SHOULDER DYSTOCIA By Dale Seguin& Grace Warmels

La dystocie de l’épaule est l’impaction de l’épaule antérieur contre la symphyse pubienne, après que la tête du bébé est sortie.

Ceci est une urgence médicale!!

…JUST KIDDING.

Shoulder dystocia is the impaction of anterior shoulder of fetus against symphysis pubis after fetal head has been delivered

It is a life threatening emergency!!

DIAGNOSIS

Diagnosed by:

1) the difficult delivery of the shoulder

2) delivery of the shoulder requiring the use of procedures in addition to downward traction on the fetal head

3) a prolonged head-to-body delivery interval of more than 60 seconds

Turtle Sign: the head is delivered but then retracts against inferior portion of pubic symphysis

RISK FACTORS

1) Fetal: prolonged gestation, macrosomia (4000g)

2) Maternal: obesity, diabetes, multiparity

3) Labour: - Prolonged first/second stage of labour,

- instrumental midpelvic delivery

- prolonged deceleration phase on FHR (problem of descent)

4) Prior shoulder dystocia

To note: Shoulder dystocia is an unpredictable event. Risk factors for shoulder dystocia have small predictive value.

CASE

A 30 yo G2P1 is delivering at 41 weeks gestation. She is moderately obese, but

the fetus appears to clinically weigh approximately 3700 g. After a 4-hour

first stage of labor and 2-hr second stage of labor, the fetal head delivers but is

noted to then retract back toward the patient’s introitus (turtle sign). The

fetal shoulders do not deliver, despite strong maternal pushing.

MANAGEMENT

Call for help!

The goal is to displace the anterior shoulder from the symphysis pubis. Try each manoeuvre for 30-60 seconds before moving on to the next one.

First line / External maneuvers: • McRoberts maneuver• Suprapubic pressure• Gaskin•+/- Episiotomy

Second line / Internal maneuvers: • Woods maneuver• Rubin maneuver• Removal of posterior arm

SUPRAPUBIC PRESSURE

MCROBERTS MANEUVER

McRoberts maneuver + suprapubic pressure

GASKIN

Rolling to all fours

May get extra 10-20mm

Safe, quick and effective

WOODS MANEUVER

Approach the posterior shoulder from the front of the fetus and rotate toward symphysis, progressively rotating the posterior shoulder in a corkscrew fashion.

RUBIN MANEUVER

Rubin maneuver: rock shoulders side to side with force to the maternal abdomen, then push most accessible shoulder toward the anterior surface of the chest Often results in abduction of both shoulders (producing a smaller shoulder-to-shoulder diameter and freeing impacted shoulder)

DELIVERY OF POSTERIOR SHOULDER

Delivery of the posterior shoulder: sweep the posterior arm of the fetus across the chest, then deliver the arm, shoulder is then rotated into one of the oblique diameters of the pelvis to deliver the anterior shoulder

*Flex the elbow to deliver forearm and avoid humeral fracture

SECONDARY MANAGEMENT – LAST RESORT Fracture of the clavicle: press the anterior clavicle against the pubic ramus

Zavanelli maneuver: reposition head in anterior or posterior positions, flex the head, and push it back into the pelvis and deliver by cesarean Terbutaline 0.25mg SC for uterine relaxation

Cleidotomy: cut clavicle with scissors Usually used to deliver dead fetus

Symphysiotomy: not generally practiced Reported cases resulted in neonatal death and significant maternal morbidity

APPROACH MNEMONIC

ALARMERApply suprapubic pressure and Ask for helpLegs in full flexion (McRobert’s maneuver)Anterior shoulder disimpaction (suprapubic pressure)Release posterior shoulder by rotating it anteriorly with hand in the vagina under adequate anesthesiaManual corkscrew i.e. rotate the fetus by the posterior shoulder until the anterior shoulder emerges from behind the maternal symphysisEpisiotomyRollover (on hands and knees)

*Note that suprapubic pressure and McRoberts maneuver together will resolve 90% of cases

MATERNAL COMPLICATIONS

Symphyseal separations and transient femoral/peroneal neuropathies from hyper-flexing of the maternal thighs or inappropriate positioning

Infections: chorioamnionitis and post-partum pelvic infections (common)

Uterine rupture: during prolonged labor, it gets thingger

Fistula: excessive pressure on tissues

Pelvic flood injury: leading to prolapsus/ urine or fecal incontinence

Post-partum hemorrhage: secondary to atony or cervical lacerations

NEONATAL COMPLICATIONS

Fetal Brachial plexopathy (Erbs palsy, Klumpke’s palsy)

90% resolve after 1 year Clavicular/humeral fracture Death Head to Body delivery time:

<5 minutes no significant increase risk of fetal acidosis or hypoxic ischemic encephalopathy (HIE)

>5 minutes and risk of acidosis increases 5.9% and risk of HIE increases to 23.9%

BRACHIAL PLEXOPATHY

So, you’re delivering a baby and you see a ‘Turtle sign’.

What do you do? Apply suprapubic pressure and Ask for help

Legs in full flexion (McRobert’s maneuver)Anterior shoulder disimpaction (suprapubic pressure)Release posterior shoulder by rotating it anteriorly with hand in the vagina under adequate anesthesiaManual corkscrew i.e. rotate the fetus by the posterior shoulder until the anterior shoulder emerges from behind the maternal symphysisEpisiotomyRollover (on hands and knees)

‘ALARMER’