Shoulder Dystocia

imagesImpaction of the infant shoulders in the pelvic outlet occurring after delivery of the head during a vertex vaginal delivery


PROCEDURAL DEFINITION



imagesManeuvers intended to disimpact the shoulders by adducting the shoulders, either by direct pressure or by rotating the infant’s trunk


INDICATIONS



imagesFailure of delivery of anterior shoulder with usual downward traction after delivery of infant head


images“Turtle Sign”—Retraction of fetal head back into maternal perineum after initial delivery


CONTRAINDICATIONS



imagesImmediate availability of obstetric services for cesarean section


CONSENT



imagesNone. Considered an obstetrical emergency since fetal demise can occur if the procedure is indicated and not performed.



imagesGeneral Basic Steps


   imagesRecognize shoulder dystocia


   imagesCall for help immediately (including emergency department personnel and appropriate consulting services)


   imagesPrepare patient


      imagesIV, oxygen, and maternal and fetal monitor must be available


      imagesCall for assistance and obstetric, anesthesia, and pediatric backup


      imagesDrain bladder if distended


      imagesAvoid maternal pushing while attempts are made to reposition fetus


      imagesAvoid excessive head and neck traction or uterine fundal pressure


   imagesApply maneuvers to facilitate delivery (may need to attempt multiple maneuvers)


TECHNIQUES



imagesMazzanti Maneuver (FIGURE 41.1)


   imagesAdduct shoulders by applying downward or oblique suprapubic pressure to dislodge anterior shoulder from pubic symphysis


   imagesAvoid applying fundal pressure, which may cause further fetal injury



images


FIGURE 41.1 Mazzanti maneuver.


imagesMcRoberts Maneuver (FIGURE 41.2)


   imagesHyperflex maternal hips to a knee-to-chest position


   imagesThis flattens the lumbar spine and rotates the pelvis toward the head, which frees the impacted anterior shoulder


imagesWoods Screw Maneuver (FIGURE 41.3)


   imagesRotate the fetus 180 degrees by applying pressure to the clavicular surface of the posterior shoulder in an attempt to dislodge anterior shoulder


   imagesDo not twist the head and neck


imagesRubin Maneuver (FIGURE 41.4)


   imagesPlace one hand behind the posterior shoulder and adduct shoulder while rotating it anteriorly


imagesGaskin Maneuver


   imagesMother 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


imagesDelivery of the Posterior Arm (FIGURE 41.5)


   imagesLocate the posterior arm in the vagina


   imagesApply pressure to the antecubital fossa to flex the elbow and bring the forearm across chest


   imagesLocate the forearm and hand and pull through the vagina to deliver the posterior shoulder


imagesClavicular Fracture


   imagesFracture the clavicle intentionally to decrease bisacromial diameter by pulling the anterior clavicle outward away from the lung to avoid causing a pneumothorax


imagesZavanelli Maneuver (FIGURE 41.6)


   imagesReverse the cardinal movements of labor and take the patient to the operating room (OR) for cesarean section


   imagesRelax the uterus with terbutaline (0.25 mg SC (subcutaneously)) or nitroglycerin (50–200 µg/min IV)


   imagesRotate fetal head to occiput anterior position


   imagesFlex fetal neck and apply gentle cephalad pressure to fetal head to replace the fetus back into the pelvis


   imagesPrepare for cesarean section



images


FIGURE 41.2 McRoberts maneuver.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Shoulder Dystocia
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