High-Risk Obstetrics for the Family Physician

March 2017

Simulation Training for Shoulder Dystocia

Disclosures - No Financial Conflicts

Deborah Cahill, MD

Physician Facilitator, Gossman Advanced Healthcare Simulation

Mark A Johnson, MD

Swedish Family Medicine

Susan Bryar, ARNP

Program Facilitator, Gossman Advanced Healthcare Simulation

Merllie Flores, RN

Program Facilitator, Gossman Advanced Healthcare Simulation

By the end of this presentation you should be able to –

1. Define shoulder dystocia

2. Have a standardized team approach to this emergency

3. Describe the main maneuvers for managing shoulder dystocia

4. Know the important information to be recorded in the medical record after a shoulder dystocia & ALWAYS use the EMR Dystocia template (or paper equivalent)

ACOG Practice Bulletin 2002 (reaffirmed 2013) “Shoulder Dystocia”

“a delivery that requires additional obstetric maneuvers

following failure of gentle downward traction on the fetal head to effect delivery of the shoulders”

Resnik R. Management of shoulder girdle dystocia.

Clin Obstet Gynecol 1980;23:559-64

Note – time is not in the definition

This is also not the baby who takes a while to deliver but whose shoulder isn’t stuck (avoid calling it body dystocia)

History of Shoulder Dystocia

(>10% recurrence)

Diabetes

Macrosomia history

Maternal obesity, <5 ft tall

Excessive weight gain

DEVELOP IN LABOR

Long 1st stage

Long 2nd stage (espec. multips)

Labor Augmentation

Instrumented delivery

Precipitous delivery

MANY CASES UNANTICIPATED. CONSIDER THOSE IN LABOR -

CAN WE HEIGHTEN AWARENESS OF RISK AND BE BETTER PREPARED?

PLAN AHEAD: “Break” the bed & prophylactic Mc Roberts • Wait for next contraction - then with exam hand ready, use momentum

of next contraction w/mom pushing until shoulder clears symphysis • Don’t stop pushing until shoulder clears – No routine bulb suctioning • Don’t check for a nuchal cord - Can reduce as shoulders deliver or cut

after anterior shoulder clears the symphysis

All internal maneuvers done with your left hand working with fetal left

arm/shoulder and your right hand working with fetal right arm/shoulder

• Deliver posterior arm (84%) - Use hand on side fetus is facing

• Rotational maneuver: Ant/Woods (72%), Post/Rubin (66%)

Episiotomy, if needed to do internal maneuvers

• Suprapubic (62%) - Smooth oblique move/CPR hands

• Gaskin maneuver (hands/knees; to side if epidural)

• Repeat all maneuvers, break clavicle

Zavanelli procedure with C/S - if nothing else works and only if the decision is made

early enough that delivery can be done in enough time to avoid hypoxia

Ref: A Comparison of Obstetric Maneuvers for the Acute Management of Shoulder

Dystocia. Hoffman et al, Obstet & Gynecology; Vol 117: p1272, 6/2011

Do -

Cord gases on all cases

Document fully

Discuss with parents

Newborn exam

Inform “pediatrician”

Documentation debrief

Documentation Needed Duration of dystocia Discouraged pushing

Confirm NO fundal pressure Sequence of maneuvers Which shoulder anterior Names of all staff present

McRoberts Maneuver

Only Effect is Tilting the Pelvis

Posterior Arm Maneuver

Vaginal access with flattened

whole hand

Sweep the wrist up to flex arm,

keep the elbow flexed

Sweep posterior upper arm

across chest which usually

rotates ant. shoulder backward,

then can have mother push

Or arm can be delivered, but

need to be sure that anterior

shoulder is no longer stuck

Anterior Shoulder Rotation

Modified Wood’s Screw Maneuver

MODIFIED WOOD’s: Position

hand behind the anterior

shoulder; apply pressure to

rotate the anterior shoulder away

from the symphysis, in the

direction the baby is facing

ORIGINAL WOOD SCREW - Anterior

approach as above plus: Position

fingers in front (on clavicle) of the

posterior shoulder & apply pressure

Suprapubic Pressure = External Rotation

Smooth Lateral Move in direction baby is facing

“CPR” Hands placed near inguinal

region, above symphysis

Lateral-oblique smooth move

Only if order is given - specify

correct person & direction

Firm, smooth continuous

pressure laterally, in the

direction the fetus is facing

Provider’s exam hand in place,

touching baby’s scapula/back

prior to maneuver to assess

success & do anterior rotation

if needed

Posterior Rotational Maneuver

(Rubin’s Maneuver)

Consider if the Posterior Arm ,

Anterior Rotation or Suprapubic

maneuvers were not successful

Apply pressure w/flat hand on

the back, adjacent to the

posterior shoulder –

Rotate anteriorly using your

shoulder/upper body, wrist fixed

& elbow flexed to effect rotation

– approx 120 degree arc

Need thumb on clavicle to

stabilize hand for rotation

www.shoulderdystociainfo.com

Gaskin Maneuver – All Fours

May consider as 1st maneuver if

no epidural

Weight of maternal abdomen off

stuck shoulder

May be easier access for

posterior maneuvers

If epidural, may roll patient to the

side appropriate for the planned

maneuver

Int J Gynaecol Obstet 2006;

95(2),153-4

What to Avoid What to Do

Avoid the P’s -

• Panic (don’t do it, or at least don’t show it)

• Pulling (on the head/neck)

• Pushing (coach maternal breathing)

• Pivoting (sharply angulating the head)

Do the C’s –

*Calm yourself & Calm the room (anyone can do)

*Controlled Maneuvers (rotations, no force)

*Coordinated teamwork

*Clearly state concerns, make suggestions

“P’s” from McMaster University, Ontario