Surgery Block

SECTION IV: LABOR & DELIVERY

2012

CHAPTER 20
Abnormal Labor
DYSTOCIA II
Dr. Estimo

FETOPELVIC DISPROPORTION

FETAL DIMENSIONS IN
Fetopelvic Disproportion

Introduction
Fetal size alone SELDOM a suitable explanation for failed
labor
 Most cases of disproportion arise in fetuses whose
weight is well within the range of the general
obstetrical population
rd
 2/3 of neonates who required cesarean delivery
after failed forceps delivery weighed < 3700 g
OTHER factors responsible for fetopelvic disproportion
FACE PRESENTATION
 MALPOSITION OF THE HEAD
⚜ obstruct fetal passage through the birth canal
⚜ include FETAL CONDITIONS & DYTOCIA
 Asynclitism
 Occiput Posterior Position
 Face Presentation FETAL PRESENTATIONS CAUSING
 Brow Presentations Fetopelvic Disproportion
Estimation of Fetal Head Size
FLEXED HEAD overriding the Symphysis Pubis Face Presentation
 PRESUMPTIVE EVIDENCE of disproportion FEATURES
MEULLER HILLIS MANEUVER:  head is HYPEREXTENDED
 CLINICAL MANEUVER to predict disproportion ⚜ OCCIPUT is in contact with the fetal back
 fetal brow and the suboccipital region are grasped ⚜ CHIN (MENTUM) is presenting
through the abdominal wall with the fingers VARIETIES IN RELATION to maternal symphysis pubis
 firm pressure is directed downward in the axis of the  MENTUM ANTERIOR PRESENTATION
inlet ⚜ w/ flexion of head can achieve vaginal delivery
 If NO DISPROPORTION exists  MENTUM POSTERIOR PRESENTATION
⚜ Head readily enters the pelvis ⚜ many convert spontaneously to anterior even in
⚜ Vaginal delivery can be predicted late labor
 no relationship between dystocia and failed descent ⚜ If remains MENTUM POSTERIOR
during the maneuver.  LABOR is IMPEDED because FETAL BROW
X-RAY PELVIMETRY (BREGMA) is pressed against the maternal
 Measurements of fetal head diameters using plain symphysis pubis
radiographic techniques  Position precludes flexion of the fetal head
 not used because of parallax distortions necessary to negotiate the birth canal.
⚜ distortion of fetal skull dimensions  OCCIPUT is the longer end of the head
 sensitivity is poor to predict cephalopelvic lever.
disproportion  CHIN is directly posterior.
SONOGRAPHIC EXAMINATION ⚜ Vaginal delivery is IMPOSSIBLE unless the chin
 Measures rotates anteriorly.
⚜ Biparietal Diameter ⚜ incidence of 1 in 600, or 0.17 percent
⚜ Head Circumference ⚜ requires CESAREAN DELIVERY (CSD)
FETAL-PELVIC INDEX ETIOLOGY
 USED to identify labor complications  FACTORS Favoring Extension or Preventing Head
 POOR sensitivity of measurements to predict Flexion
cephalopelvic disproportion
⚜ Preterm Infants
⚜ there is no currently satisfactory method for  Smaller head dimensions, can engage prior
accurate prediction of fetopelvic disproportion to conversion to vertex position
based on head size
⚜ Marked enlargement of the neck or coils of
cord around the neck
 may cause extension or limit flexion
⚜ Fetal Malformations & Hydramnios
 risk factors for face or brow presentations.

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⚜ Anencephalic Fetuses
 naturally present by the face.
⚜ CONTRACTED pelvis
 40% incidence of inlet contraction
 FACE presentation common
ANTHROPOID pelvis
⚜ LARGE fetus
⚜ PENDULOUS ABDOMEN In High Parity
 predisposing factor to face presentation
 PENDULOUS ABDOMEN permits the back of
the fetus to sag forward or laterally, often
in the same direction in which the occiput
points
 promotes extension of the cervical and
thoracic spine.
DIAGNOSIS
 ABDOMINAL EXAMINATION
⚜ LEUPOLDS MANEUVER
 VAGINAL EXAMINATION
⚜ PALPATION OFDISTINCTIVE FACIAL FEATURES
 can mistake a breech for a face
presentation because the anus may be
mistaken for the mouth and the ischial
tuberosities for the malar prominences
 palpate for distinctive facial features of the
mouth & nose, malar bones, and the orbital
ridge
 Radiographic exam
⚜ (+) hyperextended head with the facial bones at
or below the pelvic inlet
 CHARACTERISTIC FINDING
MECHANISM OF LABOR
 Face presentations rarely are observed ABOVE the
pelvic inlet
 BROW
⚜ generally presents early
⚜ usually converted to present the face after
further extension of the head during descent.
 Consists the following CARDINAL movements:
⚜ DESCENT
 Brought about by the same factors as in
cephalic presentations
 Pressure of Amniotic Fluid
 Direct Pressure of Fundus
 Bearing-down efforts of maternal
abdominal muscles
 FETUS position
 Extension and straightening of the fetal
body
⚜ INTERNAL ROTATION
 OBJECTIVE
 bring the chin ANTERIORLY under the
symphysis pubis
☀ so neck can traverse the posterior
surface of symphysis pubis
 If the chin rotates directly POSTERIORLY
 the relatively short neck
☀ CANNOT span the anterior surface
of the sacrum, which measures
about 12 cm in length
 the fetal brow (bregma) is pressed
against the maternal symphysis pubis
☀ position precludes flexion
necessary to negotiate the birth
canal
☀ Hence, birth of the head from a
mentum posterior position is
IMPOSSIBLE unless
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Cardinal Movements of Labor in
FACE PRESENTATION
in
❧ the shoulders enter the pelvis
at the same time
❧ if fetus is extremely small or
macerated
 Internal rotation results from the same
factors as in vertex presentations.
⚜ FLEXION
⚜ EXTENSION
 results from the relation of the fetal body to
the deflected head, which is converted into
a TWO-ARMED LEVER
 longer arm extends from the occipital
condyles to the occiput
 When resistance is encountered, the
occiput must be pushed toward the
back of the fetus while the chin
descends.
⚜ EXTERNAL ROTATION
 After ANTERIOR ROTATION and DESCENT
⚜ Chin and mouth appear at the vulva
⚜ Undersurface of the chin presses against the
symphysis
⚜ Head is delivered by flexion
⚜ Nose, Eyes, Brow (Bregma), & Occiput then
APPEAR IN SUCCESSION over the anterior
margin of the perineum
 After birth of the head
⚜ occiput sags backward toward the anus
⚜ chin rotates externally to the side toward which
it was originally directed
⚜ shoulders are born as in cephalic presentations
 Edema may sometimes significantly distort the face.
 Skull may undergo considerable MOLDING
⚜ manifested as  Occipitomental Diameter of
the head
MANAGEMENT
 If NO contracted pelvis + EFFECTIVE labor  vaginal
delivery
 If FACE PRESENTATION w/ contracted pelvis  CSD
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 Fetal heart rate monitoring

⚜ better done with external devices to avoid
damage to the face and eyes
 face presentations among TERM-SIZE fetuses
⚜ more common when there is some degree of
pelvic inlet contraction
⚜ cesarean delivery frequently is indicated
 These approaches are DANGEROUS & MUST NOT BE
ATTEMPTED!!!
⚜ Attempts to convert a face presentation
MANUALLY into a vertex presentation
⚜ Manual or forceps rotation of a persistently
posterior chin to a mentum anterior position
⚜ Internal podalic version and extraction BROW PRESENTATION

Brow Presentation
RARE ☀  occipitomental diameter
FEATURE  CARDINAL MOVEMENTS
 Portion of the fetal head between the orbital ridge ⚜ Brow  face presentation
and the anterior fontanel presents at the pelvic inlet ⚜ Descent
Fetal head occupies a position MIDWAY between full ⚜ Internal rotation
flexion (occiput) and extension (face) ⚜ Flexion
Except when the fetal head is small or the pelvis is
⚜ Extension
unusually large, engagement of the fetal head and
⚜ External rotation
subsequent delivery cannot take place as long as the
TRANSIENT BROW PRESENTATIONS
brow presentation persists.
ETIOLOGY & DIAGNOSIS  prognosis depends on the ultimate presentation
 CAUSES of persistent brow presentation are the  If the brow persists
same as those for face presentation ⚜ prognosis is POOR for vaginal delivery
 brow presentation  FACTORS that allow VAGINAL delivery in BROW
⚜ commonly UNSTABLE presentations
⚜ often converts to FACE or OCCIPUT presentation ⚜ SMALL fetus
 ABDOMINAL PALPATION
⚜ LARGE birth canal
⚜ both the occiput and chin can be palpated  Principles of management are the same as those for
easily
a face presentation.
 VAGINAL EXAMINATION
⚜ usually necessary
Transverse Lie Presentation
⚜ CAN PALPATE
FEATURE
 frontal sutures
 long axis of the fetus is approximately perpendicular
 large anterior fontanel
to that of the mother
 orbital ridges
 head occupies one iliac fossa, and the breech the
 eyes
other
 root of the nose
INCIDENCE
⚜ UNABLE TO PALPATE
 0.3 percent
 mouth
if long axis forms an acute angle: Oblique Lie
 chin
 usually only transitory
MECHANISM OF LABOR
 either a longitudinal or transverse lie commonly
 With a VERY SMALL FETUS and a LARGE PELVIS
results when labor supervenes
⚜ labor is generally easy  AKA: Unstable Lie
 with a LARGER FETUS Shoulder Presentation
⚜ labor is usually DIFFICULT  Presenting part is the SHOULDER
⚜ ENGAGEMENT is impossible until there is ⚜ usually positioned over the pelvic inlet
 marked molding that shortens the  ACROMION determines designation of the lie
occipitomental diameter ⚜ Right Acromial
 change presentation to either
⚜ Left Acromial
 flexion to an occiput presentation
Position of the back can be determined by ABDOMINAL
 extension to a face presentation
PALPATION
☀ MORE COMMON  DORSOANTERIOR
⚜ Considerable molding ESSENTIAL for vaginal ⚜ Back directed anteriorly
delivery of a persistent brow characteristically
⚜ Can palpate back
deforms the head
 DORSOPOSTERIOR
 CAPUT SUCCEDANEUM
⚜ Back directed posteriorly
 present over the FOREHEAD
 may be so extensive that identification ⚜ Will palpate small parts
of the brow by palpation is impossible. ETIOLOGY
 abdominal wall relaxation from high parity
☀ FOREHEAD is prominent and
squared ⚜ Women with > 4 deliveries have a 10x incidence
of transverse lie compared with nulliparas.

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⚜ relaxed and pendulous abdomen allows the  DORSOPOSTERIOR

uterus to fall forward, deflecting the long axis of  Back is posterior
the fetus away from the axis of the birth canal  irregular nodulations representing fetal
and into an oblique or transverse position small parts are felt through the
 preterm fetus abdominal wall.
 placenta previa
 abnormal uterine anatomy
 hydramnios
 contracted pelvis

VISUAL INSPECTION
 Abdomen appears unusually wide
ABDOMINAL EXAMINATION: Leopold Maneuver
 Done to assess position of baby
 Leopold 1: FUNDAL GRIP
⚜ no palpable fetal pole on the fundus
 no head
 no buttocks
⚜ uterine fundus extends to only slightly above
the umbilicus
LEOPOLD 3:
Palpate Fetal shoulder & back

 Leopold 4: PELVIC GRIP

⚜ NO palpable fetal brow or occiput
⚜ Shoulder is presenting

LEOPOLD 1: No Fetal Pole

 Leopold 2: UMBILICAL GRIP

⚜ NO palpable fetal back or small parts
⚜ PALPABLE PART
 ballottable head is found in one iliac fossa
 breech in the other iliac fossa

LEOPOLD 4:
No Fetal Brow or Occiput

Vaginal examination:
 Early labor:
⚜ “GRIDIRON” feel of the ribs
 Further dilatation:
⚜ SCAPULA & CLAVICLE felt on opposite side of
the thorax
⚜ position of the axilla indicates the side of the
mother toward which the shoulder is directed.
Mechanism of Labor
LEOPOLD 2: Palpate Fetal Head on 1
 Need CSD!!!
Iliac Fossa & Breech on the other ⚜ Spontaneous delivery of a fully developed
newborn is impossible with a PERSISTENT
TRANSVERSE LIE.
 Leopold 3: PAWLICKS GRIP  W/ MEMBRANE RUPTURE + ACTIVE LABOR
⚜ FETAL BACK is lying above the pelvic inlet ⚜ Fetal shoulder is forced into the pelvis
⚜ Position of the back is readily identifiable. ⚜ Corresponding arm frequently prolapses
 DORSOANTERIOR  AFTER SOME DESCENT
 back is anterior ⚜ Shoulder is ARRESTED by the margins of the
 hard resistance plane extends across pelvic inlet
the front of the abdomen ⚜ head in one iliac fossa and the breech in the
other
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SECTION IV: LABOR & DELIVERY
 AS LABOR CONTINUES
⚜ Shoulder is IMPACTED firmly in the upper part
of the pelvis
⚜ Uterus then contracts vigorously in an
unsuccessful attempt to overcome the obstacle
Compound Presentation
NEGLECTED SHOULDER PRESENTATION. A thick muscular band
forming a Pathological Retraction Ring has developed just
ABOVE the thin lower uterine segment.
⚜ Pathologic Retraction Ring
 rises increasingly higher becomes more
marked above the thinned segment
 force generated during a uterine
contraction is directed centripetally at and
above the level of the pathological
retraction ring  uterus stretch further 
possible to rupture the thin lower segment
below the retraction ring
 Hence, NEGLECTED Transverse Lie 
UTERINE RUPTURE!!!
⚜ Even without above complication, morbidity is
 d/ frequent association with
 placenta previa
  risk of cord prolapse
 necessity for major operative efforts:
 CSD
 FACTORS that will allow Spontaneous VAGINAL
delivery despite PERSISTENT Transverse Lie
⚜ SMALL fetus
 < 800g
⚜ LARGE pelvis
 CONDUPLICATO CORPORE
⚜ fetus is compressed with the head forced
against its abdomen.
⚜ portion of the thoracic wall below the shoulder
thus becomes the most dependent part,
appearing at the vulva.
⚜ head and thorax then pass through the pelvic
cavity at the same time.
⚜ The fetus is “doubled upon itself” as it is
expelled
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MANAGEMENT
 Active labor in a woman w/ a trasverse lie  CSD
 Before labor or early in labor w/ intact membranes:
⚜ attempts at external version in the absence of
other complications
 DORSOANTERIOR presentations
⚜ CLASSICAL Incision
 Preferred but has Increased risk for uterine
rupture in subsequent pregnancy
⚜ TRANSVERSE Incision
 Not preferred d/t difficult fetal extraction
 DORSOPOSTERIOR
⚜ Can do TRANSVERSE incision
FEATURE
 Extremity prolapses alongside presenting part
 (B) head & extremity present simultaneously in the
pelvis
INCIDENCE
 1/700 deliveries
ETIOLOGY
 Conditions that prevent complete occlusion of the
pelvic inlet by the fetal head
⚜ Preterm babies
 Small head prevent complete occlusion of
the pelvic inlet allowing extremity to pass
through
MANAGEMENT
 Prolapsed part should be left alone
⚜ most often it will not interfere with labor
 If arm is prolapsed alongside the head  close
observation
⚜ Tends to retract by itself
⚜ If it fails to retract & prevents descent
 Prolapsed arm is pushed gently upwards &
head simultaneously downward by fundal
pressure
⚜ If arm continue to prolapse & prevents descent
 can CSD
 Possible COMPLICATION w/ vaginal delivery
 Presenting Infant arm can develop
ischemic necrosis
PROGNOSIS
 FACTORS that increase PERINATAL mortality &
morbidity:
⚜ Preterm delivery
⚜ Prolapsed cord
⚜ Traumatic obstetrical procedures.
COMPOUND PRESENTATION
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Persistent Occiput Posterior Persistent Occiput Transverse

FEATURE usually transitory in the absence of pelvic architecture
 Failure of the occiput posterior position to undergo abnormality or asynclitism
spontaneous anterior rotation RISK FACTORS
Most occiput posterior positions undergo spontaneous  Obesity
anterior rotation followed by uncomplicated delivery  Multiparity
CONTRIBUTING FACTORS  Overt and gestational DM
 Transverse narrowing of midpelvis  Birthweight > 4500 grams
 MALROTATION of OA position to OP during labor  Midforceps delivery
⚜ 2/3 of OP deliveries occurred with fetuses who
rd
DELIVERY OPTIONS
were OA at the beginning of labor  Occiput may be manually rotated anteriorly or
⚜ MC cause of OP posteriorly
INCIDENCE ⚜ Easiest approach
 Early labor: 15% occiput posterior position  Application of KEILLAND forceps TO ROTATE the
 Outset of labor: occiput transverse position to the anterior position
⚜ 90% of OP spontaneously rotate to OA ⚜ Then can use either KEILLAND, SIMPSON, or
VAGINAL DELIVERY POSSIBILITIES TUCKER-McLANE forceps to DELIVER the head
 Spontaneous Delivery ⚜ PELVIC Type that can cause DIFFICULT rotation
⚜ rapid spontaneous delivery often will take place  PLATYPELLOID
if:  d/t wide transverse diameter
 pelvic outlet is roomy  flattened anteroposteriorly
 vaginal outlet and perineum are somewhat  ANDROID
relaxed from previous deliveries  d/t heart shaped pelvis
 head may not even be engaged
⚜ Will cause PROLONGED 1 stage &/or 2 stage
st nd

labor if: ☀ scalp may be visible through the

 vaginal outlet is resistant to stretch vaginal introitus d/t considerable
 perineum is firm molding and caput formation.
 forceps delivery is attempted but
⚜ During each expulsive effort, the head is driven
undue force should be avoided.
against the perineum to a much greater degree
 OXYTOCIN infusion
than when anterior.
⚜ Given if spontaneous rotation fails because of
 Hence, FORCEPS delivery often is indicated.
HYPOTONIC uterine contractions WITHOUT
 A GENEROUS EPISIOTOMY usually is needed
cephalopelvic disproportion
 Forceps Delivery W/ OP
⚜ Needs close monitoring
⚜ LARGER EPISIOTOMY
Fetal consequence
  perineal resistance; hence,  the need
 Transient Erb or Duchenne brachial plexus palsies
for more traction
 Clavicular fracture
⚜ use of forceps and a large episiotomy warrant  Humeral fracture
more complete analgesia than may be achieved  Fetal/neonatal death
with pudendal block and local perineal
infiltration.
⚜ forceps are applied bilaterally along the OTHER FETAL CONDITIONS CAUSING
occipitomental diameter Dystocia
⚜ If w/ large caput succedaneum
 labor is characteristically long and descent
of the head is slow.
 Prompt cesarean delivery is appropriate Dystocia from Hydrocephalus
 Manual Rotation to OA then Spontaneous Or FEATURE
Forceps Delivery  Macrocephaly from excessive accumulation of CSF
⚜ Requirements for forceps rotation must be met prohibit vaginal delivery
before performing a manual rotation. ⚜ Normal fetal head circumference at term
⚜ When the hand is introduced to locate the  32 to 38 cm.
posterior ear the occiput often spontaneously
rotates toward the anterior position
⚜ If not, the head may be grasped with the fingers
over one ear and the thumb over the other and
rotation of the occiput to the anterior position
attempted
 Forceps Rotation to OA & Delivery
⚜ ATTEMPTED if:
 head is engaged
 cervix fully dilated
 pelvis adequate
OUTCOME
 Increased delivery complication
 46% delivered spontaneously
 9% delivered by cesarean section DYTOCIA w/ Hydrocephalus
 Increased adverse short-term neonatal outcomes

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HYDROCEPHALUS ⚜ Most cases of shoulder dystocia cannot be

 Head circumference (HC) > 50 cm and may reach 80
cm.
 Fluid volume is usually between 500 and 1500 mL
but as much as 5 L may accumulate.
 Associated defects are frequent
⚜ especially neural-tube defects
 Breech presentation
⚜ Found in 1/3rd of fetuses
MANAGEMENT
 VAGINAL delivery can be attempted if:
⚜ BPD is < 10cm
⚜ HC is < 36 cm
 Macrocephalic head must be reduced in size to
deliver it even w/ CSD
 Removal of fluid by CEPHALOCENTESIS
⚜ HISTORICALLY was the MAINSTAY treatment
⚜ CURRENTLY use is limited to fetuses with severe
associated abnormalities
 Need precise knowledge of the extent of fetal
malformation
 RECOMMEND CSD
accurately predicted or prevented
⚜ Elective induction of labor or elective cesarean
delivery for all women suspected of having a
macrosomic fetus is NOT APPROPRIATE
⚜ Planned CS may be considered for
 nondiabetic woman with a fetus is >5000 g
 diabetic woman whose fetus is > 4500 g
MANEUVERS in the MANAGEMENT of Shoulder Dystocia
 MODERATE SUPRAPUBIC PRESSURE
⚜ Applied by an assistant while downward traction
is applied to the fetal head
Moderate Suprapupic
Pressure

Dytocia d/t Fetal Abdominal Distension

 McROBERT MANEUVER
Cause
⚜ Remove legs from stirrup and sharply flex up to
 Greatly distended bladder
the abdomen like in “frog position”
 Ascites
 Enlargement of the kidneys ⚜ Straightens sacrum relative to the lumbar
 Enlargement of the liver vertebra
NSD may be IMPOSSIBLE  CSD ⚜ Decreases angle of pelvic inclination
PROGNOSIS:
 POOR fetal prognosis
McRobert Maneuver
Shoulder Dystocia
INCIDENCE
  in recent decades d/t  birthweight
MEAN HEAD-TO-BODY DELIVERY TIME:
 NORMAL births: 24 seconds
 SHOULDER Dystocia: 79 seconds
⚜ Hence, head-to-body delivery time > 60
seconds is used to define shoulder dystocia
MATERNAL CONSEQUENCES
 Postpartum hemorrhage d/t
⚜ Uterine Atony
⚜ Vaginal & cervical laceration
FETAL CONSEQUENCES
 Transient Brachial plexus palsies
⚜ 2/3 of injuries
rd
 WOODS CORKSCREW MANEUVER
⚜ Types ⚜ hand is placed behind the posterior shoulder of
 Erb or Duchenne Palsy the fetus
 Klumpke Paralysis ⚜ Progressively rotating the posterior shoulder
 Clavicular fractures 180 degrees in a corkscrew fashion to release
 Humeral fractures IMPACTED anterior shoulder
 Neonatal death
PREDICTION & PREVENTION of SHOULDER DYSTOCIA
 Risk Factors
⚜ Obesity
⚜ Multiparity
⚜ DM
 Produce macrosomic babies
 body size is bigger than normal d/t
increased accumulation of fats
 head is delivered but shoulder gets
impacted
⚜ Postterm
⚜ Prior Shoulder Dystocia Woods Maneuver
 Summary

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 DELIVERY OF POSTERIOR SHOULDER ⚜ Strong fundal pressure applied at the wrong

⚜ Done when there is ANTERIOR IMPACTED time may result in even further impaction of the
shoulder anterior shoulder & associated with
⚜ STEP A:  fetal orthopedic and neurologic damage
 Operator's hand is introduced into the  ZAVANELLI MANEUVER
vagina along the fetal posterior humerus ⚜ Cephalic placement into the pelvis followed by
⚜ STEP B CSD
 Operator’s hand sweeps the posterior arm ⚜ Mm relaxants given when doing this
across chest keeping the arm flexed at the  CLEIDOTOMY
elbow followed by the delivery of the arm ⚜ Cutting the clavicle w/ scissors
⚜ STEP C ⚜ Done in dead fetus
 Fetal hand is grasped and the arm extended  SYMPHYSIOTOMY
along the side of the face. The posterior ⚜ Resulted in significant maternal urinary injury
arm is delivered from the vagina ⚜ Rarely done
 Shoulder girdle is then rotated into one of SHOULDER DYSTOCIA DRILL for emergency management
the oblique diameters of the pelvis with of an IMPACTED shoulder
subsequent delivery of the anterior  CALL FOR HELP,
shoulder
⚜ mobilize:
 Assistants
 Anesthesiologist
 Pediatrician
⚜ Initially, a GENTLE ATTEMPT AT TRACTION is
made.
⚜ DRAIN the bladder if it is distended.
 GENEROUS EPISIOTOMY:
⚜ Mediolateral or Episioproctotomy
 Afford room posteriorly.
 MANEUVERS That Will Resolve Most Cases Of
Shoulder Dystocia
⚜ SUPRAPUBIC PRESSURE
 used initially by most practitioners because
it has the advantage of simplicity.
 Only one assistant is needed to provide
suprapubic pressure
 normal downward traction is applied to the
fetal head
⚜ McROBERTS MANEUVER
 requires two assistants.
st
 “NEXT IN LINE” Maneuvers if the 1 2 FAIL:
⚜ Woods Screw Maneuver
⚜ Delivery of the Posterior Arm
 usually difficult to accomplish with a fully
extended arm
Delivery of Posterior Shoulder
DYSTOCIA COMPLICATIONS

 RUBIN MANEUVER MATERNAL & FETAL COMPLICATIONS w/

⚜ Consists of 2 maneuvers: Dystocia
 MANEUVER 1
 Fetal shoulder are rocked form side to
side by applying force to the abdomen Maternal Complication
 MANEUVER 2 Infection
 If step 1 is not successful, operator’s  Intrapartum Chorioamnionitis
hand reaches for the most easily  Postpartum Pelvic Infection
accessible shoulder then push toward Uterine rupture
the anterior chest  Pathologic Retraction Ring of Bandl
⚜ Results in abduction of both shoulders  ⚜ a/w marked stretching and thinning of the lower
smaller shoulder-to-shoulder diameter  uterine segment.
displacement of the anterior shoulder from ⚜ seen clearly as a uterine indentation
behind the symphysis pubis
⚜ signifies IMPENDING RUPTURE of the lower
 DELIBERATE FRACTURE OF CLAVICLE
uterine segment.
⚜ Press clavicle against ramus if the pubis Fistula formation
 HIBBARD  vesicovaginal, vesicocervical, or rectovaginal fistulas
⚜ Application of pressure of fetal jaw & neck in Pelvic floor injury
the direction of the maternal rectum with strong  Injury to the pelvic floor muscles, nerve supply, or
fundal pressure applied by an assistant as the interconnecting fascia
anterior shoulder is freed.

8 Williams Obstetrics 23rd Edition

 Surgery Block
SECTION IV: LABOR & DELIVERY
2012

 urinary and anal incontinence

 pelvic organ prolapse
Postpartum lower extremity nerve injury
 d/t external compression of the peroneal nerve by
inappropriate leg positioning in stirrups, especially
during a prolonged second-stage labor.

Fetal Complications
Peripartum fetal sepsis
Mechanical injuries
Caput succedaneum
Fetal head molding

9 Williams Obstetrics 23rd Edition