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Shoulder dystocia

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Shoulder dystocia

  1. 1. SHOULDER DYSTOCIA & UMBILICAL CORD PROLAPSE Nur Haizum Binti Mohamed Aris O&G CME, Aug 2 2012
  2. 2. SHOULDER DYSTOCIA
  3. 3.  Definition  Prevalance  Risk factors  HELPERR  Complication  Prevention  Simulation 3
  4. 4. DEFINITION  Vaginal cephalic delivery that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed.  An objective diagnosis of a prolongation of head- to-body delivery time of more than 60 seconds  Occurs in 1% of births (normal birth weight) and up to 10% of births of infants of higher birth weight (>4500g) 4
  5. 5. PREVALANCE  Studies involving the largest number of vaginal deliveries (34 800 to 267 228) report incidences between 0.58% and 0.70%  Macrosomia shows the strongest correlation with shoulder dystocia  Occurs more often with gestational diabetes and twice as often in postdate pregnancies  In women without diabetes, labor induction for suspected fetal macrosomia does not lower the rates of shoulder dystocia or cesarean delivery 5
  6. 6.  There is a relationship between fetal size and shoulder dystocia but it is not a good predictor:  partly because fetal size is difficult to determine accurately  large majority of infants with a birth weight of ≥4500g do not develop shoulder dystocia.  Equally important, 48% of births complicated by shoulder dystocia occur with infants who weigh less than 4000g 6
  7. 7. RISK FACTORS FOR SHOULDER DYSTOCIA 7
  8. 8. WARNING SIGNS  Failure of restitution  “Turtle Neck Sign” 8
  9. 9. SHOULDER DYSTOCIA  H Call for help  E Evaluate for episiotomy  L Legs (The McRoberts Maneuver)  P Suprapubic (not fundal) pressure to disengage the anterior shoulder  E Enter maneuvers  R Remove posterior arm  R Roll the patient over * Make sure to note start time of dystocia and delivery time 9
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  11. 11. MCROBERTS AND SUPRAPUBIC PRESSURE  McRoberts maneuver - flex the legs toward the patient's chest to open the anterior posterior diameter of the pelvis 11 Figure 1. The McRoberts' maneuvre
  12. 12. SUPRAPUBIC PRESSURE (RUBIN I)  Suprapubic pressure – apply a “rolling” pressure over the fetal anterior shoulder on mother’s lower abdomen so that the shoulder will adduct and pass under the symphysis 12 Figure 2 Suprapubic pressure
  13. 13. RUBIN II MANEUVER  Hand is inserted into the vagina  Digital pressure is applied to the posterior aspect of the anterior shoulder  Push towards the fetal chest, rotating the shoulders forward into an oblique diameter. 13
  14. 14. WOODS SCREW MANEUVER  While maintaining pressure as above in the Rubin II maneuver, a second hand locates the anterior aspect of the posterior shoulder.  Apply pressure to rotate the posterior shoulder.  Attempt delivery once the shoulders move into the oblique diameter.  If unsuccessful continue rotation through 180° and attempt deliver 14
  15. 15. REVERSE WOODS SCREW MANEUVER  Apply pressure to the posterior aspect of the posterior shoulder  Attempt to rotate it through 180° in the opposite direction to that described in the Wood Screw maneuver 15
  16. 16. POSTERIOR ARM  Pass hand into the vagina over the chest of the fetus to identify the posterior arm and elbow.  Apply pressure to the antecubital fossa to flex the elbow in front of the body, and/or grasp the posterior hand to sweep the arm across the chest and deliver the arm.  Rotate the fetus into the oblique diameter of the pelvis, or through 180°, bringing the anterior shoulder under the symphysis pubis 16
  17. 17. 17 Figure 3 Delivery of the posterior arm
  18. 18. SHOULDER DYSTOCIA  Do not persist in any one maneuver if it is not immediately successful. Try another maneuver.  NEVER apply fundal pressure - this can further engage the anterior shoulder under the pubic bone.  Uterine relaxants (nitroglycerin or general anesthesia with halothane) may be needed to overcome the expulsive forces of the uterus.  Rotation of the patient onto all fours may also facilitate delivery by increasing the pelvic diameters and allowing better access to the posterior shoulder. 18
  19. 19.  In extreme situations try: • Intentional clavicle fracture • Symphysiotomy Rarely • Zavanelli Maneuver  Document severity of shoulder dystocia and maneuvers, management and timing 19
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  21. 21.  DON’T 3 P’s: Pushing (on the head) Pulling (on the fundus) Pivoting (sharply angulating the head, using the coccyx as a fulcrum) Some add the 4th P: Don’t Panic 21
  22. 22. COMPLICATIONS • Postpartum hemorrhage • Rectovaginal fistula • Symphyseal separation or diathesis • Third or fourth degree episiotomy or tear • Uterine rupture Psychological trauma • Brachial plexus palsy • Clavicle fracture • Fetal death • Fetal hypoxia, with or without permanent neurologic damage • Fracture of the humerus Maternal Fetal 22
  23. 23. PREVENTION  Control maternal weight gain  Optimize glycemic control in diabetics  If concern for LGA offer C-section if efw>5000 gm in non-diabetics, if efw>4500 gm in diabetics  In high risk patients, the head and shoulder maneuver can be used (delivery of head and shoulders in one move without suctioning the nasopharynx after delivery of the head)  Be prepared - call for help 23
  24. 24.  Shoulder dystocia simulation video 24
  25. 25. CORD PROLAPSE 25
  26. 26.  Definition  Types  Risk  Diagnosis  Management  Prevention 26
  27. 27. DEFINITION  Cord prolapsed: descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes  Cord presentation : presence of the umbilical cord between the fetal presenting part and the cervix, with or without membrane rupture 27
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  29. 29. TYPES  Occult prolapse: the prolapsed cord is contained within the uterus usually by the side of the presenting part unnoticed  Overt prolapse: the cord protrude into the vagina 29
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  31. 31. RISK FACTORS 31
  32. 32. DIAGNOSIS  Appearance of loop of umbilical cord  Pulsation of cord on V/E  Suspect in unexplained fetal distress  Variable decelerations  Prolonged bradycardia 32
  33. 33. DELIVERY- IS BABY VIABLE?  IUD - Aim for vaginal delivery  Alive - aim for most expedient delivery method Instrumental delivery – only if os full and expecting a relatively easy and fast delivery Otherwise crash Caesarean section emergency CS, regardless of indications, should be performed within 30 minutes from the time decision was made 33
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  35. 35. MANAGEMENT  Call for help  Give explanations to the woman and her birth partner  Move the woman into the knee-chest or exaggerated Sims’ position (see Appendix A)  If syntocinon augmentation is in progress, discontinue immediately  Elevate the presenting part digitally or by bladder filling 35
  36. 36.  Avoid excessive handling of umbilical cord.  If cord is presenting outside of vagina, it can be replaced gently or wrapped in warmed saline- soaked gauze to prevent reactive vasoconstriction.  Continue to assess fetal heart rate  Expedite the birth of the baby  Transport the woman to the operating theatre, if required 36
  37. 37. RELIEVE CORD COMPRESSION  Replace cord gently into vagina  Place hand in vagina, cord cradled in palm  Tips of fingers elevating presenting part  Mother in trendelenburg or knee-chest position  Fill bladder (16 Foley catheter, 500-800ml of saline)  Several studies have shown reduced perinatal mortality with elevation of the presenting part by bladder filling.  Allow time for anaesthesia & transfer of the woman to the secondary or tertiary unit from other settings. 37
  38. 38.  Continuation of relieving of cord compression during  Induction of anaesthesia  Placement of sterile sheet  LSCS  Remove hands only when the surgeon tells you! 38
  39. 39. 39 Trendelenberg position
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  42. 42. PREVENTION 42
  43. 43. REFERENCES 43  RCOG  Green-top guideline No. 42 / 2nd edition/ March 2012/ Shoulder Dystocia http://www.rcog.org.uk/files/rcog-corp/GTG42_150713.pdf  Green-top Guideline No. 50/ April 2008/ Umbilical Cord Prolapse http://www.rcog.org.uk/files/rcog-corp/uploaded files/GT50UmbilicalCordProlapse2008.pdf  http://www.networks.nhs.uk/nhs- networks/staffordshire-shropshire-and-black- country/documents/Umbilical%20Cord%20Prolapse.pdf

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