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SHOULDER DYSTOCIA
ROSSHINI JAGATHESWARAN
DEFINITIONS
• Obstetric emergency
• vaginal cephalic delivery that requires additional
obstetric maneuvers to deliver the ...
DEFINITIONS
• Impaction of fetal shoulders at the pelvic outlet
after the delivery of the head
Source: Handbook of Obstetr...
MECHANISM OF LABOUR
Process of delivery during labor normally passes
through these steps:
Engagement  Descend  Flexion  Internal rotation ...
Unilateral Shoulder Dystocia
Bilateral shoulder dystocia
RISK FACTORS – Pre-labour
• Previous shoulder dystocia
• Induction of labour
• Infants of diabetic mothers
• Fetal macroso...
RISK FACTORS – Intrapartum
• Prolonged first stage of labour
• Secondary arrest
• Prolonged second stage of labour
• Oxyto...
PREVENTION
The risk factor assessment and progress of labour may help in
prediction of it but they are insufficient.
But t...
Management of
suspected fetal macrosomia
• Early induction of labour
- Doesn’t prevent SD in non-diabetic woman with
suspe...
Approach
History
Examination
Investigation:
early
Monitoring
and
Partograph
Delivery of
the head of
the baby
Delivery of
s...
Preparation for labour
All birth attendants should be aware of the methods
for diagnosing shoulder dystocia and the techni...
DIAGNOSIS
• Difficulty with delivery of the face and chin
• The head remaining tightly applied to the vulva or
even retrac...
Turtle-neck sign
Fetal head emerges and
retracts against the
perineum
Routine traction in an axial direction can be used to
diagnose shoulder dystocia but any other traction
should be avoided....
Management
First-line
Maneuvers
Second-line
Maneuvers
Call for Help, initiate RED ALERT!
• State clearly
• Experienced obstetrician, midwife, nurses,
neonatologist, anesthetist...
Episiotomy
• To create more space for greater access to the
pelvis
• An episiotomy is not always necessary.
Legs: McRoberts’ Maneuver
External Pressure - suprapubic pressure
Enter pelvis: rotational maneuvers
Rubin II +
Woodscrew’s
Maneuver
Reverse
Woodscrew’s
Maneuver
Remove the posterior arm
Roll the patient to her hands & knees
Gaskin maneuver
Third-linemaneuvers
* The baby most likely in hypoxic-acidotic state…
 Cleidotomy
 Zavanelli maneuver (mostly for bilate...
Cleidotomy
• Anterior clavicle is pressed against the ramis of the
pubis.
• Avoid puncturing the lung by angling the fract...
Zavanelli maneuver
Consists of cephalic replacement
+ caesarean delivery.
• Relax uterus with terbutaline
• Rotate head ba...
Symphysiotomy
• Insert Foley catheter
• Use vaginal hand to
laterally displace
urethra to avoid
injury
• Incise symphysis
...
AFTER DELIVERY
MATERNAL COMPLICATIONS
• Postpartum hemorrhage – 11%
• Vaginal lacerations
• Cervical lacerations
• Third and fourth degre...
FETAL COMPLICATIONS
• Brachial plexus injury
• Fetal fractures - humerus or clavicle
• Erb’s palsy
• Perinatal asphyxia
• ...
Brachial Plexus Injury
• Most cases resolve
without permanent
disability
• Larger infants at higher
risk
• Due to excess t...
Future pregnancy
• Mode of delivery – LSCS or vaginal delivery
• Important to discuss with patient and her husband
THANK YOU
Shoulder Dystocia
Shoulder Dystocia
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Shoulder Dystocia

Obstetric emergency

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Shoulder Dystocia

  1. 1. SHOULDER DYSTOCIA ROSSHINI JAGATHESWARAN
  2. 2. DEFINITIONS • Obstetric emergency • vaginal cephalic delivery that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed • occurs when either the anterior, or less commonly the posterior fetal shoulder impacts on the maternal symphysis, or sacral promontory, respectively Source : RCOG Guidelines
  3. 3. DEFINITIONS • Impaction of fetal shoulders at the pelvic outlet after the delivery of the head Source: Handbook of Obstetrics & Gynaecologic Emergencies • Difficulty in delivery of the fetal shoulders Source: Obstetrics by Ten Teachers
  4. 4. MECHANISM OF LABOUR
  5. 5. Process of delivery during labor normally passes through these steps: Engagement  Descend  Flexion  Internal rotation  Extension  Restitution  External rotation  Delivery of the body In shoulder dystocia: Engagement  Descend  Flexion  Internal rotation  Extension  Restitution  External rotation  /// /// /// /// /// ///  Delivery of the body
  6. 6. Unilateral Shoulder Dystocia
  7. 7. Bilateral shoulder dystocia
  8. 8. RISK FACTORS – Pre-labour • Previous shoulder dystocia • Induction of labour • Infants of diabetic mothers • Fetal macrosomia >4.5kg - excessive weight gain during pregnancy - maternal obesity (BMI>30) - asymmetric accelerated fetal growth in non-diabetic patients - post-term pregnancy - parity
  9. 9. RISK FACTORS – Intrapartum • Prolonged first stage of labour • Secondary arrest • Prolonged second stage of labour • Oxytocin augmentation • Assisted vaginal delivery
  10. 10. PREVENTION The risk factor assessment and progress of labour may help in prediction of it but they are insufficient. But trials include: A. Management of suspected fetal macrosomia B. History of previous shoulder dystocia and its sequelae C. Partograph may signal you the delay of the stages and any fetal distress
  11. 11. Management of suspected fetal macrosomia • Early induction of labour - Doesn’t prevent SD in non-diabetic woman with suspected macrosomic fetus - Reduce incidence of SD at term for GDM mothers • Elective LSCS - Should be considered if pregnancies complicated by pre-existing or gestational DM, regardless of treatment, with an estimated fetal weight of greater than 4.5 kg.
  12. 12. Approach History Examination Investigation: early Monitoring and Partograph Delivery of the head of the baby Delivery of shoulders + Body After delivery
  13. 13. Preparation for labour All birth attendants should be aware of the methods for diagnosing shoulder dystocia and the techniques required to facilitate delivery. Birth attendants should routinely look for the signs of shoulder dystocia. Timely management of shoulder dystocia requires prompt recognition.
  14. 14. DIAGNOSIS • Difficulty with delivery of the face and chin • The head remaining tightly applied to the vulva or even retracting (turtle-neck sign) • Failure of restitution of the fetal head • Failure of the shoulders to descend
  15. 15. Turtle-neck sign Fetal head emerges and retracts against the perineum
  16. 16. Routine traction in an axial direction can be used to diagnose shoulder dystocia but any other traction should be avoided. Routine traction is defined as ‘that traction required for delivery of the shoulders in a normal vaginal delivery where there is no difficulty with the shoulders’. Axial traction is traction in line with the fetal spine i.e. without lateral deviation.
  17. 17. Management First-line Maneuvers Second-line Maneuvers
  18. 18. Call for Help, initiate RED ALERT! • State clearly • Experienced obstetrician, midwife, nurses, neonatologist, anesthetist • Secure IV line • Lithotomy position, legs in stirrup with buttocks at edge of bed • Empty/catheterise the bladder Time window for brain hypoxia is 5 minutes. * Fundal pressure should not be used. * Encourage the mother not to push.
  19. 19. Episiotomy • To create more space for greater access to the pelvis • An episiotomy is not always necessary.
  20. 20. Legs: McRoberts’ Maneuver
  21. 21. External Pressure - suprapubic pressure
  22. 22. Enter pelvis: rotational maneuvers Rubin II + Woodscrew’s Maneuver Reverse Woodscrew’s Maneuver
  23. 23. Remove the posterior arm
  24. 24. Roll the patient to her hands & knees Gaskin maneuver
  25. 25. Third-linemaneuvers * The baby most likely in hypoxic-acidotic state…  Cleidotomy  Zavanelli maneuver (mostly for bilateral dystocia) Symphysiotomy Future: Posterior axillary sling
  26. 26. Cleidotomy • Anterior clavicle is pressed against the ramis of the pubis. • Avoid puncturing the lung by angling the fracture anteriorly. • Theoretically, a fracture of the clavicle is less serious than a brachial nerve injury and often heals rapidly.
  27. 27. Zavanelli maneuver Consists of cephalic replacement + caesarean delivery. • Relax uterus with terbutaline • Rotate head back to OA (“reverse restitution”) • Flex neck • Upward pressure • To Operation Theatre
  28. 28. Symphysiotomy • Insert Foley catheter • Use vaginal hand to laterally displace urethra to avoid injury • Incise symphysis through mons pubis
  29. 29. AFTER DELIVERY
  30. 30. MATERNAL COMPLICATIONS • Postpartum hemorrhage – 11% • Vaginal lacerations • Cervical lacerations • Third and fourth degree tears – 3.8% • Puerperal infection
  31. 31. FETAL COMPLICATIONS • Brachial plexus injury • Fetal fractures - humerus or clavicle • Erb’s palsy • Perinatal asphyxia • HIE • Neonatal death
  32. 32. Brachial Plexus Injury • Most cases resolve without permanent disability • Larger infants at higher risk • Due to excess traction, maternal propulsive force • Damage to the posterior shoulder plexus is unlikely due to healthcare professional
  33. 33. Future pregnancy • Mode of delivery – LSCS or vaginal delivery • Important to discuss with patient and her husband
  34. 34. THANK YOU

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