Shoulder dystocia 2016

SHOULDER DYSTOCIA

GOALS

1. To learn how to diagnose & manage shoulder dystocia

2. Steps to prevent fetal asphyxia while avoiding physical injury

3. Documentation & risk management to reduce obstetric litigation

DEFINITION

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

Occurs when the breadth of the shoulder is greater than the biparietal diameter of the head.

Shoulder dystocia remains one of the most dreaded obstetric complications and one that is often unanticipated.

It is one of the primary causes of perinatal mortality and morbidity, maternal morbidity and a costly source of litigation.

One must be prepared for the possibility of shoulder dystocia in all deliveries, and have a prepared plan of management.

IT CANNOT BE PREVENT

ANDIT CANNOT BE PREDICT ED!!

1:500 deliveries Predisposing factors includes large babies,

maternal diabetes, prolonged pregnancy, short stature, instrumental deliveries, previous shoulder dystocia

Up to 10 minutes to dislodge shoulder Call for experienced staff and assistants stat

OBSTETRIC EMERGENCIES!!

**However, most cases occur without risk factors. Therefore, all clinicians need to be prepared for unexpected shoulder dystocia at all deliveries **

EARLY DETECTION

“Head bobbing": the head coming down towards the introitus with pushing, but retracting back between contraction

“Turtle sign at delivery": The delivered head becomes tightly pulled back against the perineum

COMPLICATIONSMATERNAL Perineal trauma Uterine atony Uterine rupture PPH

FETUS Brachial plexus

injury Clavicle or humerus

fracture Neurological deficit /

HIE Death

H- Call for HELP!!!E- EpisiotomyL- Leg in Mc Robert’s PositionP- Suprapubic pressureE- Enter Wood’s screw manouevereR- Removal of posterior armR- Roll overR- Repeat all method

Shoulder Dystocia: The drill

McRobert’s position

Suprapubic pressure

•Hyperflex the hips

•Abduct the hips

·Flex the knees

Preferably done with 2 assistant, each at both sides of the patientThe direction of pushing should be in the direction of where the baby is facing

COCKSCREW Maneuvreanal.

Deliver The Posterior Arm

Flex the forearm at the elbow if the forearm is extended.

Deliver the arm by sweeping it across the chest and face.

ROLL OVER This position is called “on all-fours”, knee-chest position or hands-and-knee position.

REPEAT Repeat the above

procedures from McRoberts maneuver

If the above maneuvers are unsuccessful, all maneuvers may be tried again.

The order is which each and the entire manoeuvre is attempted may be revised.

IF ALL PROCEDURES FAIL……. Symphysiotomy – cutting the symphysis

pubis to allow delivery of the anterior shoulder

Clavicular fracture (@cleidotomy) – allows further adduction of the fetal shoulder, reducing the diameter of the shoulders, thus allowing delivery

Zavanelli maneuvre – push the baby’s head back into the uterus and proceed with Em. caesarean

POST DELIVERY

Watch-out for complications Counseling for both patient and partner Documentation

- Accurate & comprehensive- Important to document which fetal shoulder was

anterior

QUESTIONS??