Shoulder Dystocia “Making the Best of a Bad Situation”

1. Shoulder Dystocia“Making the Best of a Bad Situation” Sandesh Kamdi, M. Pharm

2. Incidence • Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%. • An increase in the incidence of shoulder dystocia has been recorded over the last 20 years • Incidence appears to be increasing as birth weights increase. Ceska Gynekol 2010 ; 75(4):274-79

3. 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

4. Definition • “Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.” • It is the complication of vaginal delivery that requires additional obstetric manoeuvres to release the shoulders of the baby. • Due to impaction of the fetal shoulder behind the symphysis pubis. Ceska Gynekol 2010 ; 75(4):274-79

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

6. Unilateral Shoulder Dystocia • Unilateral shoulder dystocia is usually easilydealt with by standard techniques. Clinical Obstetrics and Gynecology, 1984l 27:106)

7. Diagnosis • One often described feature is the turtle sign which involves the appearance and retraction of the fetal head (analogous to a turtle withdrawing into its shell) and the erythematous, red puffy face indicative of facial flushing. • This occurs when the baby's shoulder is impacted in the maternal pelvis Ceska Gynekol 2010 ; 75(4):274-79

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

9. Risk factors • Fetalmacrosomia and maternal diabetes most strongly associated with shoulder dystocia • No single risk factor or combination of risk factors are predictive for which infants will experience shoulder dystocia ACOG Practice Pattern No. 40 2002

10. Fetal Complications • Fetal Fractures - • In 18 to 25% of cases • Erb’s Palsy - • Although 80% will resolve by 18 months • Perinatal Asphyxia – Uncommon • Brachial plexus injury • Neonatal Death - Rare

11. Maternal Complications • Postpartum Hemorrhage • Vaginal Lacerations • Cervical Lacerations • Puerperal Infection

12. 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”

13. Who’s 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.

14. 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!!!

15. Prevention • Prophylactic McRobertsManeuver • Prophylactic Cesarean Delivery

16. 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)

17. Maneuvers • • McRobertsManeuver • • Suprapubic Pressure • • Gaskin Maneuver • • Episiotomy • • Woods Maneuver/Rubin Maneuver • • Delivery of posterior shoulder • • ZavanelliManeuver • • Symphysiotomy

18. McRobert’s 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

19. McRobert’s Maneuver

20. Mazzanti Technique

21. Key points • Instruct the mother to stop pushing until suprapubic pressure has been applied • Apply direct downward pressure above the maternal symphysis – Dislodges the anterior shoulder by pushing it under the maternal symphysis • Do not use fundal pressure

22. Rubin Technique

23. Key points • Move to the side of the bed opposite of the infant’s face • Instruct the mother to stop pushing • Apply firm pressure on the backside of the infant’s anterior shoulder and shove in the direction of the infant’s face – Decreases shoulder to shoulder diameter • Note: Applying pressure in front of the anterior shoulder and shoving in the opposite direction of the infant’s face increases the shoulder to shoulder diameter up to 2 cm

24. Suprapubic 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)

25. 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.)

26. Woods’ Corkscrew Maneuver • 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 !!

27. 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.)

28. Delivery of the Posterior Arm • Sweep the fetal forearm down over the front of the chest.

29. 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.

30. When All Else Fails... • The Rubin Maneuver • The Chavis Maneuver • The Hibbard Maneuver • Fracture of the Clavicle / Cleidotomy • The Zavanelli Maneuver • Symphysiotomy

31. 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.

32. 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.

33. 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.

34. The 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.

35. 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.

36. 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.

37. The Zavanelli Maneuver • First described in 1988 • Consists of cephalic replacement and then cesarean delivery. • Mixed reviews in the literature.

38. ... Don’t 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.

39. Complications Associated with Symphysiotomy • Vesicovaginal Fistula • Osteitis Pubis • Retropubic Abscess • Stress Incontinence • Long Term Walking Disability / Pain

40. Although shoulder dystocia represents a catastrophic event in obstetrics, a well-reasoned 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.

41. Can Cesarean Sections for Suspected Macrosomia Reduce the Rates of Shoulder Dystocia? • No • 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)

42. 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 McRobert’s 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

43. 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