250 g
2. Macrosomia & 2nd stage arrest with midpelvic
ventouse or forceps
Aboubakr Elnashar
11. PREDICTION OF FETAL
MACROSOMIA
A. Clinical
Sensitivity is only 20%
(Park & Ziel,1978)
The diagnosis of f macrosomia is imprecise.
Accuracy of EFW using US is no better than that
obtained with cl palpation (Leopold's maneuver).
ACOG Guidelines, 2000 (Level :A)
Aboubakr Elnashar
12. B. U/S
1. EFW: 10-15 % error (Hadlock or Shepard)
2. Femur SC tissue
3. Cheek to cheek D.
4. Chest D - BPD > 1.4 cm
5. Chest C. - HC. > 1.6 cm.
6. Shoulder C. - HC > 4.8 cm.
Aboubakr Elnashar
13. CLINICAL PICTURE
(Rubin, 1969)
Early
1. Slow crowing.
2. It is necessary to press the perineum back to
deliver the face.
3. Fatty cheeks.
4. Turtle sign (head is drawn tight against the
perineum).
5. Restitution is slow or does not occur.
Aboubakr Elnashar
14. Late
1. Usual down traction of the head does not result in
appearance of the anterior shoulder
2. Vascular congestion of the face.
3. Vaginal ex is difficult
Aboubakr Elnashar
15. PREVENTION
A. Ante partum
1. Identification of risk factors & proper management.
2. IOL at 38 W:
History of S dystocia
(Kjos et al,1993).
Suspected f macrosomia:
increased CS without improving perinatal outcomes
(ACOG Issues Guideline 2000 (Level B)
(Sanchez-Ramos, Systematic Review, 2002)
Aboubakr Elnashar
16. DM treated with insulin:
Dec risk of macrosomia
Small dec in s dystocia
No dec in maternal or neonatal morbidity
(Cochrane review).
Aboubakr Elnashar
17. 3. C.S:
Cumulative risk factors
(Basket, 2001).
Previous history of S dystocia:
Either CS or vaginal delivery is appropriate
The decision should be made by the woman and her
careers
(RCOG, 2005).
Aboubakr Elnashar
18. EFW:
In DM:
>4250 g in DM
(Dildy & Clark, 2000)
>4,500 g (ACOG, 2003)
Non diabetic
> 5,000 g (ACOG, 2003)
Planned CS on the basis of suspected macrosomia in the general
population is not a reasonable strategy
{1. Number & cost of additional CS required to prevent one
permanent injury is excessive To prevent one Erb,s palsy an
additional 500 CS are done
2. 3% of brachial plexus injury are associated with C.S
.
Aboubakr Elnashar
19. B. Intrapartum
Management of macrosomic F. during labor
(Louca & Johanson,1998)
1. Manage as far as CS during labor:
NPO, IVF, decrease stomach acidity
2. Close observation of the fetus & mother.
3. Experienced obstetrician, anesthetist &
neonatologist.
4. Prophylactic Mc Roberts maneuver if risk factors.
Position can be maintained by the woman herself.
5. Generous episiotomy
6. Early detection of S. dystocia.
Aboubakr Elnashar
20. MANAGEMENT
I. Effective plan
1. Call for help
2. Clear infant mouse & nose.
3. Avoid 5 P:
Panic,
pulling,
pushing,
pressure on the fundus {an unacceptably high neonatal
complication rate and may result in uterine rupture}
pivoting
Aboubakr Elnashar
21. II. Improve pelvic dimensions
1. Episiotomy or extend it.
{facilitate manoeuvres such as delivery of the posterior
arm or internal rotation of the shoulders}.
Episiotomy is not mandatory
(RCOG, 2005).
2. Mc Roberts maneuver
Aboubakr Elnashar
22. III. Disimpact F. shoulders
1. Suprapupic pressure
2. Rotation of the shoulders:
Wood,s maneuver, Rubin M.
3. All-fours maneuver
4. Delivery of the posterior arm.
Aboubakr Elnashar
23. IV. If all else fail
3rd -line methods
1. Cleidotomy
(bending the clavicle with a finger or surgical division),
2. Symphysiotomy
(dividing the symphyseal ligament)
3. Zavanelli maneuver.
4. Abdominal rescue
Aboubakr Elnashar
25. Increase IU pressure by 97%
Increase U. contraction amplitude by 25%
Applied additional 31 Newtons pushing
force (Buhimschi et al, 2001)Aboubakr Elnashar
26. McRoberts manoeuvre: X ray pelvimetry study
(Gherman et al, 2000)
No increase in pelvic dimensions.
Decrease in the angle of pelvic inclination
Straightening of the sacrum
Tends to free the impacted anterior shoulder
Aboubakr Elnashar
27. Suprapubic pressure:
Mazzanti:
directed posterioly to dislodge the ant shoulder &
push it beneath S.P.
Rubin:
directed laterally, with pressure applied to the
posterior surface of the anterior shoulder.
Apply for 30 seconds.
No difference in efficacy between continuous
pressure or ‘rocking’ movement.
Aboubakr Elnashar
30. .
The Mc Roberts manoeuvre can
be applied with Suprapubic
pressure to increase success
rate
(ACOG , 1991; RCOG, 2005)
Aboubakr Elnashar
31. Rotation of the F. shoulders:
Woods screw M.:
Pressure on the anterior surface of the posterior shoulder:
±increase shoulder to shoulder D.
Aboubakr Elnashar
32. Rubin M.
Pressure on the posterior surface of the posterior
shoulder.: decrease shoulder to shoulder D.
It is preferred by many obstetrician
Aboubakr Elnashar
33. All-fours M.:
The woman is placed on her hands & knees.
Gravity pushes the posterior shoulder anteriorly.
The flexibility of the sacro-iliac joints increases the
saggital D of the pelvic inlet.
The posterior shoulder is delivered first.
Aboubakr Elnashar
34. • It allows rotational movement of the sacroiliac
joints: 1-2 cm increase in the sagittal diameter of the
pelvic outlet.
• It disimpacts the shoulders, and allowing it to slide
over the sacral promontory.
Aboubakr Elnashar
35. •Success rate: 83%
• Maternal complications: 1.2%
•Neonatal complications: 4.9%,
•Time for complete delivery: 2 to 3 ms.
•Effective also for bilateral Sh. D.
(Drummond et al; 1998)
Aboubakr Elnashar
36. Delivery of the posterior arm:
± difficult to insert the hand in the vagina.
Fracture of the humerus is common.
{No advantage between delivery of the posterior arm
and internal rotation maneuvers}: clinical judgment
and experience can be used to decide their order.
Aboubakr Elnashar
37. By inserting a hand into
the posterior vagina and
ventrally rotating the arm
at the shoulder
Delivery over the
perineumAboubakr Elnashar
38. Cephalic replacement & C.S.
(Zavanelli) :
Early indicated in bilateral S. dystochia.
If replacement is done within 4 min: good Apgar.
Aboubakr Elnashar
39. Zavanelli
2.Flexion of the head,
Returning it to the vagina with
upward constant firm
pressure, followed by CS
1.The head first manually
rotated to the occipito
anterior (Pre-restitution)
position
Reversing the mechanism
of delivery of the vertex
under tocolytic
Aboubakr Elnashar
40. Abdominal rescue:
If cephalic replacement is failed.
C.S
direct disimpaction of the shoulder
vaginal delivery.
Aboubakr Elnashar
41. •Bilateral Shoulder dystocia
All- Fours Maneuver
Used at all circumstances
except if the patient has received
epidural analgesia,
heavy analgesia or anesthesia
Zavanelli Maneuver
Used if the patient has received epidural analgesia or
heavy analgesia with obstetric facilities for
emergency CS
Aboubakr Elnashar
42. The HELPERR mnemonic
H Call for help
E Evaluate for episiotomy
L Legs (the McRoberts’ manoeuvre)
P Suprapubic pressure
E Enter maneuvers (internal rotation)
R Remove the posterior arm
R Roll the patient
Aboubakr Elnashar
44. COMPLICATIONS
A. Fetal
1. Death:
{asphyxia}.
8% of all intrapartum F. death.
(Baskett,2001)
Head –shoulder interval
4-6 min: No permanent hypoxic damage
>7 min: permanent hypoxic damage
With hypoxic fetus it is much shorter
(Quzounian et al, 1998)
Aboubakr Elnashar
45. 2. Injuries:
Cerebral hge.
Brachial plexus palsy
10%
Determine whether the affected shoulder was
anterior or posterior at the time of delivery
{damage to the plexus of the posterior shoulder is
considered not due to action by the accoucheur}.
Fracture clavicle (the most common) or
humerus.
Traction combined with fundal pressure:
high rate of brachial plexus injuries and
fractures
(ACOG , 1997)
Aboubakr Elnashar