Shoulder Dystocia
Definition
- ▪ Impaction of the fetal shoulders in the pelvic outlet occurring after delivery of the head in the vertex presentation.
- Prohibits adequate fetal respiration.
- Compromises fetal circulation.
- ▪ These maneuvers in general are intended to disimpact the shoulders by adducting the shoulders with direct pressure or rotating the trunk.
Contraindications
- ▪ Immediate availability of obstetric services for cesarean section.
Risks/Consent Issues
- ▪ Brachial plexus injury
- ▪ Humeral/clavicular fractures
- ▪ Hypoxic brain injury
- ▪ Fetal demise
- ▪ Maternal hemorrhage
Techniques:
More than one maneuver may be required.
- ▪ Patient Preparation
- IV, oxygen, and maternal and fetal monitor must be available.
- Call for assistance and obstetric, anesthesia, and pediatric backup.
- Drain bladder if distended.
- Avoid maternal pushing while attempts are made to reposition fetus.
- Avoid excessive head and neck traction or uterine fundal pressure.
- ▪ Manzanti Maneuver
- Adduct shoulders by applying downward or oblique suprapubic pressure to dislodge anterior shoulder from pubic symphysis.
- ▪ McRoberts Maneuver
- Hyperflex maternal hips to a knee to chest position.
- This flattens the lumbar spine and rotates the pelvis toward the head, which frees the impacted anterior shoulder.
- ▪ Woods Screw Maneuver
- Rotate the fetus 180 degrees by applying pressure to the clavicular surface of the posterior shoulder in an attempt to dislodge anterior shoulder.
- Do not twist the head and neck.
- ▪ Rubin Maneuver
- Place one hand behind the posterior shoulder and adduct shoulder while rotating it anteriorly.
- ▪ Gaskin Maneuver
- Mother is repositioned on her hands and knees (on “all fours”) and gentle downward traction is applied to posterior shoulder or upward traction applied to the anterior shoulder.
- ▪ Delivery of the Posterior Arm
- Locate the posterior arm in the vagina.
- Apply pressure to the antecubital fossa to flex the elbow and bring the forearm across chest.
- Locate the forearm and hand and pull through the vagina to deliver the posterior shoulder.
- ▪ Clavicular Fracture
- Fracture the clavicle intentionally to decrease bisacromial diameter by pulling anterior clavicle outward away from the lung to avoid causing a pneumothorax.
- ▪ Zavanelli Maneuver (cephalic replacement)—in preparation for cesarean section
- Relax the uterus with terbutaline (0.25 mg SC) or nitroglycerin (50 to 200 µg/minute IV).
- Reverse the cardinal movements of labor.
- Rotate fetal head to occiput anterior position.
- Flex fetal neck and apply gentle cephalad pressure to fetal head to replace the fetus back into the pelvis.
- Prepare for cesarean section.
- ▪ Symphysiotomy—use as last resort, if all other techniques fail and cesarean delivery is unavailable.
- Sterilize the skin over the pubic symphysis area with povidone-iodine solution.
- Infiltrate skin and fibrocartilaginous area with local anesthetic.
- Displace urethra laterally.
Incise skin and fibrocartilage of pubic symphysis.
Complications
- ▪ Fetal
- Brachial plexus injury due to excessive head and neck traction
- Fractures of humerus and clavicle
- Pneumothorax
- Hypoxic brain injury
- Fetal death
- ▪ Maternal
- Hemorrhage
- Severe perineal lacerations
- Uterine atony
Common Pitfalls
- ▪ Failure to approach shoulder dystocia methodically
- ▪ Excessive traction on the fetal head and neck
- ▪ Prolong dystocia
Pearls
- ▪ Consult obstetrics EMERGENTLY to assist with delivery and prepare for possible cesarean section.
- ▪ A combination of McRoberts and Manzanti maneuvers is most often used and effective; however, more than one maneuver may be required depending on the severity of the dystocia.
- ▪ Never rotate the head and neck or use excessive traction.
- ▪ Approach dystocia methodically.
- ▪ Be aware of how much time has lapsed since delivery of head; fetal morbidity and mortality is significantly increased with dystocia <7 minutes.
- ▪ Document, document, document.
- Maneuvers used during delivery
- Time of delivery of head, shoulder, and infant
- All associated injuries
- ▪ Send umbilical blood for pH analysis.
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