Shoulder Dystocia Making the Best of a Bad Situation

1
Shoulder DystociaMaking 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

2
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.

3
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.

4
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

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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

6
Maternal Complications

• Postpartum Hemorrhage
• Vaginal Lacerations
• Cervical Lacerations
• Puerperal Infection

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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.

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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

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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.

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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!!!

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The Principle Maneuvers

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

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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.)

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Unilateral Shoulder Dystocia

• Unilateral shoulder dystocia is usually
  easilydealt with by standard techniques. (B.
  Harris, Shoulder dystocia. Clinical
  Obstetricsand Gynecology, 1984l 27106)

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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 (gt45 degrees) is to be
  avoided.

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

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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)
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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 27106.)

(B.Harris, Shoulder dystocia, Clinical Obstetrics
and Gynecology, 1984 27106.)
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Woods Corkscrew Maneuver

• Delivery may be facilitated by counterclockwisero
  tation 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 !!

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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.)
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Delivery of the Posterior Arm

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

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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.

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When All Else Fails...

• The Rubin Maneuver
• The Chavis Maneuver
• The Hibbard Maneuver
• Fracture of the Clavicle / Cleidotomy
• The Zavanelli Maneuver
• Symphysiotomy

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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.

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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.

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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.

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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.

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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.

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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.

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The Zavanelli Maneuver

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

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... 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.

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Conclusions

• 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.

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Addendum to Lecture
33
Although half of shoulder dystocias occur in
infants weighing less than 4000 gms. The
incidence of shoulder dystocia is directly
related to fetal size.
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Complications Associated with Symphysiotomy

• Vesicovaginal Fistula
• Osteitis Pubis
• Retropubic Abscess
• Stress Incontinence
• Long Term Walking Disability / Pain

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

• Sensitivity of clinical estimates of BW gt 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 gt 4500 gms)

A NO
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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
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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