Shoulder Dystocia

International

Shoulder Dystocia

Shoulder Dystocia
International

Objectives
Definition and Incidence Significance Risk Factors Diagnosis Management

Shoulder Dystocia
International

Definition
impaction of anterior shoulder above symphysis inability to delivery shoulders by usual methods

Incidence
1 to 2 per 1000 deliveries 16 per 1000 deliveries of babies > 4000 g

Shoulder Dystocia
International

Shoulder Dystocia
International

Shoulder Dystocia

Shoulder Dystocia
International

Shoulder Dystocia
International

Complications of Shoulder Dystocia

Fetal/neonatal

- death - asphyxia and sequelae - fractures - clavicle, humerus - brachial plexus palsy
Maternal

- postpartum hemorrhage - uterine rupture

Shoulder Dystocia
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Risk Factors
post-term pregnancy maternal obesity fetal macrosomia previous shoulder dystocia operative vaginal delivery prolonged labour poorly controlled diabetes

Shoulder Dystocia
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Risk factors are present in < 50% of cases

Shoulder Dystocia
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Diagnosis

head recoils against perineum, turtle sign spontaneous restitution does not occur failure to deliver with expulsive effort and usual gentle direction

Shoulder Dystocia
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Turtle sign

Shoulder Dystocia
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Aim :

1.Release anterior shoulder from impaction at symphisis 2.Reduce biacromial diameter 3.Enlarge pelvic capacity

Shoulder Dystocia
International

Ask for help Lift - the buttocks

} - the legs

McRoberts maneuver

Anterior disimpaction of shoulder

- suprapubic pressure (Massanti) - rotate to oblique (Rubin) Rotation of the posterior shoulder - Woods maneuver - Rubin+Wood Cockscrew Manual removal of posterior arm (Schwartz) Episiotomy consider Roll over onto 2-4 or knee chest (Gaskin)

Shoulder Dystocia
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Avoid the Ps
Panic Pulling (on the head) Pushing (on the fundus) Pivoting (sharply angulating the head, using the coccyx as a fulcrum)

Shoulder Dystocia
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Ask for HELP

get the mother on your side partner, coach nursing notify physician back up or other appropriate personnel

Shoulder Dystocia
International

Lift - McRoberts Maneuver

Shoulder Dystocia
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Lift - McRoberts Maneuver

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34 (2007)501531

Shoulder Dystocia
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Lift - McRoberts Maneuver

TheMcRobertsmaneuverdoesnotchangetheactualdimensionofthematernalpelvis. Rather,themaneuverstraightensthesacrumrelaQvetothelumbarspine,allowingcephalic rotaQonofthesymphysispubisslidingoverthefetalshoulder.

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34(2007)501531

Shoulder Dystocia
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Shoulder Dystocia
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McRoberts'maneuver.A,Bisacromialdiameterpinnedbehindpubicsymphysis.B,Removing thematernallegsfromthesQrrupsandpuUngthekneesuptothechestfulcrumsthepubic symphysisovertheimpactedanteriorshoulder

JohnA.Marx,RobertS.Hockberger,RonM.Walls.JamesG.Adams.Rosen'sEmergencyMedicine:ConceptsandClinicalPracQce,6thed. Mosby2006

Shoulder Dystocia
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Lifting the legs and buttocks

(McRoberts maneuver) flexion of thighs on abdomen requires assistance 70% of cases are resolved with this manoeuvre alone

Shoulder Dystocia
International

Anterior Disimpaction 1) Suprapubic Pressure (Massanti Maneuvre)

NO fundal pressure Abdominal approach: suprapubic pressure applied with heel of clasped hand from the posterior aspect of the anterior shoulder to dislodge it

Shoulder Dystocia
International

Anterior Disimpaction 1) Suprapubic Pressure (Massanti Maneuvre)

NO fundal pressure Abdominal approach: suprapubic pressure Suprapubicpressure.Suprapubic pressureisapplieddirecQngtheanterior applied with heel of shoulderdownwardandlaterally.If clasped hand from the possible,pressureshouldbedirected posterior aspect of the fromthesideofthefetalspinetoward theface.Pressureshouldbeappliedby anterior shoulder to anassistantwitheitherthepalmorst. dislodge it
AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34(2007)501531

Shoulder Dystocia
International

Suprapubic Pressure (Massanti Maneuver)

Shoulder Dystocia
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Suprapubic Pressure (Massanti Maneuver)

Shoulder Dystocia
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Anterior Disimpaction 2) Rubin Maneuver

vaginal approach adduction of anterior shoulder by pressure applied to the posterior aspect of the shoulder (the shoulder is pushed toward the chest) consider episiotomy NO fundal pressure

Shoulder Dystocia
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Rubin Maneuver

Shoulder Dystocia
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Rubin Maneuver

Rubin'smaneuver decreasesthe bisacromial diameter.AP, anteroposterior.

JohnA.Marx,RobertS.Hockberger,RonM.Walls.JamesG.Adams.Rosen'sEmergencyMedicine:ConceptsandClinicalPracQce,6thed. Mosby2006

Shoulder Dystocia
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Rubin Maneuver
Rubin'smaneuverdecreasesthebisacromial diameter.AP,anteroposterior. TheRubinsmaneuver.Thismaneuverinvolvesapplying pressuretothemostaccessiblepartofthefetalshoulder (ie,eithertheanteriororposteriorshoulder)toeect shoulderadducQon(A).(B)Curvedarrowsshows rotaQonoffetalshoulders.

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34(2007)501531

Shoulder Dystocia
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Rotation of Posterior Shoulder - Step 1

pressure on anterior aspect of posterior shoulder may be combined with anterior disimpaction manoeuvers NO fundal pressure

Shoulder Dystocia
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Rotation of Posterior Shoulder - Step 2

Woods screw maneuver can be done simultaneously with anterior dissimpaction

Shoulder Dystocia
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Rotation of Posterior Shoulder - Step 3

may be repeated if delivery not accomplished by Steps 1 & 2

Shoulder Dystocia
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Rotation of Posterior Shoulder - Step 4

Shoulder Dystocia
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Shoulder Dystocia
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TheWoodscorkscrewmaneuver. Thismaneuverinvolvesapplying pressuretotheclavicularsurfaceof theposteriorarm,allowingrotaQon (A)suchthattheanteriorshoulder dislodges(B)frombehindthe maternalsymphysis.Curvedarrow showsrotaQon.Straightarrow showsmanualrotaQonofinfants bodyincoordinaQonwithrotaQon byhandbelow
AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34(2007)501531

Shoulder Dystocia
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Manual removal of posterior arm

flex arm at elbow (pressure in antecubital fossa to flex arm) sweep arm over chest grasp wrist/forearm or hand deliver arm

Shoulder Dystocia
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Manual removal of the posterior arm

Deliveryoftheposteriorarm.Todeliverthe posteriorarm,pressureshouldbeappliedatthe antecubitalfossatoexthefetalforearm.The forearmorhandissubsequentlygraspedandthe armsweptoutovertheinfantschestand deliveredovertheperineum.RotaQonofthetrunk tobringtheposteriorarmanteriorlyissomeQmes required.(A)First,turnfetalheadtoallowentryof pracQQonershandtofacilitatemanipulaQon.(B) Second,supportfetalheadwithonehandand sweepsecondhandposteriorly.(C)Next,ex infantsarmatantecubitalfossatoallow pracQQonertograspposteriorforearmorhand. (D)Deliverposteriorarm.ThisallowsrotaQonof thefetuswiththegoalofdisimpacQngthe anteriorshoulder.(E)Furtherrotatefetusto facilitatedelivery.

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34(2007)501531

Shoulder Dystocia
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Episiotomy

may facilitate Woods Manoeuver or allow room for delivery of the posterior arm

Shoulder Dystocia
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Roll Over

= all-fours (Gaskin maneuver) May allow easier access to posterior shoulder Radiographic studies : pelvic diameters increase (10 mm true obstetric conjugate & sagital pelvic outlet)

Shoulder Dystocia
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Gaskin maneuver
TheGaskinposiQon.The allfoursposiQonexploits theeectsofgravityand increasedspaceinthe hollowofthesacrumto facilitatedeliveryofthe posteriorshoulderand arm.

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34(2007)501531

Shoulder Dystocia
International

Gaskin maneuver

Shoulder Dystocia
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As a last resort

clavicular fracture cephalic replacement (Zavenelli manoeuvre) symphysiotomy

Shoulder Dystocia
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Zavenelli manoeuvre

Shoulder Dystocia
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Last Resort
(A,B)Thisgureshows deliveryoftheposteriorarm withfacilitaQonofdeliveryby hysterotomy.Theintra abdominalhandcanbeused torotatetheanterior shouldertoallowvaginal delivery;oraZavanelli maneuvercanbeperformed subsequently,allowing cesareandelivery.

Shoulder Dystocia
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Symphysiotomy

Shoulder Dystocia
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Afterwards

be prepared for PPH inspect for maternal lacerations and trauma examine the baby for evidence of injury explain the delivery and manoeuvers chart what was done

Shoulder Dystocia
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Recommendation that a shoulder dystocia intervention form should include the following information

When and how the dystocia was diagnosed Progress of labor (active phase and second stage) Position and rotation of the infants head Presence of episiotomy Anesthesia required Estimation of force of traction applied Order, duration, and results of maneuvers used Duration of shoulder dystocia Documentation of adequate pelvimetry before initiating labor induction or augmentation Neonatal and obstetric impressions of the infant after delivery Information given to gravida that shoulder dystocia had occurred
AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34(2007)501531

Shoulder Dystocia
International

Conclusions

anticipate and be prepared (most are unpredictable) remember the mnemonic ALARMER stay calm, dont panic, pull, push or pivot

Shoulder Dystocia
International

Ask for help Lift - the buttocks

- the legs

McRoberts Maneuver

Anterior disimpaction
- rotate to oblique - suprapubic pressure

Rotate the posterior shoulder - Woods maneuver Manual removal of the posterior arm Episiotomy consider Roll over

Shoulder Dystocia
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THANK YOU

Shoulder Dystocia
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Shoulder Dystocia
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Hibbard Manuever

Shoulder Dystocia
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Schwartz Dixon

Shoulder Dystocia
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Shoulder Dystocia

Shoulder Dystocia
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Shoulder Dystocia

Shoulder Dystocia
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Shoulder Dystocia
Management Help obstetrician, pediatrician Episiotomy Legs elevate (McRoberts) Pressure - suprapubic Enter vagina Rubins and Woods screw Roll or Remove posterior arm Zavanelli, clavicular #, symphysiotomy

Shoulder Dystocia
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McRoberts Maneuver
hyperflexion of maternal hips brings symphysis over anterior shoulder straightens sacral promontory

Shoulder Dystocia
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Suprapubic Pressure
direct posterior or oblique suprapubic pressure to disimpact anterior shoulder

Shoulder Dystocia
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Rubins Maneuver
adduction of the most accessible shoulder moves the fetus into an oblique position and decreases the bisacromial diameter

Shoulder Dystocia
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Woods Screw Maneuver

rotational pressure on the anterior aspect of the posterior shoulder, moving the fetus 180

Shoulder Dystocia
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Woods Screw Maneuver

the former posterior shoulder is now anterior and past the pubic symphysis

Shoulder Dystocia
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All-Fours Maneuver
changes pelvic dimensions in a similar way to McRoberts maneuver apply downward traction to disimpact the posterior shoulder

Shoulder Dystocia
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Deliver posterior arm

grasp the posterior arm and sweep it across the anterior chest to deliver it

Shoulder Dystocia
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Zavanelli Maneuver
cephalic replacement via reversal of the cardinal movements of labor follow be Cesarean section

Shoulder Dystocia
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Clavicular Fracture

fracture the anterior clavicle by pushing it against the pubic ramus or using a closed pair of scissors risk of pneumothorax

Shoulder Dystocia
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Symphysiotomy

mostly in developing countries significant maternal morbidity in terms of orthopedic and urinary tract injuries