Shoulder dystocia: Difference between revisions
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==Background==
==Background==
*Occurs in 0.2 to 3 percent of all births
*Occurs in 0.2-3% of all births<ref name="Silver">Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.</ref>
*Due to reverse traction from the shoulders being impacted at the pelvic inlet
*Anterior shoulder becomes impacted in pubic symphysis


===Risk Factors===
===Risk Factors===
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==Clinical Features==
==Clinical Features==
*Routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder
*Routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder '''or''' additional obstetric maneuvers are required for delivery of anterior shoulder.
*Fetal head retracts into the perineum (ie, turtle sign) after expulsion
*"Turtle sign" - fetal head retracts against perineum after it appears (rare)


==Differential Diagnosis==
==Differential Diagnosis==
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==Treatment==
==Treatment==
*No method of delivery has been shown to be better or safer
No consensus on best treatment/maneuver or order of their application.
'''HELPER'''
 
'''HELPERR''' mnemonic - all maneuvers able to be performed by Emergency Physician, generally from least to most invasive
*'''H''' call for help
*'''H''' call for help
*'''E''' episiotomy (or episioproctotomy) to increase the anteroposterior diameter of passage
*'''E''' Evaluate for possible episiotomy (or episioproctotomy) to increase the anteroposterior diameter of passage
*'''L''' Legs flex (McRoberts maneuver)
*'''L''' Legs flex (McRoberts maneuver) - best first option - hyperflexion of legs with mild abduction and external rotation (successful in 40% of cases<ref name="Silver" />)
*'''P''' Pressure - rocking suprapubic pressure and Rubin’s maneuver (applying shoulder pressure to the fetus to decreases the bisacromial diameter) - try for 30 seconds
*'''P''' Pressure (suprapubic pressure, aka Rubin I maneuver) - apply pressure just proximal to pubic symphysis, either continuously or in rocking motion (in conjunction with McRoberts, increases success rate to 54%<ref name="Silver" />
*'''E''' Enter the vagina and attempt Wood’s corkscrew maneuver by pushing the most accessible shoulder toward the chest to corkscrew the shoulders through - maintain rocking suprapubic pressure at the same time
*'''E''' Entry maneuvers - Wood’s corkscrew maneuver by pushing the most accessible shoulder toward the chest to corkscrew the shoulders through, while maintaining rocking suprapubic pressure at the same time
*'''R''' Remove posterior arm by sweeping it across the chest and bring fetal hand to the chin, grasp and pull out of the birth canal and across the face
*'''R''' Remove posterior arm by sweeping it across the chest and bring fetal hand to the chin, grasp and pull out of the birth canal and across the face
 
*'''R''' Roll on all fours
*Repeat maneuvers on all fours - move pt to her hands and knees, 82 cases of shoulder dystocia, ~80% delivered without additional maneuvers<ref>Bruner JP et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med. 1998 May;43(5):439-43.</ref>


==Complications==
==Complications==

Revision as of 09:17, 3 August 2015

Background

  • Occurs in 0.2-3% of all births[1]
  • Anterior shoulder becomes impacted in pubic symphysis

Risk Factors

  • Pre-labor
    • Previous shoulder dystocia
    • Macrosomia
    • DM
    • Maternal BMI > 30
    • Induction of labor
  • Intrapartum
    • Prolonged first or second stage
    • Oxytocin augmentation
    • Assisted vaginal delivery

Clinical Features

  • Routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder or additional obstetric maneuvers are required for delivery of anterior shoulder.
  • "Turtle sign" - fetal head retracts against perineum after it appears (rare)

Differential Diagnosis

Emergent delivery and related complications

Diagnosis

  • Clinical diagnosis

Treatment

No consensus on best treatment/maneuver or order of their application.

HELPERR mnemonic - all maneuvers able to be performed by Emergency Physician, generally from least to most invasive

  • H call for help
  • E Evaluate for possible episiotomy (or episioproctotomy) to increase the anteroposterior diameter of passage
  • L Legs flex (McRoberts maneuver) - best first option - hyperflexion of legs with mild abduction and external rotation (successful in 40% of cases[1])
  • P Pressure (suprapubic pressure, aka Rubin I maneuver) - apply pressure just proximal to pubic symphysis, either continuously or in rocking motion (in conjunction with McRoberts, increases success rate to 54%[1]
  • E Entry maneuvers - Wood’s corkscrew maneuver by pushing the most accessible shoulder toward the chest to corkscrew the shoulders through, while maintaining rocking suprapubic pressure at the same time
  • R Remove posterior arm by sweeping it across the chest and bring fetal hand to the chin, grasp and pull out of the birth canal and across the face
  • R Roll on all fours

Complications

  • Transient brachial plexus palsy (3.0 to 16.8 percent)
  • Clavicular fracture (1.7 to 9.5 percent)
  • Humerus fracture (0.1 to 4.2 percent)
  • Permanent brachial plexus palsy (0.5 to 1.6 percent)
  • Hypoxic-ischemic encephalopathy (0.3 percent)
  • Death (0 to 0.35 percent)

See Also

References

  1. ↑ 1.0 1.1 1.2 Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.
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