SHOULDER DYSTOCIA DR SAMEENA PARIKH

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Defined as impaction of the anterior shoulder (and less commonly the posterior shoulder) following delivery of the vertex

Occurs in 1% of births (normal birth weight) and up to 10% of births of infants of higher birth weight

Risk Factors for Shoulder DystociaMaternal •Abnormal pelvic anatomy •Gestational diabetes •Post-dated pregnancy •Previous shoulder dystocia •Short stature •Maternal obesity

Fetal •Suspected macrosomia

Labor related •Assisted vaginal delivery (forceps or vacuum) •Protracted active phase of first-stage labor •Protracted second-stage labor

• Document severity of shoulder dystocia and maneuvers, management and timing

• Be prepared for sequelae

Warning Signs

Protracted labor“Turtle Sign”

Shoulder DystociaThe turtle sign

Complications of Shoulder DystociaMaternal •Postpartum hemorrhage •Rectovaginal fistula •Symphyseal separation or diathesis •Third or fourth degree episiotomy or tear •Uterine rupture

Fetal •Brachial plexus palsy •Clavicle fracture •Fetal death •Fetal hypoxia, with or without permanent

neurologic damage •Fracture of the humerus

Shoulder DystociaAOCG Guidelines1) Call for help - assistants, anesthesiology,

pediatrician. Initiate gentle traction of the fetal head at this time. Drain the bladder if distended.

2) Generous episiotomy.3) Suprapubic pressure with normal

downward traction on fetal head.4) McRoberts maneuver. Then, if these maneuvers fail,5) Wood's screw maneuver.6) Attempt delivery of posterior arm.

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 internal rotation maneuvers (“Wood

Screw”)•R Remove posterior arm•R Roll the patient over*Make sure to note start time of dystocia and

delivery time

•McRoberts maneuver -flex the legs toward the patient's chest to open the anterior posterior diameter of the pelvis

•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

Shoulder Dystocia Management

Shoulder Dystocia ManagementSuprapubic Pressure

SHOULDER DYSTOCIA

Rubin Maneuver

Hand is inserted into the vagina and digital pressure is applied to the posterior aspect of the anterior shoulder pushing it towards the fetal chest, rotating the shoulders forward into an oblique diameter.

SHOULDER DYSTOCIARubin maneuver -1st, the fetal shoulder are rocked from side to side by applying force to the abdomen -if not successful, push the ant. shoulder

toward the anterior surface of

the chest

Woods Screw Maneuver

While maintaining pressure as above in the Rubin 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 delivery.

Shoulder Dystocia ManagementWood’s Screw Maneuver – high risk for

humeral fx

Reverse Woods Screw Maneuver

Apply pressure to the posterior aspect of the posterior shoulder and attempt to rotate it through 180°in the opposite direction to that described in the Wood Screw maneuver

Posterior ArmPass 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.

SHOULDER DYSTOCIAHibbard (1982) -press the fetal jaw and neck in the direction of the maternal rectum -strong fundal pressure anterior shoulder delivery -only fundal pressure, absence of other maneuver :77% complication fetal prthoprdic and neurologoc damage

SHOULDER DYSTOCIAZavanelli maneuver -cephalic replacement into the pelvis and then c/sec -return fetal head flex head push head back into

vagina

-terbutaline: Ut relaxation -fetal injury neonatal death stillbirth, brain damage

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.•Severe cases may require breaking the fetal clavicle or arm.•Lastly the Zavenelli maneuver –flex the fetal head and replace it

inside the vagina and emergency cesarean section performed.•Uterine relaxants (nitroglycerin or general anesthesia with

halothane) may be needed to overcome the expulsive forces of the uterus.

•Subcutaneous symphysiotomy has been practiced in remote areas of the world.

•Rotation of the patient onto all fours may also facilitate delivery by increasing the pelvic diameters and allowing better access to the posterior shoulder.

Shoulder Dystocia Avoid the 3 P’s: Pushing, Pulling, Pivoting What to do!!! •Initiate emergency call and get assistance •Evaluate need for episiotomy •McRoberts Maneuver •Suprapubic Maneuver •Rubin Maneuver •Woods Screw Maneuver •Reverse Woods Screw Maneuver •Delivery of Posterior Arm In extreme situations try: •Intentional clavicle fracture •Symphysiotomy •Zavanelli Maneuver

Shoulder Dystocia Prevention

Control maternal weight gainOptimize glycemic control in diabeticsIf concern for LGA… Offer C-section if efw>5000 gm in non-

diabetics, if efw>4500 gm in diabeticsIn 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