Shoulder dystocia

Background

• Occurs in 0.2 to 3 percent of all births
• Pre-labor risk factors:
  • Previous shoulder dystocia
  • Macrosomia
  • DM
  • Maternal BMI > 30
  • Induction of labor
• Intrapartum risk factors:
  • Prolonged first or second stage
  • Oxytocin augmentation
  • Assisted vaginal delivery

Clinical Presentation

A clinical diagnosis. It should be suspected when the fetal head retracts into the perineum (ie, turtle sign) after expulsion due to reverse traction from the shoulders being impacted at the pelvic inlet. The diagnosis is made when the routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder.

Differential Diagnosis

Emergent delivery and related complications

• Emergent delivery
• Umbilical cord prolapse
• Breech delivery
• Shoulder dystocia
• Perimortem cesarean delivery

Treatment

• No method of delivery has been shown to be better or safer
• All fours maneuver - move pt to her hands and knees, 82 cases of shoulder dystocia, ~80% delivered without additional maneuvers

HELPER

• H call for help
• E episiotomy (or episioproctotomy) to increase the anteroposterior diameter of passage
• L Legs flex (McRoberts maneuver)
• P Pressure- suprapubic pressure and Rubin’s maneuver (applying shoulder pressure to the fetus to decreases the bisacromial diameter)
• E Enter the vagina and attempt Wood’s corkscrew maneuver by pushing the most accessible shoulder toward the chest to corkscrew the shoulders through
• 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

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

• Emergent delivery