Shoulder Dystocia Quick Facts
PB178
Shoulder dystocia = failure to deliver the fetal shoulder/s with gentle
downward traction on the fetal head, requiring additional obstetric
maneuvers to effect delivery (occurs in 0.2-3% of deliveries) *turtle
sign is predictive but not diagnostic
*can be anterior shoulder impacted
by symphysis or posterior shoulder impacted by sacral promontory
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Complications:
o
Maternal: PPH, perineal lacerations and anal sphincter
injuries, symphyseal separation, lateral femoral cutaneous neuropathy
related to extreme hyperflexion
o
Fetal: brachial plexus injuries, clavicle/humerus
fractures, very rarely hypoxic-ischemic encephalopathy and death It
should be noted that a
significant % of brachial plexus injuries are not associated with
dystocia, occurring either during uncomplicated vaginal delivery or
cesarean delivery.
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Risk Factors: increased birth weight, maternal diabetes,
h/o shoulder dystocia (NOT obesity, excessive maternal weight gain,
oxytocin use,
operative delivery, epidural use, precipitous or prolonged
2nd
stage, multiparity, fetal AC:BPD)
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Recurrence: ~10% (underestimated as some women will have
elective C/S next pregnancy)
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Management:
o
Note the time when shoulder dystocia was diagnosed
o
Request additional nursing, providers and anesthesia
o
Instruct patient not to push, position patient
appropriately for optimal access
o
If traction is used, it should be axial, in alignment with
the fetal cervico-thoracic spine…typically has a downward component
25-45 degrees
below the
horizontal plane when patient is in the dorsal lithotomy position.
o
Attempt McRobert’s maneuver first = sharp flexion of
maternal thighs against the abdomen to rotate the symphysis cephalad and
flatten the lumbar lordosis.
Can be done in
conjunction with suprapubic pressure = pressure above the maternal pubic
bone to direct the fetal anterior shoulder downward and medially towards
its face.
o
Attempt posterior arm delivery next (will relieve 95% of
dystocias within 4 minutes, less force required and fewer branchial
plexus injuries compared to other maneuvers)
o
Attempt “rotational maneuvers” next Rubin = hand on back
surface (scapula) of fetal posterior shoulder, rotate anteriorly toward
fetal face -> decreases bisacromial diameter and rotates
Wood Screw = hand on front surface (clavicle) of fetal posterior
shoulder, rotate posteriorly toward fetal spine -> only rotates
o
Other methods include…Gaskins – patient on all-fours, try
all of the above maneuvers in this position Posterior axilla sling
– soft
catheter around posterior arm, steady traction Zavenelli – cephalic
replacement followed by C/SAbdominal rescue
– laparotomy
and hysterotomy to manually dislodge anterior shoulder and effect
vaginal deliveryClavicular fracture – may decrease bisacromial diameter
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Documentation: critical for informing patient and their future
providers, should include counseling re: future risks
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Simulation: increases evidence-based management and
decreases branchial plexus injury
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