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Shoulder Dystocia

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Information about Shoulder Dystocia

Published on March 10, 2009

Author: devender1

Source: slideshare.net

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Shoulder Dystocia Dr. Devender Kumar

Introduction Deliveries requiring maneuvers to deliver shoulder, in addition to downward traction (lateral flexion) and episiotomy Head – body delivery time exceeding 60secs* Mean 24 secs Shoulder dystocia 79 secs *Spong et al. Obstet Gynecol, 86; 433, 1995

Deliveries requiring maneuvers to deliver shoulder, in addition to downward traction (lateral flexion) and episiotomy

Head – body delivery time exceeding 60secs*

Mean 24 secs

Shoulder dystocia 79 secs

Incidence 0.6 – 1.4% (ACOG 2002) Maternal Intrapartum Fetal Risk factors

0.6 – 1.4% (ACOG 2002)

Maternal

Intrapartum

Fetal

Maternal risk factors Obesity GDM (7%) Post-term Multiparity Prior h/o shoulder dystocia

Obesity

GDM (7%)

Post-term

Multiparity

Prior h/o shoulder dystocia

Intrapartum risk factors Low mid cavity forceps delivery Prolong / protracted first and second stage LGA

Low mid cavity forceps delivery

Prolong / protracted first and second stage

LGA

Fetal risk factors Macrosomia Anencephaly USG markers for neck fold thickness

Macrosomia

Anencephaly

USG markers for neck fold thickness

Diagnosis Prolong second stage or delay in head delivery EFW >4kgs

Prolong second stage or delay in head delivery

EFW >4kgs

ACOG 2002 (USPSTF based) Most cases of shoulder dystocia cannot be predicted or prevented Elective induction of labor or elective LSCS for all women suspected of carrying a macrosomic fetus is not appropriate Planned LSCS may be considered for the non diabetic women carrying a fetus with EFW exceeding 5kgs or the diabetic woman whose fetus is estimated to weigh more than 4.5kgs.

Most cases of shoulder dystocia cannot be predicted or prevented

Elective induction of labor or elective LSCS for all women suspected of carrying a macrosomic fetus is not appropriate

Planned LSCS may be considered for the non diabetic women carrying a fetus with EFW exceeding 5kgs or the diabetic woman whose fetus is estimated to weigh more than 4.5kgs.

Management Must do Bladder should be empty Liberal episiotomy Gentle traction with maternal expulsive efforts Maneuvers Moderate suprapubic pressure Other maneuvers

Must do

Bladder should be empty

Liberal episiotomy

Gentle traction with maternal expulsive efforts

Maneuvers

Moderate suprapubic pressure

Other maneuvers

McRobert’s maneuver Acute flexion and abduction of thighs Reduces the angle of pelvic inclination by 10degree Straightens the pelvic curve Suprapubic pressure On ant shoulder of fetus and press posteriorly to cause adduction Posterior traction on fetal head

Acute flexion and abduction of thighs

Reduces the angle of pelvic inclination by 10degree

Straightens the pelvic curve

Suprapubic pressure

On ant shoulder of fetus and press posteriorly to cause adduction

Posterior traction on fetal head

Wood’s corkscrew 180 degree shoulder rotation of posterior shoulder Delivery of posterior shoulder

180 degree shoulder rotation of posterior shoulder

Delivery of posterior shoulder

Delivery of posterior shoulder

Rubins maneuver Two maneuvers First rocking the fetal side to side by applying pressure to the maternal abdomen Second Reverse corkscrew Abduction of both shoulders

Two maneuvers

First

rocking the fetal side to side by applying pressure to the maternal abdomen

Second

Reverse corkscrew

Abduction of both shoulders

Hibbard’s maneuver Pressure applied to fetal jaw and neck towards maternal rectum with fundal pressure by assistant

Pressure applied to fetal jaw and neck towards maternal rectum with fundal pressure by assistant

Javanelli’s maneuver Return head to OA or OT position and reposition in vagina Terbutaline 250mcg to produce uterine relaxation Abdominal delivery

Return head to OA or OT position and reposition in vagina

Terbutaline 250mcg to produce uterine relaxation

Abdominal delivery

Destructive Deliberat # of clavicle Cleidotomy Symphysiotomy Hartfield’s method Urinary tract injury other morbidities and neonatal mortality

Deliberat # of clavicle

Cleidotomy

Symphysiotomy

Hartfield’s method

Urinary tract injury other morbidities and neonatal mortality

Summary Increase the functional size of the bony pelvis McRoberts Manoeuvre Decrease the bisacromial diameter of the fetus utilising: Suprapubic pressure Woods Screw Manoeuvre Change the relationship of the bisacromial diameter within the bony pelvis by rotating the fetus into the wider oblique diameter Rubin 2 Woods Screw Reverse Woods Screw Manoeuvres

Increase the functional size of the bony pelvis

McRoberts Manoeuvre

Decrease the bisacromial diameter of the fetus utilising:

Suprapubic pressure

Woods Screw Manoeuvre

Change the relationship of the bisacromial diameter within the bony pelvis by rotating the fetus into the wider oblique diameter

Rubin 2

Woods Screw

Reverse Woods Screw Manoeuvres

Shoulder dystocia “Drill” Call for help Generous episiotomy Suprapubic pressure McRobert’s maneuver Wood’s screw maneuver Delivery of posterior arm Other techniques reserved

Call for help

Generous episiotomy

Suprapubic pressure

McRobert’s maneuver

Wood’s screw maneuver

Delivery of posterior arm

Other techniques reserved

Complication Maternal PPH Vaginal and cervical laceration Retention of urine Infection Fetal Nerve injuries Fracture Clavicle and humerus Birth asphyxia

Maternal

PPH

Vaginal and cervical laceration

Retention of urine

Infection

Fetal

Nerve injuries

Fracture Clavicle and humerus

Birth asphyxia

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