Shoulder dystocia

Revision as of 04:10, 3 August 2015 by Rossdonaldson1 (talk | contribs)

Background

  • Occurs in 0.2 to 3 percent of all births
  • Due to reverse traction from the shoulders being impacted at the pelvic inlet

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 Presentation

  • Routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder
  • Fetal head retracts into the perineum (ie, turtle sign) after expulsion

Differential Diagnosis

Emergent delivery and related complications

Diagnosis

  • Clinical diagnosis

Treatment

  • No method of delivery has been shown to be better or safer

HELPER

  • H call for help
  • E episiotomy (or episioproctotomy) to increase the anteroposterior diameter of passage
  • L Legs flex (McRoberts maneuver)
  • P Pressure - rocking suprapubic pressure and Rubin’s maneuver (applying shoulder pressure to the fetus to decreases the bisacromial diameter) - try for 30 seconds
  • 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
  • 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
  • Repeat maneuvers on all fours - move pt to her hands and knees, 82 cases of shoulder dystocia, ~80% delivered without additional maneuvers[1]

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. Bruner JP et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med. 1998 May;43(5):439-43.