Shoulder Dystocia

Making the Best of a Bad Situation

Chukwuma I. Onyeije, M.D.

Director of Obstetrics and Perinatal Services North Central Bronx Hospital Albert Einstein College of Medicine

Incidence
Varies widely based on criteria used for diagnosis. Gross et al, Toronto General Hospital - 1987

0.9 Percent based on coding 0.2 Percent based on use of maneuvers

Acker et al 1986
2 Percent based on assessment of operator

Incidence appears to be increasing as birthweights increase.

Definition and Diagnosis

Difficulty encountered in the delivery of

the fetal shoulders after delivery of the head. Due to impaction of the fetal shoulder behind the symphysis pubis.

Risk Factors
Remember, many cases of shoulder dystocia occur with no readily identified risk factors!!!! ANTEPARTUM FACTORS Maternal Obesity Maternal Diabetes Mellitus Postterm Pregnancy Excessive Weight Gain INTRAPARTUM FACTORS Prolonged Second Stage of Labor Oxytocin Induction Midforceps and Vacuum Extraction

Fetal Complications
Fetal Fractures -

In 18 to 25% of cases
Erbs Palsy -

Although 80% will resolve by 18 months

Perinatal Asphyxia - Uncommon Neonatal Death - Rare

Maternal Complications
Postpartum Hemorrhage

Vaginal Lacerations
Cervical Lacerations

Puerperal Infection

Management of Shoulder Dystocia

Know the Drill!

CALL FOR HELP

REMAIN CALM

CALL FOR HELP

REMAIN CALM
Oh, and by the way, dont forget to call for help.

Management of Shoulder Dystocia

Individuals who MUST be present in the

room if shoulder dystocia is anticipated or encountered

Attending physician Anesthesiologist Pediatrician Nursing Staff Extra Hands

Whos the Boss?

It is important that the conduct of any

shoulder dystocia be managed by the most experienced person in the room. This individual ( generally the attending physician) must have the ability to intervene at any time and should be the only one giving orders.

Preliminary Steps
Call for help and have the team assembled Drain the bladder Perform a generous episiotomy TAKE YOUR TIME, THIS IN AN EMERGENCY, BUT

IT IS NOT A RACE!!!

The Principle Maneuvers

Gentle Traction (?) McRoberts Maneuver Suprapubic Pressure Woods Corkscrew Maneuver Delivery of the Posterior Arm

Bilateral Shoulder Dystocia

A bilateral shoulder dystocia. The posterior shoulder is not in the hollow of the pelvis. This presentation oftern requires a cephalic replacement. (C.Pauerstein [ed.], Clinical

Obstetrics, Churchill Livingstone, New York, 1987.)

Unilateral Shoulder Dystocia

Unilateral shoulder dystocia is usually easily dealt with by standard techniques.

(B. Harris, Shoulder dystocia. Clinical Obstetrics and Gynecology, 1984l 27:106)

Preliminary Measures:

Gentle

pressure on the fetal vertex in a dorsal direction will move the posterior fetal shoulder deeper into the maternal pelvic hollow, usually resulting in easy delivery of the anterior shoulder.

Excession angulation (>45 degrees) is to be avoided.

(Gabbe, et al., Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986)

McRoberts Maneuver
Marked flexion of the maternal thighs unto

the abdomen Decreases the angle of pelvic inclination Cephalic rotation of the pelvis frees the anterior shoulder

Suprapubic Pressure

Moderate suprapubic pressure is often the only additional maneuver necessary to disimpact the anterior fetal shoulder. Stronger pressure can only be exerted by an assistant.

(Gabbe, et al., 1986)

Woods Corkscrew Maneuver

Woods' corkscrew maneuver. The shoulders must be rotated utilizing pressure on the scapula and clavicle. The head is never rotated. (B.Harris, Shoulder dystocia, Clinical Obstetrics and Gynecology, 1984; 27:106.)

(B.Harris, Shoulder dystocia, Clinical Obstetrics and Gynecology, 1984; 27:106.)

Woods Corkscrew Maneuver

Delivery may be facilitated by counterclockwise rotation of the anterior shoulder to the more favorable oblique pelvic diameter, or clockwise rotation of the posterior shoulder.

During these maneuvers, expulsive efforts should be stopped and the head is never grasped !!

Delivery of the Posterior Arm

To bring the fetal wrist within reach, exert pressure with the index finger at the antecubital junction.

(E. Sandberg. American Journal of Obstetrics and Gynecology, 1985; 152: 481.)

Delivery of the Posterior Arm

Sweep the fetal forearm down over the front of the chest.

Delivery of the Posterior Arm

If less invasive maneuvers fail to affect this impaction, delivery should be facilitated by manipulative delivery of the posterior arm by inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder with delivery over the perineum.

When All Else Fails...

The Rubin Maneuver The Chavis Maneuver The Hibbard Maneuver Fracture of the Clavicle / Cleidotomy

The Zavanelli Maneuver

Symphysiotomy

The Rubin Maneuver

Step 1:

The fetal shoulders are rocked from side to side by applying force to the maternal abdomen. Step 2: If step one is not successful, push the presenting fetal shoulder toward the chest. This will often cause abduction of both shoulders and create a smaller shoulder to shoulder diameter.

The Chavis Maneuver

Described in 1979. A shoulder horn consisting of a concave

blade with a narrow handle is slipped between the symphysis and the impacted anterior shoulder. This used like a shoe-horn as a lever where the symphysis is the fulcrum.

The Hibbard Maneuver

Release of the anerior shoulder is initiated by firm pressure against the infant's jaw and neck in a posterior and upward direction. An assistant is poised, ready to apply fundal pressure after proper suprapublic pressure As the anterior shoulder slips free, fundal pressure is applied, and pressure against the neck is shifted slightly toward the rectum. Proper suprapubic pressure is continued.

The Hibbard Maneuver

Continued fundal and suprapublic pressure results in an upwardinward rotation of the newly freed anterior shoulder and a further descent in a position beneath the pubic symphysis.

The Hibbard Maneuver

As a result of the previous maneuvers, the

transverse diameter of the shoulders is reduced. Lateral (upward) flexion of the head releases the posterior shoulder into the hollow of the sacrum.

Fracture of the Clavicle

The anterior clavicle is pressed against the

ramis of the pubis. Care should be taken to avoid puncturing the lung by angling the fracture anteriorly. Theoretically, a fracture of the clavicle is less serious than a brachial nerve injury and often heals rapidly.

The Zavanelli Maneuver

First

described in 1988 Consists of cephalic replacement and then cesarean delivery. Mixed reviews in the literature.

... Dont Even Think About It...

Symphysiotomy is a dangerous procedure

with substantial risk to maternal health and well being.

It is difficult to justify this procedure for

shoulder dystocia in modern medicine.

Conclusions
Although shoulder dystocia represents a

catastrophic event in obstetrics, a wellreasoned plan of action with adequate support and skilled personnel can reduce fetal morbidity. Proper patient selection and awareness of risk factors for shoulder dystocia can also reduce morbidity.

Addendum to Lecture

Although half of shoulder dystocias occur in infants weighing less than 4000 gms. The incidence of shoulder dystocia is directly related to fetal size.

10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0%

10.0%

1.7% 0.2%

BW 2500 to 4000 gms

BW 4000 to 4500 gms

BW > 4500 gms

Complications Associated with Symphysiotomy

Vesicovaginal Fistula Osteitis Pubis Retropubic Abscess Stress Incontinence

Long Term Walking Disability / Pain

Q: Can Cesarean Sections for Suspected Macrosomia Reduce the Rates of Shoulder Dystocia?

Sensitivity of clinical estimates of BW > 4500 gms is only 20% USG is not very accurate at extremes of EFW Most cases of shoulder dystocia occur in infants of average weight The incidence of birth trauma in large infants is not trivial

(2.5% with BW > 4500 gms)

A: NO

Top Reasons for Successful Claims Against Obstetricians in Cases of Shoulder Dystocia
Inappropriate obstetrical delivery notes Absence of delivery notes Failure to document the dystocia Failure to document use of McRoberts maneuver Lack of prenatal documentation or follow-up of

Abnormal or borderline GTT Unexpected large maternal weight gain.

Harvard Risk Management Foundation (1994) www.rmf.org

Things To Do After Dystocia Occurs

Check for and treat reproductive tract injuries Pediatric neurology and neonatology consultation Document a detailed delivery note, including maneuvers used Explain the occurrence of dystocia to the parents of the infant Do not finger-point Be truthful, but avoid discrepancies in notes by doctors, midwives and nurses.
Harvard Risk Management Foundation (1994)

www.rmf.org