Shoulder Dystocia

Shoulder DystociaShoulder Dystocia“Making the Best of a Bad “Making the Best of a Bad

Situation”Situation”

Chukwuma I. Onyeije, M.D.Chukwuma I. Onyeije, M.D.Director of Obstetrics and Perinatal Director of Obstetrics and Perinatal

ServicesServices

North Central Bronx HospitalNorth Central Bronx Hospital

Albert Einstein College of MedicineAlbert Einstein College of Medicine

IncidenceIncidence

Varies widely based on criteria used for Varies widely based on criteria used for diagnosis.diagnosis.

Gross et al, Toronto General Hospital - 1987 Gross et al, Toronto General Hospital - 1987 • 0.9 Percent based on coding0.9 Percent based on coding• 0.2 Percent based on use of maneuvers0.2 Percent based on use of maneuvers

Acker et al 1986Acker et al 1986• 2 Percent based on assessment of operator2 Percent based on assessment of operator

Incidence appears to be increasing as Incidence appears to be increasing as birthweights increase.birthweights increase.

Definition and DiagnosisDefinition and Diagnosis

““Difficulty encountered in the Difficulty encountered in the delivery of the fetal shoulders after delivery of the fetal shoulders after delivery of the head.” delivery of the head.”

Due to impaction of the fetal Due to impaction of the fetal shoulder behind the symphysis shoulder behind the symphysis pubis.pubis.

Risk FactorsRisk Factors

ANTEPARTUM FACTORSANTEPARTUM FACTORS Maternal ObesityMaternal Obesity Maternal Diabetes Maternal Diabetes

MellitusMellitus Postterm PregnancyPostterm Pregnancy Excessive Weight Excessive Weight

GainGain

INTRAPARTUM INTRAPARTUM FACTORSFACTORS

Prolonged Second Prolonged Second Stage of LaborStage of Labor

Oxytocin InductionOxytocin Induction Midforceps and Midforceps and

Vacuum ExtractionVacuum Extraction

Remember, many cases of shoulder dystocia occur with no readily identified risk factors!!!!

Fetal ComplicationsFetal Complications

Fetal Fractures - Fetal Fractures - • In 18 to 25% of casesIn 18 to 25% of cases

Erb’s Palsy - Erb’s Palsy - • Although 80% will resolve by 18 Although 80% will resolve by 18

monthsmonths Perinatal Asphyxia - UncommonPerinatal Asphyxia - Uncommon Neonatal Death - RareNeonatal Death - Rare

Maternal ComplicationsMaternal Complications

Postpartum HemorrhagePostpartum HemorrhageVaginal LacerationsVaginal LacerationsCervical LacerationsCervical LacerationsPuerperal InfectionPuerperal Infection

Management of Shoulder Management of Shoulder DystociaDystocia

Know the Drill!Know the Drill!

CALL FOR HELPCALL FOR HELP

REMAIN CALMREMAIN CALM

CALL FOR HELPCALL FOR HELP

REMAIN CALMREMAIN CALMOh, and by the way, don’t forget to call for Oh, and by the way, don’t forget to call for

help.help.

Individuals who MUST be present Individuals who MUST be present in the room if shoulder dystocia is in the room if shoulder dystocia is anticipated or encounteredanticipated or encountered• Attending physicianAttending physician• AnesthesiologistAnesthesiologist• PediatricianPediatrician• Nursing StaffNursing Staff• ““Extra Hands”Extra Hands”

Management of Shoulder Management of Shoulder DystociaDystocia

Who’s the Boss?Who’s the Boss?

It is important that the conduct of It is important that the conduct of any shoulder dystocia be managed any shoulder dystocia be managed by the most experienced person in by the most experienced person in the room.the room.

This individual ( generally the This individual ( generally the attending physician) must have the attending physician) must have the ability to intervene at any time and ability to intervene at any time and should be the only one giving orders.should be the only one giving orders.

Preliminary StepsPreliminary Steps

Call for help and have the team Call for help and have the team assembledassembled

Drain the bladderDrain the bladder Perform a generous episiotomyPerform a generous episiotomy TAKE YOUR TIME, THIS IN AN TAKE YOUR TIME, THIS IN AN

EMERGENCY, BUT IT IS NOT A EMERGENCY, BUT IT IS NOT A RACE!!!RACE!!!

The Principle ManeuversThe Principle Maneuvers

Gentle Traction (?)Gentle Traction (?)McRoberts ManeuverMcRoberts ManeuverSuprapubic PressureSuprapubic PressureWoods’ Corkscrew ManeuverWoods’ Corkscrew ManeuverDelivery of the Posterior ArmDelivery of the Posterior Arm

Bilateral Shoulder Bilateral Shoulder DystociaDystocia

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.)

Unilateral Shoulder Unilateral Shoulder DystociaDystocia

Unilateral shoulder dystocia is usually easilydealt with by standard techniques. (B. Harris, Shoulder dystocia. Clinical Obstetricsand Gynecology, 1984l 27:106)

Preliminary Measures: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 (>45 degrees) is to be avoided.

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

McRobert’s ManeuverMcRobert’s Maneuver

Marked flexion of the maternal Marked flexion of the maternal thighs unto the abdomenthighs unto the abdomen

Decreases the angle of pelvic Decreases the angle of pelvic inclinationinclination

Cephalic rotation of the pelvis Cephalic rotation of the pelvis frees the anterior shoulderfrees the anterior shoulder

Suprapubic PressureSuprapubic 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)

Woods’ Corkscrew Woods’ Corkscrew ManeuverManeuver

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; 27:106.)

(B.Harris, Shoulder dystocia, Clinical Obstetrics and Gynecology, 1984; 27:106.)

Delivery may be facilitated by counterclockwiserotation 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 !!

Woods’ Corkscrew Woods’ Corkscrew ManeuverManeuver

Delivery of the Posterior Delivery of the Posterior ArmArm

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.)

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


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.


When All Else Fails...When All Else Fails...

The Rubin ManeuverThe Rubin Maneuver The Chavis Maneuver The Chavis Maneuver The Hibbard ManeuverThe Hibbard Maneuver Fracture of the Clavicle / Fracture of the Clavicle /

CleidotomyCleidotomy The Zavanelli ManeuverThe Zavanelli Maneuver SymphysiotomySymphysiotomy

The Rubin ManeuverThe Rubin Maneuver

Step 1: The fetal shoulders are Step 1: The fetal shoulders are rocked from side to side by applying rocked from side to side by applying force to the maternal abdomen.force to the maternal abdomen.

Step 2: If step one is not successful, Step 2: If step one is not successful, push the presenting fetal shoulder push the presenting fetal shoulder toward the chest. This will often toward the chest. This will often cause abduction of both shoulders cause abduction of both shoulders and create a smaller shoulder to and create a smaller shoulder to shoulder diameter.shoulder diameter.

The Chavis ManeuverThe Chavis Maneuver

Described in 1979.Described in 1979. A “shoulder horn” consisting of a A “shoulder horn” consisting of a

concave blade with a narrow handle concave blade with a narrow handle is slipped between the symphysis and is slipped between the symphysis and the impacted anterior shoulder.the impacted anterior shoulder.

This used like a shoe-horn as a lever This used like a shoe-horn as a lever where the symphysis is the fulcrum.where the symphysis is the fulcrum.

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.

The Hibbard ManeuverThe 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.

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.


Fracture of the ClavicleFracture of the Clavicle

The anterior clavicle is pressed The anterior clavicle is pressed against the ramis of the pubis.against the ramis of the pubis.

Care should be taken to avoid Care should be taken to avoid puncturing the lung by angling the puncturing the lung by angling the fracture anteriorly.fracture anteriorly.

Theoretically, a fracture of the Theoretically, a fracture of the clavicle is less serious than a brachial clavicle is less serious than a brachial nerve injury and often heals rapidly.nerve injury and often heals rapidly.

The Zavanelli ManeuverThe Zavanelli Maneuver

First described in 1988First described in 1988 Consists of cephalic replacement Consists of cephalic replacement

and then cesarean delivery.and then cesarean delivery. Mixed reviews in the literature.Mixed reviews in the literature.

... Don’t Even Think About ... Don’t Even Think About It...It...

Symphysiotomy is a dangerous Symphysiotomy is a dangerous procedure with substantial risk to procedure with substantial risk to maternal health and well being.maternal health and well being.

It is difficult to justify this It is difficult to justify this procedure for shoulder dystocia in procedure for shoulder dystocia in modern medicine.modern medicine.

ConclusionsConclusions

Although shoulder dystocia represents Although shoulder dystocia represents a catastrophic event in obstetrics, a a catastrophic event in obstetrics, a well-reasoned plan of action with well-reasoned plan of action with adequate support and skilled adequate support and skilled personnel can reduce fetal morbidity.personnel can reduce fetal morbidity.

Proper patient selection and Proper patient selection and awareness of risk factors for shoulder awareness of risk factors for shoulder dystocia can also reduce morbidity.dystocia can also reduce morbidity.

Addendum to LectureAddendum to Lecture

0.2%

1.7%

10.0%

0.0%1.0%

2.0%3.0%

4.0%5.0%

6.0%7.0%8.0%

9.0%10.0%

BW 2500 to 4000 gms BW 4000 to 4500 gms BW > 4500 gms

Although half of shoulder dystocias occur in infants weighing less than 4000 gms…. The incidence of shoulder dystocia is directly related to fetal size.

Complications Associated Complications Associated with Symphysiotomywith Symphysiotomy

Vesicovaginal FistulaVesicovaginal Fistula Osteitis PubisOsteitis Pubis Retropubic AbscessRetropubic Abscess Stress IncontinenceStress Incontinence Long Term Walking Disability / PainLong Term Walking Disability / Pain

Sensitivity of clinical estimates of BW > Sensitivity of clinical estimates of BW > 4500 gms is only 20%4500 gms is only 20%

USG is not very accurate at extremes of USG is not very accurate at extremes of EFWEFW

Most cases of shoulder dystocia occur in Most cases of shoulder dystocia occur in infants of average weightinfants of average weight

The incidence of birth trauma in large The incidence of birth trauma in large infants is not trivialinfants is not trivial• (2.5% with BW > 4500 gms)(2.5% with BW > 4500 gms)

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

A: NO

Top Reasons for Successful Claims Top Reasons for Successful Claims Against Obstetricians in Cases of Against Obstetricians in Cases of Shoulder DystociaShoulder Dystocia

Inappropriate obstetrical delivery notesInappropriate obstetrical delivery notes Absence of delivery notesAbsence of delivery notes Failure to document the dystociaFailure to document the dystocia Failure to document use of McRobert’s Failure to document use of McRobert’s

maneuvermaneuver Lack of prenatal documentation or follow-Lack of prenatal documentation or follow-

up ofup of• Abnormal or borderline GTTAbnormal or borderline GTT• Unexpected large maternal weight gain.Unexpected large maternal weight gain.

Harvard Risk Management Foundation (1994)

www.rmf.org

Things To Do After Dystocia Things To Do After Dystocia OccursOccurs

Check for and treat reproductive tract injuriesCheck for and treat reproductive tract injuries Pediatric neurology and neonatology consultationPediatric neurology and neonatology consultation Document a detailed delivery note, including maneuvers Document a detailed delivery note, including maneuvers

used used Explain the occurrence of dystocia to the parents of the Explain the occurrence of dystocia to the parents of the

infantinfant Do not finger-pointDo not finger-point Be truthful, but avoid discrepancies in notes by doctors, Be truthful, but avoid discrepancies in notes by doctors,

midwives and nurses.midwives and nurses.

Harvard Risk Management Foundation (1994)

www.rmf.org

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Shoulder Dystocia