shoulder dystocia 1
TRANSCRIPT
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Shoulder Dystocia
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OBJECTIVES:
Definition .
Incidence .
Consequences .
Risk factors .
Management.
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Why is it important?
An obstetric emergency.
Increased maternal morbidity.
Increased fetal morbidity & mortality .
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Definition
A head-to-body delivery time > 60 seconds due toimpaction of the shoulder ( anterior ) against thesymphsis pubis.
(Williams Ob)
Use of any of the obstetric maneuvers to release theshoulder after gentle downward traction has failed.
(RCOG ,2005)
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Mean time of normal delivery24 sec.
Mean time of delivery with dystocia 79 sec.
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Shoulder dystocia
Shoulder dystocia can be one of the most frighteningemergencies in the delivery room
Although many factors have been associated withshoulder dystocia, most cases occur with no warning
Defined as a delivery in which additional maneuvers arerequired to deliver the fetus after normal gentledownward traction has failed
Shoulder dystocia occurs when the fetal anterior shoulderimpacts against the maternal symphysis
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Epidemiology
The overall incidence of shoulder dystocia varies basedon fetal weight 0.6-1.4%: 2500g(5lb,8oz) to 4000g(8lb,13oz)
5-9%: 4000g to 4500g(9lb,14oz), born to mothers withoutdiabetes
3969g (8lb,12oz)our patient
Shoulder dystocia occurs with equal frequency inprimigravid and multigravid women More common in infants born to women with diabetes
However, most cases occur in fetuses of normal birth
weight and are unanticipated, limiting the clinicalusefulness of risk-factor identification
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Risk Factors for Shoulder
Dystocia Maternal
Abnormal pelvic anatomy
Gestational diabetes
Post-dates pregnancy
Previous shoulder dystocia Short stature
Fetal
Suspected macrosomia
Labor related
Assisted vaginal delivery
(forceps or vacuum) Prolonged active phase of
first-stage labor
Prolonged second-stagelabor
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Complications of Shoulder
Dystocia* Maternal
Postpartum hemorrhage(11%)
Rectovaginal fistula Symphyseal separation
With or without transientfemoral neuropathy
3rdor 4thdegree (3.8%)episiotomy or tear
Uterine rupture
Fetal Brachial plexus palsy (4-
15%) Clavicle fracture Fetal hypoxia
With or withoutpermanent neurologic
damage Fracture of the humerus Fetal death
Nearly all palsies resolve within sixto 12 months, with fewer than10% resulting in permanent injury
*These rates remain constant, independent of operator experience
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Management
H
E
L
P
E
R
R
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Each step 30-60 Sec
For a total 3- 5 minutes (All Maneuvers)
Noindication thatany of these maneuvers is superior, they
represent a valuable tool to help clinicians take effective steps
to relieve impacted shoulder ( Category C )
ACOG..October 1997
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Benefits
1. Increase the size of the bony pelvis
2. Decrease bisacromial diameter
3. Change the relation of bisacromial diameter within the bony
pelvis .
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How to recognize SD?
Prolonged 1st& 2ndstage of labor.
Head bobbing , then retracting back in the birth canal.
Minimal downward traction does not affect delivery.
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Once recognized
Do NOT ask the patient to push.
Do NOTapply fundal pressure. ( Grade C )
DoNOT panic !!
RCOG guidelines..December,2005
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HELPERR
Although there is no indication that any one ofthese techniques is superior to another, togetherthey effectively relieve the impacted shoulder
The order of the steps is not as important as the
fact that they each be employed efficiently andappropriately
Persistence in any one ineffective maneuvershould be avoided
Clinical judgment always should guide theprogression of procedures used
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H - Help
This refers to activating the pre-arrangedprotocol or requesting the appropriate personnelto respond with necessary equipment to thelabor and delivery unit
If standard levels of traction do not relieve theshoulder dystocia, the physician must movequickly to other maneuvers while asking for helpand notifying the family
A critical step in addressing the emergencymanagement of shoulder dystocia is ensuringthat all involved hospital personnel are familiarwith their roles and responsibilities
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E - Evaluate for episotomy
Episiotomy should be considered when ashoulder dystocia is encountered, althoughbecause the primary problem is a bonyimpaction, episiotomy by itself will not release
the impaction
Episiotomy does provide additional room for thephysician's hand when internal rotationmaneuvers are required
Given the success of the McRoberts maneuverand suprapubic pressure in relieving a largepercentage of cases of shoulder dystocia,performing an episiotomy can wait until later inthe sequence
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L Legs (McRoberts
maneuver) The simplicity of the McRoberts maneuver and its
proven effectiveness make it an ideal first step in themanagement of shoulder dystocia
This procedure results in a cephalad rotation of thesymphysis pubis and a flattening of the sacral
promontory These motions push the posterior shoulder over the sacral
promontory, allowing it to fall into the hollow of the sacrum, androtate the symphysis over the impacted shoulder
When this maneuver is successful, the fetus should be
delivered with normal traction The McRoberts maneuver alone is believed to relieve
more than 40% of all shoulder dystocias and, whencombined with suprapubic pressure, resolves more than50% of shoulder dystocias
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P Pressure (suprapubic)
When applying suprapubic pressure, an assistant's handshould be placed on top of the mother's abdomen overthe fetal anterior shoulder, applying pressure in acompression/relaxation cycle analogous tocardiopulmonary resuscitation, so that the shoulder will
adduct and pass under the symphysis Pressure should be applied from the side of the mother,
with the heel of the assistant's hand moving in adownward and lateral motion on the posterior aspect ofthe fetal impacted shoulder
Initially, the pressure can be continuous, but if delivery isnot accomplished, a rocking motion is recommended todislodge the shoulder from behind the pubic symphysis
Fundal pressure is never appropriate and only serves toworsen the impaction, potentially injuring the fetus or
mother
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E Enter maneuvers
Rotation maneuvers may require episiotomy to gainposterior vaginal space for the physicians hand
The Rubin II maneuver consists of inserting the fingers ofone hand vaginally behind the posterior aspect of the
anterior shoulder of the fetus and rotating the shouldertoward the fetal chest
This motion will adduct the fetal shoulder girdle,reducing its diameter
The McRoberts maneuver also can be applied during this
maneuver and may facilitate its success
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E Enter maneuvers (cont.)
If the Rubin II maneuver is unsuccessful, the Woodscorkscrew maneuver may be attempted
The physician places at least two fingers on the anterioraspect of the fetal posterior shoulder, applying gentleupward pressure around the circumference of the arc in
the same direction as with the Rubin II maneuver The Rubin II and Woods corkscrew maneuvers may be
combined to increase torque forces by using two fingersbehind the fetal anterior shoulder and two fingers infront of the fetal posterior shoulder
Procedurally, this step often is difficult because of limitedspace for the physician's hand
Downward traction should be continued during theserotational maneuvers, simulating the rotation of a screwbeing removed
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E Enter maneuvers (cont.)
If the Rubin II or Woods corkscrew maneuversfail, the reverse Woods corkscrew maneuver maybe tried
In this maneuver, the physician's fingers areplaced on the back of the posterior shoulder ofthe fetus, and the fetus is rotated in the oppositedirection as in the Woods corkscrew or Rubin IImaneuvers
This maneuver adducts the fetal posteriorshoulder in an attempt to rotate the shouldersout of the impacted position and into an obliqueplane for delivery
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Rubin II
At vaginal examination apply pressure
as indicated. If shoulders move into the
oblique diameter, attempt delivery
Rubin II + Woods corkscrew
maneuver
If unsuccessful, add the Woods
corkscrew maneuver and continue
rotation in the same direction. Use both
hands and apply pressure as indicated.If shoulders now move into the oblique,
attempt delivery. If this is unsuccessful,
continue rotation 180 degrees and
deliver
Reverse Woods corkscrew maneuverIf the last maneuver is unsuccessful,
change to reverse Woods corkscrew
maneuver. Slide fingers down to back of
posterior shoulder and attempt 180-
degree rotation in the opposite direction
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R Remove the posterior arm
Removal of the posterior arm involves placing thephysician's hand in the vagina and locating the fetal arm,which sometimes is displaced behind the fetus and mustbe nudged anteriorly The physician's hand, wrist, and forearm may need to enter the
vagina, necessitating an episiotomy or extension The fetal elbow is then flexed, and the forearm is
delivered in a sweeping motion over the anterior chestwall of the fetus
The upper arm should never be grasped and pulled
directly, because this step may result in a fracture of thehumerus
The posterior hand, followed by the arm and shoulder,will be reduced, facilitating delivery of the infant
The anterior shoulder will then fall under the symphysis
and deliver
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RRoll the patient
Rolling the patient onto her hands and knees, known asthe all-fours or Gaskin maneuver, is a safe, rapid, andeffective technique for the reduction of shoulderdystocia
Once the patient is repositioned, the physician provides
gentle downward traction to deliver the posteriorshoulder with the aid of gravity
The all-fours position is compatible with all intravaginalmanipulations for shoulder dystocia, which can then bereattempted in this new position
All-fours positioning may be disorienting to physicianswho are unfamiliar with attending a delivery in thisposition
Performing a few normal deliveries in this positionbefore encountering a case of shoulder dystocia may
prepare physicians for more emergent situations
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Maneuvers of last resort
If the maneuvers described in HELPERR are
unsuccessful, several techniques have been
described as last-resort maneuvers
Once the infant is delivered, quick assessmentand employment of resuscitation efforts, if
necessary, are vital
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Maneuvers of last resort (cont.)
Deliberate clavicle fracture Direct upward pressure on the mid-portion of the fetal
clavicle; reduces the shoulder-to-shoulder distance
Zavanelli maneuver
Cephalic replacement followed by cesarean delivery;involves rotating the fetal head into a direct occiputanterior position, then flexing and pushing the vertexback into the birth canal, while holding continuousupward pressure until cesarean delivery isaccomplished
An operating team, anesthesiologist, and physicianscapable of performing a cesarean delivery must bepresent, and this maneuver should never beattempted if a nuchal cord previously has beenclamped and cut
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Maneuvers of last resort (cont.)
General anesthesia Musculoskeletal or uterine relaxation with halothane
(Fluothane) or another general anesthetic may bringabout enough uterine relaxation to affect delivery
Oral or intravenous nitroglycerin may be used as analternative to general anesthesia
Abdominal surgery with hysterotomy General anesthesia is induced and cesarean incision
performed, after which the surgeon rotates the infant
transabdominally through the hysterotomy incision,allowing the shoulders to rotate, much like a Woodscorkscrew maneuver
Vaginal extraction is then accomplished by anotherphysician
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Maneuvers of last resort (cont.)
Symphysiotomy
Intentional division of the fibrous cartilage of
the symphysis pubis under local anesthesia has
been used more widely in developingcountries than in North America
It should be used only when all other
maneuvers have failed and capability of
cesarean delivery is unavailable
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Documentation
Documentation of the management of shoulder dystociashould concentrate on the maneuvers performed andthe duration of the event
Terms such as mild, moderate, or severe shoulderdystocia offer little information about the situation or
care encountered Other team members assisting the delivery should be
listed, as well as cord pH, if obtained
Specific notation regarding which arm was impactedagainst the pubis should be made in the event that
subsequent nerve palsy develops The delivery should be reviewed with the parents, and
the management and prognosis for any infant palsyshould be explained