Shoulder Dystocia!

Question 1

How would you define shoulder dystocia, and what is the rate of occurence?

Answer 1

The need for additional obstetrics maneuvers to deliver fetal shoulders in vaginal delivery. It is an obstetric emergency. 0.2-3% of all births!

In other words, shoulder dystocia = head is already out, but the shoulders cannot be delivered.

Question 2

Let’s start with the proper cardinal movements of labor, 8 steps, let’s go:

Answer 2

1, head floating, before engagement

2. Engagement, descent, felxion
3. Further descent, internal rotation
4. COmplete rotation, beginning extension.
5. Complete extension
6. Restitution (external rotation)
7. Deliver of anterior shoulder
8. Delivery of posterior shoulder

Question 3

What is the most typical injury during shoulder dystocia, how doesit happen??

Answer 3

Well, the most typical injury during shoulder dystocia is called Erb’s palsy. It occurs when the descent of the fetal head continues while the anterior or posterior shoulder remains impacted, then the brachial pleus can be stretched and injured

Question 4

What is the most typical injury during shoulder dystocia, how does it happen??

Answer 4

Well, the most typical injury during shoulder dystocia is called Erb’s palsy. It occurs when the descent of the fetal head continues while the anterior or posterior shoulder remains impacted, then the brachial pleus can be stretched and injured.

Question 5

How is shoulder dystocia diagnosed?

Answer 5

A subjective clinical diagnosis is based on the turtle sign: when the fetal head retracts into perineu after expulsion due to reverse traction from the shoulders being impacted at the pelvic inlet.

A more objective diagnosis is when head-to-body expulsion time is greater than 60 seconds.

Question 6

What are 12 risk factors for shoulder dystocia?

Answer 6

1. Fetal macrosomia (EFV> 4500g)
2. Fetal tumors
3. Fetal malformations
   4 Diabetes Mellitus (not sure if with the mother or the fetus)
4. Operative vaginal delivery
5. History of shoulder dystocia
6. Labor abnormalities
7. Postterm pregnancy
8. Male fetal gender
9. Obesity (BMI > 30) and high gestational weight gain (>20kg)
10. Advanced maternal age (>40 years)
11. Should-pelvis disproportion.

That being said, at least 50% of shoulder dystocia pregnancies have no identifiable risk factors.

Question 7

What are some of the possible maternal consequences of shoulder dystocia? There’s 4 main ones, which are all fairly intuitive:

Answer 7

1. postpartum hemorrhage (find definition)
2. lacerations
3. uterine rupture
4. symphysis pubis dysfunction

Question 8

What are 5 possible fetal consequences of shoulder dystocia (one has already been mentioned;) )

Answer 8

1. Fractures of humerus and clavicle
2. briachial plexus nerve injuries (Erbs palsy
3. Phrenic nerve palsy
   4 hypoxic brain injury
4. death

Question 9

When it comes to management of shoulder dystocia, what is the primary goal?

Answer 9

To safely deliver the infant before asphyxia occur (umbilical cord compression)

Question 10

How long does the operator have to deliver a previously well oxygenated term infant before the risk of asphyxia?

Answer 10

The operator has up to 5 minutes.

Question 11

In the cases where one can predict the shoulder dystocia, how would you prepare the patient adequately?

Answer 11

For one, the patient can be placed in the dorsal lithotomy position (figure out what this is), have adequate anasthesia at hand, and have several experienced clinicians present at birth. Moreover.

• Mother should be told not to push! (this can compress the umbilical cord).
• excessive neck rotation, head and neck traction ? should be avoided
• Patient should be positioned with her buttocks flush with the edge of the bed (not sure what this means)
• drain the bladder!
• Do episiotomy

Question 12

Please list the appropriate maneuvers in correct order, in case of shoulder dystocia:

Answer 12

1. McRoberts maneuver.
2. Suprapubic pressure
3. Delivery of posterior arm
4. Rubin maneuver.
5. Woods corkscrew maneuver
6. Gaskin all-fours
7. Clavicular fracture
8. Zavanelli

Question 13

Now, for description of the aforementioned maneuvers in case of should dystocia: McRoberts, describe to me in sufficient detail! (Is it effective, and how does it work?)

Answer 13

McRoberts maneuver requires two assistants, each of who grabs a maternal leg and sharply flexes the thigh back against the abdomen.

This is effective in 50% of shoulder dystocias-

It opens the pelvis maximally, brings the pelvic inlet into almost vertical plane, which facilitates the delivery of the anterior shoulder.

Question 14

Please descrie the shoulder dystocia maneuver Suprapubic pressure:

Answer 14

So you place your fist on the pubic symphsis at an oblique angle dislodge the anterior shoulder.. this is done together with McRoberts!

Question 15

If McRoberts and Suprapubic pressure didnt work, how to do delivery of posterior arm?

Answer 15

introduce a hand into the vagina to locate the posterior arm and shoulder. #anasthesia

Question 16

Then there is the Rubin maneuver (?):

Answer 16

Place pressure on either accessible shoulder toward the anterior chest wall of the fetus to decrease the bisacromial diameter (?) and free the impacted shoulder

Question 17

There’s also the Woods corkscrew maneuver….:

Answer 17

Put pressure behind the posterior shoulder to rotate the infant and dislodge the anterior shoulder

Question 18

Now to cut it short, Describe Gaskin-all-fours and the three last maneuvers that follow.

Answer 18

1. Gaskin-all-fours: patient is on her knees.
2. clavicular fracture
3. Zavanelli is the LAST RESORT: We have to push the head back into the uterus and perform emergency c-section. It is very difficult and risky, can rupture the uterus and the risk of complications for the fetus is high.
4. A symphisiotomy can also be performed, but should be reserved for true emergencies - it is associated with chronic pain, infection, and healfing difficulties.