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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