Shoulder Dystocia

Question 1

Occurrence in vaginal deliveries

Answer 1

1.5%

Question 2

Definition

Answer 2

Definition based on Obstetrical Maneuvers:

Impaction of anterior shoulder against pubic symphysis after head delivery and failure of gentle downward traction to effect delivery

Definition Based on Time of Head-to-Body Delivery:

Head-to-body delivery time is more than 60 sec

Question 3

Risk factors:

• Antepartum
• Intrapartum

Answer 3

Antepartum:

• Prior shoulder dystocia
• Fetal macrosomia
• Diabetes
• Post-term
• Male fetus
• AMA
• Excessive weight gain
• Abnormal pelvis
• Multiparity

Intrapartum:

• Abnormal first-stage labor
• Arrest disorder
• Labor augmentation with oxytocin
• Instrument delivery
• Epidural anesthesia

Question 4

Fetal macrosomia

Answer 4

Fetal weight > 4,500 grams

Ass: higher incidence of SD, Erb’s palsy, PPH, perineal laceration

NOT an indication for labor induction

Question 5

Prevention?

Answer 5

Consider c-section if EFW > 5,000 g in women w/o diabetes and > 4,500 g in women w/ diabetes

Question 6

Mgmt of Shoulder Dystocia

Answer 6

• H: call for help
• E: evaluate for episiotomy
• L: legs –> McRoberts maneuver
• P: suprapubic pressure
• E: enter (internal maneuvers)
  
  • Woods: insert a hand into the posterior vagina and rotate posterior shoulder clockwise or counterclockwise
  • Rubin: push. posterior or anterior shoulder toward fetal chest to adduct shoulders
• R: remove the posterior arm
• R: roll the patient

If all the above fail, try deliberate clavicle fracture, Zavanelli manuever (push back the delivered fetal head into birth canala dn perform emergency c-section)

Question 7

Complications associated with Shoulder Dystocia

Maternal

Answer 7

• PPH
• 4th-degree laceration, esp when intravaginal maneuvers are used after a midline episiotomy

Question 8

Complications associated with Shoulder Dystocia

Fetal

Answer 8

• Brachial Plexus Palsy
  
  • Upper arm: Erb-Duchenne (C5-C7)
  • Lower arm: Klumpke (C8-T1)
  • Most resolve by 1 yr post-discharge
• Fractures
  
  • Clavicular
  • Humeral
  • Both recover completely without long-term complications
• Hypoxic Ischemic Encephalopathy
  
  • 6 cases (0.3%) were diagnosed among 2,018 cases of SD; mean time of head-to-body delivery was 10.75 min