Shoulder Dystocia

Obstetric emergency

1. SHOULDER DYSTOCIA ROSSHINI JAGATHESWARAN

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. 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. MECHANISM OF LABOUR

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. Unilateral Shoulder Dystocia

7. Bilateral shoulder dystocia

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. RISK FACTORS – Intrapartum Prolonged first stage of labour Secondary arrest Prolonged second stage of labour Oxytocin augmentation Assisted vaginal delivery

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. 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. Approach

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. 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. Turtle-neck sign Fetal head emerges and retracts against the perineum

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. Management First-line Maneuvers Second-line Maneuvers

18. Call for H elp, 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. E pisiotomy To create more space for greater access to the pelvis An episiotomy is not always necessary .

20. L egs: McRoberts ’ Maneuver

21. External P ressure - suprapubic pressure

22. E nter pelvis: rotational maneuvers Rubin II + Woodscrew’s Maneuver Reverse Woodscrew’s Maneuver

23. R emove the posterior arm

24. R oll the patient to her hands & knees Gaskin maneuver

25. Third-line maneuvers * The baby most likely in hypoxic-acidotic state…  Cleidotomy  Zavanelli maneuver (mostly for bilateral dystocia)  Symphysiotomy Future: Posterior axillary sling

26. Cleidotomy A nterior 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. 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. Symphysiotomy Insert Foley catheter Use vaginal hand to laterally displace urethra to avoid injury Incise symphysis through mons pubis

29. AFTER DELIVERY

30. MATERNAL COMPLICATIONS Postpartum hemorrhage – 11% Vaginal lacerations Cervical lacerations Third and fourth degree tears – 3.8% Puerperal infection

31. FETAL COMPLICATIONS Brachial plexus injury Fetal f ractures - humerus or clavicle Erb’s palsy Perinatal asphyxia HIE Neonatal death

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. Documentation This done according to the security policy of the hospital, it should be accurate and comprehensive. It is important to record within the birth record the: time of delivery of the head and time of delivery of the body anterior shoulder at the time of the dystocia maneuvers performed, their timing and sequence maternal perineal and vaginal examination estimated blood loss staff in attendance and the time they arrived general condition of the baby (Apgar score) umbilical cord blood acid-base measurements neonatal assessment of the baby . It’s important for the hospital to have a proform to avoid mistakes and for medico-legal purposes.

34. Future pregnancy Mode of delivery – LSCS or vaginal delivery Important to discuss with patient and her husband

35. THANK YOU