Shoulder Dystocia
Do you like this story?
Definition
§ Difficulty in delivery of fetal shoulders
§ Failure to deliver fetal shoulder without utilizing facilitating maneuvers
§ Prolonged head-to-body delivery time
§ >60 seconds
§ Incidence: 0.2-3% of all live births
Pathophysiology
§ Size discrepancy between fetal shoulders and maternal pelvic inlet
§ Macrosomia
§ Large chest:BPD
§ Absence of truncal rotation
§ Fetal shoulders remain A-P or descent simultaneously
Risk Factors
§ Antepartum
§ Macrosomia (>4500g)
§ DM/GDM (increases overall risk by 70%)
§ Multiparity
§ Intrapartum
§ Prolonged deceleration phase of labor
§ Prolonged 2nd stage
§ Protracted descent
§ Operative delivery (vacuum>forceps)
Risk factors cont…
§ No evidence based data:
§ Male
§ AMA
§ short maternal stature
§ abnormal pelvic shape/size
Unpredictable
§ 25-50% have no defined risk factor!
§ 50% of cases occur in infants whose birth weight is
§ 84% of patients did not have prenatal dx. of macrosomia by US
§ 82%of infants with brachial plexus palsy did not have macrosomia
Complications
§ Maternal
§ Hemorrhage
§ 4th degree laceration
§ Fetal
§ Fx of humerus or clavicle
§ Brachial plexus injury (Erb’s/Klumpke’s palsy)
§ Asphyxia/cord compression
§ Physician
§ Litigation: 11% of all obstetrical suits
Management
§ Goal: safely deliver infant before asphyxia and/or cortical injury
§ 7 minutes!!!
§ Episiotomy
§ Suprapubic Pressure
§ McRoberts Maneuver
§ Woods or Rubin Maneuvers
§ Zavenelli
McRoberts Maneuver
§ 42% success rate
§ + suprapubic pressure = 54-58%
§ Brings pelvic inlet and outlet into more vertical alignment
§ Flattens sacrum
§ Cephalad rotation of pubic symphysis
§ Elevates anterior shoulder and flexes fetal spine
§ Increases IUP by 97%
§ Increases amplitude of contractions
§ +31N of pushing force
Summary
§ Cannot accurately predict
§ BE PREPARED!
§ Consider risk factors
§ Be prepared to perform various maneuvers
§ Diagnose and treat quickly
§ Obtain assistance from nursing staff and NICU
Prophylactic C/S?
§ Not recommended by ACOG
§ Exceptions:
§ Consider if…
§ >5000g in mother without DM
§ >4500g in mother with DM
This post was written by: Franklin Manuel
Franklin Manuel is a professional blogger, web designer and front end web developer. Follow him on Twitter
