Shoulder Dystocia

SHOULDER SHOULDER DYSTOCIA (Sh.D)DYSTOCIA (Sh.D)An Evidence Based An Evidence Based

ApproachApproachDr.Mohamed El Sherbiny

MD Obstetrics&Gynecology Senior Consultant

Damietta General HospitalDamietta Egypt

SHOULDER DYSTOCIA

Evidence Based Sources:

PubMed

Cochrean libraryACOG Issues Guidelines

National Guideline Clearinghouse

Definition:Shoulder dystocia (Sh. D) is the

inability to deliver the fetal shoulders after delivery of the head, without the aid of specific maneuvers (ie. other than gentle downward traction on the head) .

Spong et al. 1995; Beal et al 1998 ; Bruner 1998

DefinitionDefinitionObjective definition :Objective definition :

Mean head-to-body

delivery time > 60 seconds

Spong et al. 1995; Beal et al 1998 ; Bruner 1998

As operative vaginal delivery of

malposition and malpreresntation

has declined, Sh.D has emerged as

one of the more important clinical

and medico-legal complications of

vaginal delivery

Baskett, 2001

Shoulder dystocia

will still the obstetric

nightmare

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Shoulder dystocia results from a size discrepancy between the

fetal shoulders and the pelvic inlet when:

1. The bisacromial diameter is large relative to the biparietal diameter

2. Pelvic prim is flat rather than gynecoid

.

Types of Shoulder Types of Shoulder DystociaDystocia

Types of Shoulder Types of Shoulder DystociaDystocia

1- High Shoulder Dystocia1- High Shoulder Dystocia

2-Low Shoulder Dystocia2-Low Shoulder Dystocia

1- High Shoulder Dystocia1- High Shoulder Dystocia

2-Low Shoulder Dystocia2-Low Shoulder Dystocia

• Both shoulders fail to engage

(Bilateral Sh.D). (Rare)

• More common with mid -pelvic assisted delivery

• This presentation often requires a cephalic replacement. (The most difficult)

11 - -HighHigh Shoulder DystociaShoulder Dystocia

A)A) Failure of engagement Failure of engagement of the anterior of the anterior shoulder (Unilateral shoulder (Unilateral Sh.D).Sh.D). ,The commonest:

Usually easily dealt with by Standard techniques

2-Low Shoulder Dystocia

IncidenceIncidence

Varies according to:

1. Criteria for diagnosis.

2. Prophylactic manoeuvre done

Subjective: 0.6-1.6%

Objective: Much lower

ACOG Bulletin,22, Novamber2000

Release techniques

1.Maternal

2.Fetal

Complications of Sh DComplications of Sh D

1. Postpartum hemorrhage 11%

2. Vaginal laceration 19%

3. Perineal tears 2nd&3rd 4%

4. Cervical laceration 2%

Maternal Complications Maternal Complications (25%)(25%)

The largest study (285 cases) Gherman et al Am J Obstet Gynecol176:656, 1997

Release techniquesFetal Complications of Sh DFetal Complications of Sh D

Injuries are a common outcome associated with shoulder

dystocia and may occur despite use of proper standard obstetric

manoeuvers

ACOG practice 1997 (B: II-2)

Fetal Complications of Sh DFetal Complications of Sh D

Brachial plexus injuries,

Fractures of the humerus, and

Fractures of the clavicle

are the most commonly reported injuries associated with shoulder

dystocia ACOG practice 1997 (A: II-2)

Fetal Complications of Sh DFetal Complications of Sh D

Traction combined with fundal pressure has been

associated with a high rate of brachial plexus injuries

and fracturesACOG practice 1997 (B: II-2)

Fetal Complications of Sh DFetal Complications of Sh D

Fewer than 10% of deliveries complicated by shoulder dystocia will result in brachial

plexus injury. ACOG practice 1997(A: II-2)

Fetal Complications of Sh DFetal Complications of Sh D

a persistenta persistent

Release techniques

Head –shoulder interval > 7min.

Brain injuryBrain injury

• With hypoxic fetus it is much shorter

Fetal ComplicationsFetal Complications

Quzounian et al Am J Obstet Gynecol 178;S76, 1998

(sensitivity & specificity :70 %)

Can shoulder dystocia be predicted?

RISK FACTORS FOR SHOULDER RISK FACTORS FOR SHOULDER DYSTOCIADYSTOCIA

PRECONCEPTIONAL:1. Maternal birth weight2. Prior shoulder dystocia 12%3. Prior macrosomia4. Pre-existing diabetes5. Obesity6. Multiparity7. Prior gestational diabetes8. Advanced maternal age

O'Leary &, Leonetti; 1990

RISK FACTORS FOR SHOULDER RISK FACTORS FOR SHOULDER DYSTOCIADYSTOCIA

Antenatal:Antenatal:• Excessive maternal weight gain

• Macrosomia

• G. diabetes

• Short stature

• Post term

O'Leary &, Leonetti; 1990

RISK FACTORS FOR SHOULDER DYSTOCIA

Intrapartum:Intrapartum:1. Protracted or arrested active phase

2. Protracted or failure of descent of head

3. Need for midpelvic assisted delivery

Hopwood,1982 ; Baskett &,Allen, 1995

RISK FACTORS FOR SHOULDER DYSTOCIA

Most of the prenatal and antenatal risk

factor are interrelated with fetal

macrosomia. So the main risk factor is:

Fetal

Macrosomia

MacrosomiaMacrosomia

Acker et al, Obst. Gynecol 66:762, 1985 Baskett &Allen Obstet Gynecol 86:14, 1995

Although macrosomia is clearly the main risk

factor,

50-60 % of Shoulder

Dystocia are of < 4 Kg !!

PredictionPrediction

Most cases of shoulder dystocia Most cases of shoulder dystocia

because because

accurate methods for identifying accurate methods for identifying

which fetuses will experience this which fetuses will experience this

complication complication do not existdo not exist, ., .

ACOG Practice 1997 (B: II-2).

cannot be predictedcannot be predicted

Fetal body configuration may be more important than macrosomia per se

MacrosomiaMacrosomia

Greater shoulder /head circumference:

1.Infant of diabetic mother

2.Post term (21% at 42 weeks)

Non Diabetic+ vacuum . Diabetic or forceps

DiabeticWight (Kg)

4 : 4.25 5.2% 8.4% 12.2%

4.25: 4.5 9.1% 12.3% 16.7%

4.5 : 4.75 14.3% 19.9% 27.3%

4.75: 5 21.1% 23.5% 34.8%

Nesbitt et al, Am J Obstet Gynecol 179;476, 1998

Macrosomia And Shoulder Dystocia

UnfortunatelyUnfortunately • The diagnosis of fetal macrosomia is

imprecise.

• For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold's manoeuver).

ACOG Issues Guidelines on Fetal Macrosomia 2000ACOG Issues Guidelines on Fetal Macrosomia 2000(Level :A)

Can shoulder dystocia be Prevented ?

MacrosomiaThere are 2 controversial

prophylactic measures1-Prophylactic labor

induction

2-Elective CS

Induction of Labor

Suspected fetal macrosomia is not an indication for induction

of labor, because induction does not improve maternal or

fetal outcomes.

.ACOG Issues Guidelines on Fetal Macrosomia 2000ACOG Issues Guidelines on Fetal Macrosomia 2000(Level B):

Labor induction for suspected fetal macrosomia results in an

increased CS delivery rate without improving perinatal

outcomes.

.

Sanchez-Ramos Obstet Gynecol Systemic Review November 2002:100:997-1002

Induction of Labor

There is very little evidence to support either elective delivery or expectant

management at term.

A single randomized controlled trial A single randomized controlled trial suggest that induction of labor in GDM suggest that induction of labor in GDM treated with insulin reduces the risk of treated with insulin reduces the risk of

macrosomia.macrosomia.

Boulvain et al:Cochrane Review,2001. In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.

Induction For Gestational DiabetesInduction For Gestational Diabetes

Planned cesarean delivery on the basis of suspected macrosomia in the general

population is not a reasonable strategy because the number and cost of

additional cesarean deliveries required to prevent one permanent injury is

excessiveACOG 1997 (B: II-2).

Prevention of Sh. D. : Prevention of Sh. D. : c.sc.s..

Furthermore 3%Furthermore 3% of of brachial plexus injurybrachial plexus injury

are associated with are associated with C.S.C.S.

When is When is CSCS

recommended in recommended in

macrosomiamacrosomia?

ACOG Issues Guidelines on Fetal ACOG Issues Guidelines on Fetal Macrosomia Macrosomia 2000 2000

Prophylactic CS may be considered for suspected fetal macrosomia with estimated fetal weights of:

.(Level :C)

<5,000 g in non diabetic women

<4,500 g in diabetic women

ACOG Issues Guidelines on Fetal ACOG Issues Guidelines on Fetal Macrosomia Macrosomia 2000 2000

With an estimated fetal weight more than 4,500 g, with :

• A prolonged second stage of labor

or

• Arrest of descent in the second stage

It is an indication for It is an indication for CSCS delivery. delivery.

.Level B

MANAGEMENT

.

(Within5- 7 minutes)

ManagementManagement1-Suprapubic pressure2-McRobert manoeuver3- Woods corkscrew .4-Rubens manoeuver5-Delivery of P. shoulder6-Zavanelli7-All fours8-Cleidotomy9-symphysiotomy

ACOG Issues Guidelines ACOG Issues Guidelines Recommendation 1991 Recommendation 1991

1-Call for help: assistants, anesthesiologist

2-Initial gentle attempt of traction.

3-Generous episiotomy.4-Suprapubic pressure.

ACOG Issues Guidelines ACOG Issues Guidelines Recommendation 1991Recommendation 1991

.

5-The Mc Roberts manoeuvre

(Exaggerated hyper flexion of the thighs

upon the abdomen.) &

Suprapubic pressure in the direction of the

Foetal face

No increase in pelvic dimensions.

Decrease in the angle of pelvic inclination P=0.001

Straightening of the sacrum P= 0.04%

Tends to free the impacted anterior shoulder

Gherman et al Obstet Gynecol 95:43 ,2000

McRoberts manoeuvre: X ray pelvimetry study

IU pressure by 97% (P<0.0001)

U. contraction amplitude by 25% (P<0. 001)

Applied additional 31 Newtons pushing force

Buhimschi et al Lancet 358:470 ,2001

Mc Roberts manoeuvre

ACOG Issues Guidelines ACOG Issues Guidelines Recommendation 1991 Recommendation 1991

.

If Mc Roberts failed:If Mc Roberts failed:

6-Woods manoeuvre6-Woods manoeuvre::

•The hand is placed

behind the posterior

shoulder of the fetus.

•The shoulder is rotated progressively 180 d in a corkscrew manner so that the impacted anterior shoulder is released.

ACOG Issues Guidelines ACOG Issues Guidelines Recommendation 1991Recommendation 1991

.

7-Delivery of the posterior arm :

By inserting a hand into the posterior

vagina and ventrally rotating the arm at

the shoulder

delivery over the perineum

ACOG Issues Guidelines ACOG Issues Guidelines Recommendation 1991 Recommendation 1991

.

8-Other techniques include:

1.Intentional fracture of the clavicles or the humerus Or

2.Zavanelli Maneuver.

The Zavanelli ManoeuverThe Zavanelli Manoeuver

Reversing the mechanism of

delivery of the vertex under tocolytic

1. The head first manually rotated to the occipito anterior

(Pre-restitution) position

2.Flexion of the head, Returning it to the vagina with upward constant firm pressure, followed by CS

Zavanelli maneuver

• It would usually only be applicable in those rare cases of bilateral Sh.D.

• It involves an emergency procedure that is not without risks of its own .

• It has minimal applicability as it needs

Immediate CS

The Zavanelli ManoeuverThe Zavanelli Manoeuver

Zavanelli maneuver

In an analysis of 92 cases of shoulder dystocia managed by Zavanelli Maneuver:

• Success rate : 92 %• Stillbirth: 7%• Neonatal death : 9%.• Brain damage : 11%

Maternal complication: Rupture uterus ,vaginal rupture ,severe infection,

The Zavanelli Manoeuver

Sanberg; Obstet Gynecol.;93:312. 1999

All- Fours Manoeuver All- Fours Manoeuver It consists of placing the patient onto It consists of placing the patient onto

her hands and knees her hands and knees

• It allows rotational movement of the sacroiliac joints resulting in a l-cm to 2-cm increase in the sagittal diameter of the pelvic outlet. • It disimpact the shoulders, and allowing it to slide over the sacral promontory.•Effective also for bilateral Sh.D.

All- Four ManoeuverAll- Four Manoeuver

All- Fours ManoeuverAll- Fours ManoeuverIn an analysis of 82 cases of shoulder dystocia managed by all-four manoeuver :

• Success rate : 83%

• Maternal complications 1.2%

•Neonatal complications : 4.9%,

•Time for complete delivery : 2 to 3 Ms.

Drummond et al. J Reprod Med. ;43:439; 1998.

Release techniques

There is no evidence that any one maneuver is superior to

another in releasing an impacted shoulder or

reducing the chance of injury.

)B: II-2.(

ACOG Issues Guidelines 1997ACOG Issues Guidelines 1997

Release techniques

However, the Mc Roberts maneuver is easily facilitated and has a high success rate

without an associated increased risk of injury to the

newborn )B: II-2.(

ACOG Issues Guidelines 1997ACOG Issues Guidelines 1997

Bilateral Shoulder ImpactionsBilateral Shoulder Impactions

Zavanelli Manoeuver:Used if the patient has received epidural

analgesia or heavy analgesia with obstetric facilities for emergency CS

All- Fours Manoeuver:Used at all circumstances except if the

patient has received epidural analgesia,

heavy analgesia or anesthesia

Prophylactic ProceduresProphylactic Procedures

When shoulder dystocia is When shoulder dystocia is

anticipated , prophylactic anticipated , prophylactic

McRobert positionMcRobert position is is

recommendedrecommended

Shoulder Dystocia Drill

Shoulder dystocia drill should be as important as CPR for the mother and neonate.

This should be taught and practiced regularly, by all staff involved with delivery

Thank You

Thank You