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5/23/2013

Shoulder dystocia refers to difficulty in delivery of the fetal shoulders. It occurs in 0.2 to 2 percent of births and can be a devastating obstetric emergency. Some shoulder dystocias can be anticipated and prevented, however, most occur in the absence of risk factors. Therefore, the obstetrician must be prepared to recognize a shoulder dystocia immediately and proceed through an orderly sequence of steps to effect delivery in a timely manner. The goal of management is to prevent fetal asphyxia, while avoiding physical injury (eg, Erb's palsy, bone fractures).

Shoulder dystocia can be defined as failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head. In practice, the diagnosis of shoulder dystocia is subjective; it is considered when the routine practice of gentle, downward traction of the fetal head fails to accomplish delivery.

The fetal bisacromial diameter normally enters the pelvis at an oblique angle with the posterior shoulder ahead of the anterior one, rotating to the anterior-posterior position at the pelvic outlet with external rotation of the fetal head.

The anterior shoulder can then slide under the symphysis pubis for delivery. If the fetal shoulders remain in an anteriorposterior position during descent or descend simultaneously rather than sequentially into the pelvic inlet, then the anterior shoulder can become impacted behind the symphysis pubis and/or the posterior shoulder may be obstructed by the sacral promontory. Then you get the dreaded “Turtle Sign” of doom.
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2 . Maternal diabetes mellitus increases the likelihood of shoulder dystocia two to six fold over the nondiabetic population. the optimal estimated weight threshold for elective cesarean delivery in diabetic gravida is controversial. Specifically. The correlation between shoulder dystocia and birth weight in diabetic and nondiabetic gravidas is shown in Table 3 The high rate of shoulder dystocia is associated with a high rate of brachial plexus injury. as well as the inherent difficulty in predicting fetal weight. For these reasons. the chest-to-head and shoulder-to-head ratios are increased in infants of diabetic mothers.5/23/2013 Maternal ◦ ◦ ◦ ◦ Abnormal pelvic anatomy Gestational diabetes Post-dates pregnancy Previous shoulder dystocia Fetal ◦ Suspected macrosomia Labor related ◦ Assisted vaginal delivery (forceps or vacuum) ◦ Protracted active phase of first-stage labor ◦ Protracted second-stage labor Diabetes mellitus — Maternal diabetes mellitus increases the incidence of largefor-gestational age (LGA) infants. thereby increasing the risk of shoulder dystocia independent of fetal weight. The increased risk of shoulder dystocia in diabetic pregnancies occurs even among infants less than 4000g because of the body habitus changes in these fetuses described above.

◦ 5 of these 17 infants suffered birth trauma (3 permanent injuries and 1 death). anthropomorphic dimensions may also account for some of the increased risk of shoulder dystocia in males. ◦ As an example. thus. ◦ However. ◦ This conclusion is supported by a large population series (n=75.445) and postterm (n=65. ◦ Fetal size was primarily responsible for the increased risk of shoulder dystocia after stratification by birth weight. in part. Turtle Sign! 3 . Oh crap. at least 50 percent of pregnancies complicated by shoulder dystocia have no risk factors. of the relationship between fetal macrosomia and gender. ◦ This is the result. Maternal diabetes and macrosomia are the strongest independent risk factors for shoulder dystocia.5/23/2013 Previous shoulder dystocia: ◦ One database of 37.465 vaginal deliveries in Louisiana found 2 percent were complicated by shoulder dystocia. Advanced maternal age: ◦ Advanced maternal age has been identified as a risk factor for shoulder dystocia. the predictive value of any one or combination of risk factors for shoulder dystocia is low. ◦ Of the women in that 2 percent that had a second vaginal delivery…14 percent of them had a recurrent dystocia. Male fetal gender: gender: ◦ The frequency of male gender is higher in pregnancies complicated by shoulder dystocia cases (55 to 68 percent) than in the overall birth population (51 percent). The highest risk of shoulder dystocia occurs when these risk factors occur together due to the combined effects of the unfavorable anthropomorphic dimensions of the IDM and large absolute size However. although the majority of postterm pregnancies are not complicated by shoulder dystocia. however.979) which did not find maternal age affected the incidence of shoulder dystocia after correction for other risk factors.796) births from Norway reported a relative risk (RR) of 1. This was illustrated in a study that found that 70 percent of newborns weighing >4545 grams (10 pounds) were male.3 for shoulder dystocia in the postterm group. a cohort study of term (n=379. Postterm pregnancy: pregnancy: ◦ A large proportion of deliveries complicated by shoulder dystocia occur in postterm pregnancies. confounding variables such as gestational diabetes and maternal weight probably account for this association.

Shoulder dystocia is a bony impaction. many women can be spared a surgical incision. This position flattens the sacral promontory and results in cephalad rotation of the pubic symphysis. the McRoberts maneuver) ◦ Decrease the bisacromial diameter. H Call for Help: ◦ This refers to activating the pre-arranged protocol or requesting the appropriate personnel to respond with necessary equipment to the labor and delivery unit. so episiotomy alone will not release the shoulder. positioning the maternal thighs up onto the maternal abdomen. applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. 4 . Nurses and family members present at the delivery can provide assistance for this maneuver. L Legs (the McRoberts maneuver): ◦ This procedure involves flexing and abducting the maternal hips. This maneuver should be attempted while continuing downward traction. P Pressure (Suprapubic): ◦ The hand of an assistant should be placed suprapubically over the fetal anterior shoulder.e. E Evaluate for episiotomy: episiotomy: ◦ Episiotomy should be considered throughout the management of shoulder dystocia but is necessary only to make more room if rotation maneuvers are required. These maneuvers are designed to do one of three things: ◦ Increase the functional size of the bony pelvis through flattening of the lumbar lordosis and cephalad rotation of the symphysis (i. the breadth of the shoulders.. ◦ Change the relationship of the bisacromial diameter within the bony pelvis through internal rotation maneuvers. of the fetus through application of suprapubic pressure.5/23/2013 The HELPERR mnemonic is a clinical tool that offers a structured framework for coping with shoulder dystocia. ◦ Because most cases of shoulder dystocia can be relieved with the McRoberts maneuver and suprapubic pressure.

attempt delivery. allowing the fetus to drop into the sacral hollow. If shoulders move into the oblique diameter. the shoulder will dislodge during the act of turning. 2. Rubin II At vaginal examination apply pressure as indicated. If shoulders now move into the oblique. continue rotation 180 degrees and deliver. gravitational forces may aid in the disimpaction of the fetal shoulders. 3. freeing the impaction.5/23/2013 E Enter maneuvers (internal rotation): ◦ These maneuvers attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. If this is unsuccessful. change to reverse Woods corkscrew maneuver. 5 . ◦ Often. so that this movement alone may be sufficient to dislodge the impaction. 3. attempt delivery. ◦ The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall. Slide fingers down to back of posterior shoulder and attempt 180180degree rotation in the opposite direction. 2. add the Woods corkscrew maneuver and continue rotation in the same direction. 1. 1. Rubin II + Woods corkscrew maneuver If unsuccessful. R Remove the posterior arm: ◦ Removing the posterior arm from the birth canal also shortens the bisacromial diameter. Use both hands and apply pressure as indicated. once the position change is completed. ◦ In addition. ◦ Grasping and pulling directly on the fetal arm may fracture the humerus R Roll the patient: ◦ The patient rolls from her existing position to the all-fours position. Reverse Woods corkscrew maneuver If the last maneuver is unsuccessful.

with or without permanent neurologic damage ◦ Fracture of the humerus ◦ ◦ ◦ ◦ Evidence is lacking to support labor induction or elective cesarean delivery in women without diabetes who are at term when a fetus is suspected of having macrosomia. with or without transient femoral neuropathy ◦ Third.5/23/2013 Maternal ◦ Postpartum hemorrhage ◦ Rectovaginal fistula ◦ Symphyseal separation or diathesis. induction for suspected fetal macrosomia did not lower the rates of shoulder dystocia or cesarean delivery. Not enough evidence is available to routinely support elective delivery in this population. While labor induction in women with gestational diabetes who require insulin may reduce the risk of macrosomia and shoulder dystocia. the risk of maternal or neonatal injury is not modified.345 cesarean deliveries. In two studies of 313 women without diabetes. the physician proceeds with immediate delivery of the anterior shoulder without stopping to suction the oropharynx.000 g. nor did it improve the rates of maternal or neonatal morbidity. Analytic decision models have estimated that 2. Next Slide One method of preliminary intervention for shoulder dystocia in a patient with risk factors involves implementing the "head and shoulder maneuver" to "deliver through" until the anterior shoulder is visible.or fourth-degree episiotomy or tear ◦ Uterine rupture Fetal Brachial plexus palsy Clavicle fracture Fetal death Fetal hypoxia. Next Slide 6 . at a cost of nearly $5 million annually. This step is accomplished by continuing the momentum of the fetal head delivery until the shoulder is visible. After controlled delivery of the head. So. would be needed to prevent one permanent brachial plexus injury in a patient without diabetes who had a fetus suspected of weighing more than 4. prophylactic cesarean delivery is not recommended as a means of preventing morbidity in pregnancies in which fetal macrosomia is suspected.