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    Shoulder Shoulder Shoulder Dystocia Dystocia Dystocia

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    Shoulder Shoulder Shoulder Dystocia Dystocia Dystocia

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    Jhon Cristian Hidalgo Canales
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    75 views38 pages

    Shoulder Shoulder Shoulder Dystocia Dystocia Dystocia

    Uploaded by

    Jhon Cristian Hidalgo Canales
    zCZX SDC AFA E SDCCSACHGASCVASHCVSAHAS SAGHCXVSAHCXVSAXVSASA XSACXASHNXC

    Copyright:

    © All Rights Reserved
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    of 38

     

    SHOULDER 
    DYSTOCIA
     

    By
    Dr.Lubna Gulnaz
    MD Obgyn
     

    SHOULDER DYSTOCIA
     

    Definition
    Defined as impaction of anterior 
    shoulder of fetus against the
    maternal symphysis pubis or (less
    commonly) the posterior shoulder 

     behind the sacral promontory


    after delivery of fetal head.
     

    Incidence
     0.5% in 11,000 deliveries
     

    Birth weight   Incidence


    3-3.5kg 0.3%
    3.5-4kg 1.0%
    4.0-4.5kg 5.4%
    >5kg 19%
     

    AIM….

    To recognize risk factors


    Timely management to reduce both maternal
    and fetal mortality and morbidity.


    Correct application of needful maneuvers.
     

    RISK FACTORS
    MATERNAL FETAL
    • Obesity
    •

    • Gest.Diabetes
    Previous h\o Shoulder  Macrosomia
    • dystocia
     Large for gestational age.
    • Multiparity (A baby may be LGA without
    • Post term pregnancy  being macrosomic)
    •
    Short stature
    • Abn.pelvic anatomy
     
     

    Pathophysiology
     A “mismatch” between fetal size and maternal
     pelvic capacity

    Positional variationsof–shoulders
    oblique orientation vertical rather than
     Increased diameter of shoulder girdle
     Subcutaneous fat dep osition may be increased in
    deposition
    infant of diabetic mother – espec ially with sub-
    especially
    optimal glucose control
     

    Sign
    Signss Helping you to diagnose

    • Turtle sign
    • Unable to deliver anterior shoulder even after 
    gentle traction.
     

    turtle sign
     

    Management..

      HELPERR  mnemonic- a clinical tool


    that provides a structured framework for 
    clinician to deal with shoulder dystocia.
     

    Objective
     To reduce time consumed from delivery of head until delivery
    of body of fetus for survival of the fetus 
    TO BE REMEMBERED

    Shoulder dystocia is never predicted priorly.


    dystocia
     None
    None of the maneuver is superior to aanother
    nother to release the impacted shoulder  
    Each maneuver should take place from 30-60 second, baby should be
    delivered by max 5-6 min.

    EPISIOTOMY is given to provide additional space for manipulation not for 


    delivery of impacted shoulder..

     
     

    Management contd….
     

    Clinical Management
     Step One: Recognize the presence of a
    shoulder dystocia

    Step Two: Be sure enough help is present


      Nursing

     Obstetrics
     Pediatrics
     Anesthesiology
     

    Clinical Management

    Step Three: Apply primary maneuvers

    Mc Roberts maneuver 

    Oblique suprapubic pressure

    Step Four: Apply secondary maneuvers; no
     prescribed order 

    Rubin; Woods screw; Reverse woods screw; All-
    fours; Clavicular fracture
     

    Step Three – Primary Maneuvers


    McRoberts maneuver 

    Patient positioned with hips at edge of the broken-

    down birthing bed


     Both hips are sharply flexed with knees
    k nees remaining
    flexed (“knees to shoulders”)
     

    McRoberts Maneuver
     

    Contd……
     

    McRoberts Maneuver

    This maneuver assists delivery by:

    Straightening maternal lumbar lordosis

    Rotates symphysis superiorly and anteriorly
     Improving angle between pelvic inlet and direction
    of maximal expulsive force

    Elevates anterior shoulder allowing posterior 
    shoulder to descend
     

    Woods screw maneuver


     Apply pressure on the clavicle to effect rotation of the
    shoulders out of the vertical orientation

    As fetus rotates, anterior shoulder should pass under 


    symphysis
     May be a good choice for a right-handed operator 
    when the fetal occiput is oriented to the maternal
    right
     

    Woods screw maneuver


     

    Rubin’s maneuver
     Apply pressure to the fetal scapula to effect
    rotation of the shoulders out of the vertical
    orientation
     As fetus rotates, anterior shoulder should pass
    under symphysis

    May be a good first choice for a right-handed
    operator when the fetal occiput is directed to
    the maternal left
     

    Delivery of Posterior Arm



    The operator inserts a hand into the vagina and
    locates the posterior arm.

    The operator applies pressure in the
    antecubital fossa to flex the elbow across the
    chest

    The operator grasps the forearm or hand and
     pulls it out of the vagina
     

    Delivery of Posterior Arm



    The anterior shoulder should pass under the
    symphysis

    Rotation maneuvers (Woods or Rubin’s) can
     be applied if needed
     This maneuver will tend to be more difficult
    with one’s non-dominant hand
     

    Delivery of Posterior Arm


     

    Delivery of Posterior Arm



    Potential complications

    Fracture of humerus

    Fracture of clavicle
     

    Gaskin All Fours Maneuver


    Attributed to midwife Ina May Gaskin
     An option for a patient without anesthesia

    Traction is applied in the opposite direction
    (still toward the floor, but now directed
    towards delivery of the posterior shoulder 
    first)
     

    Still not out?!


    What now???
     

    Step Six – Final Steps



    Zavanelli maneuver (cephalic replacement)

    Rotate head back to OA (“reverse restitution”)

    Flex neck 
     Upward pressure
     Cesarean section
     

    Step Six – Final Steps



    Symphysiotomy

     Not commonly done when cesarean is available

    Insert Foley catheter 
     Use vaginal hand to laterally displace urethra to avoid
    injury
     Incise symphysis through mons pubis
     

    Do not:
     Panic

    Apply any more lateral traction than would be applied

    in an uncomplicated delivery
     Apply fundal pressure – may worsen the shoulder 
    impaction or even rupture the uterus

    Cut a nuchal cord until after the shoulders are
    released
     

    Do:
     Remain calm

    Communicate well

    Call for help

    Document clearly and legibly
     Send cord gases


    Review with the family exactly what happened and
    answer questions
    answer the
     Follow questions
    baby’s course in the nursery

     Notify Risk Management
     

    Complications
    Maternal
    Hemorrhage- 11%
    injury-4%
    Soft tissue injury-4%
    Anal sphincter injury
    Rectovaginal fistula
    Symphyseal diathesis
    Rupture Uterus.
     

    Complications contd….
    FETAL
     Brachial plexus injury(transient,permanent)
    Or ERB’S palsy4-15%

    Fracture of clavicle.

    Fracture of humerus.
     Fetal hypoxia.

    Fetal death.
     

    IMPORTANT FACTS

    Occurs with equal frequency in both primipara
    and multigravida.

    Recurrence rate 14%

    Perinatal mortality ranging from
    21\1000.morbidity 16-48%

    Mc Robets maneuver with suprapubic pressure
    itself help >50% in shoulder dystocia.
     

    Take home message


    Early identification of risk factors and
    attaining appropriate means of delivery

    Call for seniors help.

    Always a team work.
     Pre inform pediatrician.
     

    References
     www.medescape.com
     Obs –gyn Emergency by Danyl jamison Macon
    county.
     www.aafp.org
     www.lifepassager.net

    ALSO
     Willams obstetrics.
     

    WE ALL THANK U

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