Dr. Joshi presents today’s Morning Report:
“Unfortunately and realistically speaking, outcomes of true obstetric emergencies are often bleak and essentially out of the hands of the emergency clinician”. – Roberts and Hedges
There is nothing that will cause more fear than a woman delivering a baby.. let alone:
Shoulder Dystocia
Definition:
- Impaction of fetal (anterior) shoulder in the pelvic outlet (maternal pubic symphysis) or posterior shoulder against the maternal sacrum; occurring right after delivery of the head.
- Turtle sign; head delivers but does not undergo external rotation and the cheeks and chin recoil against the perineum
- 1.6% of all births
Risk Factors:
- Poor positive predictive values
- Most common risk factor is NO risk factor
- Fetal macrosomia
- Maternal diabetes
- Obesity
- Multiparity
- Post dates pregnancy
- Prior history of dystocia
Fetal Bad Outcomes:
- Brachial plexus injuries (nerve palsies)
1. Erb – Duchenne palsy (nerve roots C5-C6), more common
2. Klumpke palsy (C8 – T1), less common, persists for 1+yr
- Clavicular fractures
- Humeral fractures
- Hypoxia
- Death
- *fetal fracture or nerve injury occurs in 25% of cases
Why:
Compression of the umbilical cord, compression of fetal carotid arteries, premature placental separation
Maternal Bad Outcomes:
postpartum hemorrhage
uterine rupture
Third / Fourth degree tear
rectovaginal fistula
Coming back and suing you
Prophylaxis: NONE
Management:
Call for neonatalogist, pediatrician, OB (load the boat!)
Set up airway management
Get someone to start recording the time (extremely important – incidence of hypoxic encephalopathy is less when the head to body delivery time is less than 5 minutes)
Maneuvers (ACOG supported):
1. McRoberts – least invasive; will resolve more than 42% of dystocias
Mother goes to extreme lithotomy position with hips completely flexed and knees resting on the chest
-> flattening of the lumbar lordosis and rotation of the maternal pelvis cephalad
= SPACE!
= increased diameter of the pelvis
= helps rotate the pelvis over the anterior shoulder
2. Suprapubic Pressure NOT FUNDAL PRESSURE – Rubin Manuever I
Assistant applies moderate suprapubic pressure to maternal abdomen while giving gentle downward traction on the fetal head (adducts and dis-impacts the anterior shoulder from behind the maternal pubis)
3. Rotational movements – Rubin II and Woods screw
Put two fingers in the vagina:
Rubin II – push along the posterior aspect of the anterior shoulder and ad-duct / flex the anterior shoulder
Woods Screw – push along the anterior aspect of the posterior shoulder and ab-duct/extend the posterior shoulder
** try it at the same time to corkscrew the head!
***reverse corkscew
4. Delivery of the posterior shoulder:
Insert the hand along the hollow of the maternal sacrum to the baby posterior elbow.
Push on the antecubital fossa and flex the posterior forearm and grab the hand or forearm.
Sweep the posterior arm of the fetus across its chest to effect delivery of the posterior arm and shoulder
Rotate the shoulders into an oblique diameter of the pelvis and subsequently deliver the anterior
Don’t push upwards on the posterior arm because you can cause fracture to the anterior humeral shaft
Gaskin – all 4s: Changes the pelvic anatomy; in this position the posterior shoulder is delivered first; you can still do rotational maneuvers
5. Destructive Procedure: Break the clavicle
6. Cephalic replacement maneuver (Zavanelli) with subsequent C-Section; hysterectomy, abdominal surgery
Consider:
episiotomy for room
hands and knees position
BOTTOM LINE: DOCUMENT THE CRAP OUT OF WHAT JUST HAPPENED INCLUDING THE TIME!
Thanks Dr. Joshi!
Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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