Shoulder DystociaShoulder Dystocia“Making the Best of a Bad “Making the Best of a Bad

Situation”Situation”

Sandesh Kamdi, M. PharmSandesh Kamdi, M. Pharm

IncidenceIncidence

Shoulder dystocia is an unpredictable Shoulder dystocia is an unpredictable obstetric complication with the incidence of obstetric complication with the incidence of 0.15% to 2%. 0.15% to 2%.

An increase in the incidence of shoulder An increase in the incidence of shoulder dystocia has been recorded over the last 20 dystocia has been recorded over the last 20 yearsyears

Incidence appears to be increasing as birth Incidence appears to be increasing as birth weights increase.weights increase.

Ceska Gynekol 2010 ; 75(4):274-79

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

Ceska Gynekol 2010 ; 75(4):274-79

DefinitionDefinition

““Difficulty encountered in the delivery of the Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.” fetal shoulders after delivery of the head.”

It is the complication of vaginal delivery that It is the complication of vaginal delivery that requires additional obstetric manoeuvres to requires additional obstetric manoeuvres to release the shoulders of the baby.release the shoulders of the baby.

Due to impaction of the fetal shoulder Due to impaction of the fetal shoulder behind the symphysis pubis.behind the symphysis pubis.

Ceska Gynekol 2010 ; 75(4):274-79

Bilateral Shoulder Bilateral Shoulder DystociaDystocia

A bilateral shoulder dystocia. The posterior shoulder is not in the hollow of the pelvis. This presentation oftern requires a cephalic replacement.

Clinical Obstetrics, Churchill Livingstone, New York, 1987.)

Unilateral Shoulder Unilateral Shoulder DystociaDystocia

Unilateral shoulder dystocia is usually easilydealt with by standard techniques.

Clinical Obstetrics and Gynecology, 1984l 27:106)

DiagnosisDiagnosis

One often described feature is the turtle sign One often described feature is the turtle sign which involves the appearance and retraction which involves the appearance and retraction of the fetal head (analogous to a turtle of the fetal head (analogous to a turtle withdrawing into its shell) and the withdrawing into its shell) and the erythematous, red puffy face indicative of erythematous, red puffy face indicative of facial flushing.facial flushing.

This occurs when the baby's shoulder is This occurs when the baby's shoulder is impacted in the maternal pelvisimpacted in the maternal pelvis

Ceska Gynekol 2010 ; 75(4):274-79

Risk FactorsRisk Factors

ANTEPARTUM FACTORSANTEPARTUM FACTORS Maternal ObesityMaternal Obesity Maternal Diabetes Maternal Diabetes

MellitusMellitus Post-term PregnancyPost-term Pregnancy Excessive Weight Excessive Weight

GainGain

INTRAPARTUM INTRAPARTUM FACTORSFACTORS

Prolonged Second Prolonged Second Stage of LaborStage of Labor

Oxytocin InductionOxytocin Induction Midforceps and Midforceps and

Vacuum ExtractionVacuum Extraction

Remember, many cases of shoulder dystocia occur with no readily identified risk factors!!!!

Risk factorsRisk factors

Fetal macrosomia and Fetal macrosomia and maternal diabetes most maternal diabetes most strongly associated with strongly associated with shoulder dystociashoulder dystocia

No single risk factor or No single risk factor or combination of risk factors are combination of risk factors are predictive for which infants will predictive for which infants will experience shoulder dystociaexperience shoulder dystocia

ACOG Practice Pattern No. 40 2002

Fetal ComplicationsFetal Complications

Fetal Fractures - Fetal Fractures - • In 18 to 25% of casesIn 18 to 25% of cases

Erb’s Palsy - Erb’s Palsy - • Although 80% will resolve by Although 80% will resolve by

18 months18 months Perinatal Asphyxia – Perinatal Asphyxia –

UncommonUncommon Brachial plexus injuryBrachial plexus injury Neonatal Death - RareNeonatal Death - Rare

Maternal ComplicationsMaternal Complications

Postpartum Postpartum HemorrhageHemorrhage

Vaginal LacerationsVaginal Lacerations Cervical LacerationsCervical Lacerations Puerperal InfectionPuerperal Infection

Individuals who MUST be present Individuals who MUST be present in the room if shoulder dystocia is in the room if shoulder dystocia is anticipated or encounteredanticipated or encountered• Attending physicianAttending physician• AnesthesiologistAnesthesiologist• PediatricianPediatrician• Nursing StaffNursing Staff• ““Extra Hands”Extra Hands”

Management of Shoulder Management of Shoulder DystociaDystocia

Who’s the Boss?Who’s the Boss?

It is important that the conduct of any It is important that the conduct of any shoulder dystocia be managed by the shoulder dystocia be managed by the most experienced person in the room.most experienced person in the room.

This individual ( generally the attending This individual ( generally the attending physician) must have the ability to physician) must have the ability to intervene at any time and should be the intervene at any time and should be the only one giving orders.only one giving orders.

Preliminary StepsPreliminary Steps

Call for help and have the team Call for help and have the team assembledassembled

Drain the bladderDrain the bladder Perform a generous episiotomyPerform a generous episiotomy TAKE YOUR TIME, THIS IN AN TAKE YOUR TIME, THIS IN AN

EMERGENCY, BUT IT IS NOT A EMERGENCY, BUT IT IS NOT A RACE!!!RACE!!!

PreventionPrevention

Prophylactic McRoberts ManeuverProphylactic McRoberts Maneuver

Prophylactic Cesarean DeliveryProphylactic Cesarean Delivery

Preliminary Measures: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)

ManeuversManeuvers

• • McRoberts ManeuverMcRoberts Maneuver • • Suprapubic PressureSuprapubic Pressure • • Gaskin ManeuverGaskin Maneuver • • EpisiotomyEpisiotomy • • Woods Maneuver/Rubin ManeuverWoods Maneuver/Rubin Maneuver • • Delivery of posterior shoulderDelivery of posterior shoulder • • Zavanelli ManeuverZavanelli Maneuver • • SymphysiotomySymphysiotomy

McRobert’s ManeuverMcRobert’s Maneuver

Marked flexion of the maternal Marked flexion of the maternal thighs unto the abdomenthighs unto the abdomen

Decreases the angle of pelvic Decreases the angle of pelvic inclinationinclination

Cephalic rotation of the pelvis Cephalic rotation of the pelvis frees the anterior shoulderfrees the anterior shoulder

McRobert’s ManeuverMcRobert’s Maneuver

Mazzanti TechniqueMazzanti Technique

Key pointsKey points

Instruct the mother to stop pushing until Instruct the mother to stop pushing until suprapubic pressure has been appliedsuprapubic pressure has been applied

Apply direct downward pressure above Apply direct downward pressure above the maternal symphysisthe maternal symphysis

– – Dislodges the anterior shoulder by Dislodges the anterior shoulder by pushing it under the maternal pushing it under the maternal symphysissymphysis

Do not use fundal pressureDo not use fundal pressure

Rubin TechniqueRubin Technique

Key pointsKey points

Move to the side of the bed opposite of the Move to the side of the bed opposite of the infant’s faceinfant’s face

Instruct the mother to stop pushingInstruct the mother to stop pushing Apply firm pressure on the backside of the Apply firm pressure on the backside of the

infant’s anterior shoulder and shove in the infant’s anterior shoulder and shove in the direction of the infant’s facedirection of the infant’s face

– – Decreases shoulder to shoulder diameterDecreases shoulder to shoulder diameter

Note: Applying pressure in front of the anterior shoulder and Note: Applying pressure in front of the anterior shoulder and shoving in the opposite direction of the infant’s face increases shoving in the opposite direction of the infant’s face increases the shoulder to shoulder diameter up to 2 cmthe shoulder to shoulder diameter up to 2 cm

Suprapubic PressureSuprapubic Pressure

Moderate suprapubic pressure is often theonly additional maneuver necessary to disimpactthe anterior fetal shoulder. Stronger pressure canonly be exerted by an assistant.

(Gabbe, et al., 1986)

Woods’ Corkscrew Woods’ Corkscrew ManeuverManeuver

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.)

Delivery may be facilitated by counterclockwiserotation of the anterior shoulder to the morefavorable oblique pelvic diameter, or clockwise rotation of the posterior shoulder.

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

Woods’ Corkscrew Woods’ Corkscrew ManeuverManeuver

Delivery of the Posterior Delivery of the Posterior ArmArm

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.)

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

Delivery of the Posterior Delivery of the Posterior ArmArm

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.

Delivery of the Posterior Delivery of the Posterior ArmArm

When All Else Fails...When All Else Fails...

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

CleidotomyCleidotomy The Zavanelli ManeuverThe Zavanelli Maneuver SymphysiotomySymphysiotomy

The Rubin ManeuverThe Rubin Maneuver

Step 1: The fetal shoulders are Step 1: The fetal shoulders are rocked from side to side by applying rocked from side to side by applying force to the maternal abdomen.force to the maternal abdomen.

Step 2: If step one is not successful, Step 2: If step one is not successful, push the presenting fetal shoulder push the presenting fetal shoulder toward the chest. This will often toward the chest. This will often cause abduction of both shoulders cause abduction of both shoulders and create a smaller shoulder to and create a smaller shoulder to shoulder diameter.shoulder diameter.

The Chavis ManeuverThe Chavis Maneuver

Described in 1979.Described in 1979. A “shoulder horn” consisting of a A “shoulder horn” consisting of a

concave blade with a narrow handle concave blade with a narrow handle is slipped between the symphysis is slipped between the symphysis and the impacted anterior shoulder.and the impacted anterior shoulder.

This used like a shoe-horn as a lever This used like a shoe-horn as a lever where the symphysis is the fulcrum.where the symphysis is the fulcrum.

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 ManeuverThe Hibbard Maneuver

The Hibbard ManeuverThe Hibbard Maneuver

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

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.

The Hibbard ManeuverThe Hibbard Maneuver

Fracture of the ClavicleFracture of the Clavicle

The anterior clavicle is pressed The anterior clavicle is pressed against the ramis of the pubis.against the ramis of the pubis.

Care should be taken to avoid Care should be taken to avoid puncturing the lung by angling the puncturing the lung by angling the fracture anteriorly.fracture anteriorly.

Theoretically, a fracture of the Theoretically, a fracture of the clavicle is less serious than a brachial clavicle is less serious than a brachial nerve injury and often heals rapidly.nerve injury and often heals rapidly.

The Zavanelli ManeuverThe Zavanelli Maneuver

First described in 1988First described in 1988 Consists of cephalic replacement Consists of cephalic replacement

and then cesarean delivery.and then cesarean delivery. Mixed reviews in the literature.Mixed reviews in the literature.

... Don’t Even Think About ... Don’t Even Think About It...It...

Symphysiotomy is a dangerous Symphysiotomy is a dangerous procedure with substantial risk to procedure with substantial risk to maternal health and well being.maternal health and well being.

It is difficult to justify this It is difficult to justify this procedure for shoulder dystocia in procedure for shoulder dystocia in modern medicine.modern medicine.

Complications Associated Complications Associated with Symphysiotomywith Symphysiotomy

Vesicovaginal FistulaVesicovaginal Fistula Osteitis PubisOsteitis Pubis Retropubic AbscessRetropubic Abscess Stress IncontinenceStress Incontinence Long Term Walking Disability / PainLong Term Walking Disability / Pain

Although shoulder dystocia represents Although shoulder dystocia represents a catastrophic event in obstetrics, a a catastrophic event in obstetrics, a well-reasoned plan of action with well-reasoned plan of action with adequate support and skilled adequate support and skilled personnel can reduce fetal morbidity.personnel can reduce fetal morbidity.

Proper patient selection and Proper patient selection and awareness of risk factors for shoulder awareness of risk factors for shoulder dystocia can also reduce morbidity.dystocia can also reduce morbidity.

NoNo Sensitivity of clinical estimates of BW > Sensitivity of clinical estimates of BW >

4500 gms is only 20%4500 gms is only 20% USG is not very accurate at extremes of EFWUSG is not very accurate at extremes of EFW Most cases of shoulder dystocia occur in Most cases of shoulder dystocia occur in

infants of average weightinfants of average weight The incidence of birth trauma in large infants The incidence of birth trauma in large infants

is not trivialis not trivial• (2.5% with BW > 4500 gms)(2.5% with BW > 4500 gms)

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

Top Reasons for Successful Claims Top Reasons for Successful Claims Against Obstetricians in Cases of Against Obstetricians in Cases of Shoulder DystociaShoulder Dystocia

Inappropriate obstetrical delivery notesInappropriate obstetrical delivery notes Absence of delivery notesAbsence of delivery notes Failure to document the dystociaFailure to document the dystocia Failure to document use of McRobert’s Failure to document use of McRobert’s

maneuvermaneuver Lack of prenatal documentation or follow-Lack of prenatal documentation or follow-

up ofup of• Abnormal or borderline GTTAbnormal or borderline GTT• Unexpected large maternal weight gain.Unexpected large maternal weight gain.

Harvard Risk Management Foundation (1994)

www.rmf.org

Things To Do After Dystocia Things To Do After Dystocia OccursOccurs

Check for and treat reproductive tract injuriesCheck for and treat reproductive tract injuries Pediatric neurology and neonatology consultationPediatric neurology and neonatology consultation Document a detailed delivery note, including maneuvers Document a detailed delivery note, including maneuvers

used used Explain the occurrence of dystocia to the parents of the Explain the occurrence of dystocia to the parents of the

infantinfant Do not finger-pointDo not finger-point Be truthful, but avoid discrepancies in notes by doctors, Be truthful, but avoid discrepancies in notes by doctors,

midwives and nurses.midwives and nurses.

Harvard Risk Management Foundation (1994)

www.rmf.org