Shoulder Dystocia

Question 1

Define Shoulder Dystocia?

Answer 1

It is the impaction of the anterior shoulder against the pubis symphysis after delivery of the fetal head.

Question 2

What are the risk Factors of shoulder dystocia?(5)

Answer 2

• Maternal Diabetes
  -Macrosomia
  -Previous history of shoulder dystocia
  -Maternal Obesity
  -Protracted Second Stage

Question 3

What factors lead to diagnosis of shoulder Dystocia?

Answer 3

1.Difficulty with the delivery of the face and chin.
2.Retraction of fetal head against the maternal perineum (Turtle sign)
3.Failure of the restitution of the fetal head
4.Failure of the shoulders to descend.

Question 4

How long does it take for there to be compromise to the fetus?

Answer 4

6mins

Question 5

What is the fetus at risk of if delivery is not done in time?

Answer 5

1.Neonatal Depression
2.Acidosis
3.Asphyxia
4. CNS damage

Question 6

Describe the HELPER acronym?

Answer 6

H:Call for Help
E; evaluate for an epiostomy
L:Legs (McRoberts Maneuver)
P: Suprapubic pressure
E: Enter internal Maneuvers
R: Remove posterior arm….Roll the patient

Question 7

If the HELPER maneuvers fail, what other maneuvers can be done?

Answer 7

1.Symphsiotomy
2. Zavanelli’s maneuver
3.Interntional fetal clavicular fracture
4.Abdominal rescue

Question 8

Describe the management of shoulder dystocia?

Answer 8

1.Start timing from when the shoulder dystocia is diagnosed.
2.Call for help(registrar, intern and midwife should be present)
-Notify the consultant on call
-Notify the pediatrician, ideally they should come deliver
-Notify the anesthetist
3. Do not apply fundal pressure
4.Tell the patient to stop pushing and only push when you instruct them to.
5.Consider episiotomy only if it will make the internal maneuvers easier
6.Cathetirize
7. Start with McRoberts’s Position-Flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen.
8.Suprapubic pressure can be employed together with McRoberts’s position
If this fails
9.Rubin’s Maneuver-Insert one hand through the vagina along the dorsal aspect of the fetal shoulder and rotate the shoulder inward about 30degrees until the shoulders lie in the oblique diameter of the pelvis.
10.Wood’s screw maneuver-The posterior shoulder may be rotated forward through a 180 degree arc, and passed under the pubic ramus as in turning a screw
11.Delivery of the posterior arm-Flex the posterior arm over the fetal chest using two fingers to allow delivery of the posterior arm.
12.Barnum’s maneuver - Slide the hand along the dorsal aspect of the humerus and press it against the fetal chest, the clinician then palpates the elbow.(If elbow is already flexed, the operator grasps the fetal forearm and wrist and sweeps the forearm over the chest and across the infant’s face, extending the arm at the elbow and the shoulder to deliver it first.
13.Gaskin-turn the patient on all fours with the back arched

Question 9

Why is fundal pressure not used?

Answer 9

Because this worsens the impaction of the fetal shoulder and increases the risk of uterine rupture.

Question 10

How does the McRoberts’s maneuver assist delivery

Answer 10

1.Straightening maternal lumbar lordosis
2.Rotates symphysis superiorly and anteriorly
3.Improving angle between the pelvic inlet and direction of maximal expulsive force
4.Elevates anterior shoulder allowing posterior shoulder to descend

Question 11

How is Suprapubic pressure applied?

Answer 11

The hand of the assistant should be placed suprapubically over the fetal anterior shoulder,applying pressure downward and lateral motion on the posterior aspect of fetal shoulder

Question 12

What are the maternal complications of shoulder dystocia?

Answer 12

1. Postpartum hemorrhage
   2.High degree lacerations(4th degree lacerations)
   3.Vaginal lacerations
   4.Uterine Rupture
   5.Pubic symphysis separation

Question 13

What are the fetal complications of shoulder dystocia?

Answer 13

1.Brachial Plexus
2.Clavicle fracture
3.Humerus Fracture
4.Increased risk of hypoxemic ischemic encephalopathy and death

Question 14

Describe Zavaneli’s maneuver?

Answer 14

Involves internal cephalic replacement followed by C/S
or
Pushing the fetal head back in with performing a c/s
or
Relax uterus with terbutaline
Reverse restitution
Flex neck and upward pressure
To OR

Question 15

How does the intentional fetal clavicular fracture help?

Answer 15

It reduces the diameter of the shoulder girdle that requires to pass through the birth canal

Question 16

How is a symphysiotomy done?

Answer 16

-A foley catheter is placed.
- The vaginal hand is used to laterally displace urethra to avoid injury
- Then the symphysis is incised through the mons pubis

Question 17

How does the symphysiotomy help with shoulder dystocia?

Answer 17

It makes the opening of the vaginal canal laxer by breaking the connective tissue between the two pubic bones facilitating the passage of the shoulders.