Shoulder Dystocia

1
Shoulder Dystocia

• District 1 ACOG Medical Student Education Module
  2008

2
Definition

• Difficulty in delivery of fetal shoulders
• Failure to deliver fetal shoulder without
  utilizing facilitating maneuvers
• Prolonged head-to-body delivery time
• gt60 seconds
• Incidence 0.2-3 of all live births

3
(No Transcript)
4
Pathophysiology

• Size discrepancy between fetal shoulders and
  maternal pelvic inlet
• Macrosomia
• Large chestBPD
• Absence of truncal rotation
• Fetal shoulders remain A-P or descent
  simultaneously

5
Risk Factors

• Antepartum
• Macrosomia (gt4500g)
• DM/GDM (increases overall risk by 70)
• Multiparity
• Intrapartum
• Prolonged deceleration phase of labor
• Prolonged 2nd stage
• Protracted descent
• Operative delivery (vacuumgtforceps)

6
Risk factors cont

• No evidence based data
• Male
• AMA
• short maternal stature
• abnormal pelvic shape/size

7
Unpredictable

• 25-50 have no defined risk factor!
• 50 of cases occur in infants whose birth weight
  is lt4000g
• 84 of patients did not have prenatal dx. of
  macrosomia by US
• 82of infants with brachial plexus palsy did not
  have macrosomia

8
Complications

• Maternal
• Hemorrhage
• 4th degree laceration
• Fetal
• Fx of humerus or clavicle
• Brachial plexus injury (Erbs/Klumpkes palsy)
• Asphyxia/cord compression
• Physician
• Litigation 11 of all obstetrical suits

9
(No Transcript)
10
Management

• Goal safely deliver infant before asphyxia
  and/or cortical injury
• 7 minutes!!!
• Episiotomy
• Suprapubic Pressure
• McRoberts Maneuver
• Woods or Rubin Maneuvers
• Zavenelli

11
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

12
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

13
Prophylactic C/S?

• Not recommended by ACOG
• Exceptions
• Consider if
• gt5000g in mother without DM
• gt4500g in mother with DM