shoulder dystocia

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1. Presentation on shoulder dystocia Submitted by Kavitha kalesan Bsc Nursing,Thevara

2. DEFINITION The term shoulder dystocia is defined to describe a wide range of difficulties encountered in the delivery of the shoulders. It occurs when either the anterior or the posterior fetal shoulder impacts on the maternal symphysis or on the sacral promontory.

3. PREDISPOSING FACTORS Fetal macrosomia Obesity Diabetes Midpelvic instrumental delivery Post maturity Multi parity Anencephaly Fetal ascites

4. COMPLICATIONS FETAL :- a) Asphyxia b) Brachial plexus injury due to stretch c) Erb d) Klumpke palsy e) Fracture humerus

5. Contd…

6. MATERNAL :- a) PPH b) Cervical, vaginal, perineal tears

7. SIGNS/ SYMPTOMS One characteristic of a minority of shoulder dystocia deliveries is the turtle sign, which involves the appearance and retraction of the fetal head (analogous to a turtle withdrawing into its shell), and the  erythematous (red), puffy face indicative of facial flushing. This occurs when the baby's shoulder is obstructed by the maternal  pelvis .

8. RISK FACTORS About 16% of deliveries where shoulder dystocia occurs will have conventional risk factors. Factors which increase the risk/are warning signs: The need for oxytocins A prolonged first or second stage of labour Turtle sign Head bobbing in the second stage Failure to restitute No shoulder rotation or descent Instrumental delivery

9. PREDICTION Previous shoulder dystocia, prolonged first or second stage of labour are the important ones. Maneuvers to prevent shoulder dystocia may be used prophylactically in cases where it is anticipated.

10. DIAGNOSIS Definite recoil of the head back against the perineum ( turtle-neck sign) Inadequate spontaneous restitution Fetal face becomes plethoric.

11. MANAGEMENT PRINCIPLES Extra help is to be called To clear infant’s mouth and nose Not to give traction over baby’s head Never to apply fundal pressure as it causes further impaction of the shoulder To perform wide mediolateral episiotomy as it provides space posteriorly. To involve the anesthetist and the pediatrician(for infants resuscitation)

12. MANAGEMENT Management of shoulder dystocia has become a focus point for many obstetrical nursing units in North America. Courses such as the Canadian More-OB program encourage nursing units to do routine drills to prevent delays in delivery which adversely affect both mother and fetus. A common treatment mnemonic is ‘ ALARMER’

13. CONTD…… A sk for help. This involves preparing for the help of an obstetrician, for anesthesia, and for pediatrics for subsequent resuscitation of the infant that may be needed if the methods below fail. L eg hyper flexion (McRoberts' maneuver)

14. CONTD…….. A nterior shoulder disimpaction (pressure) R ubin maneuver M anual delivery of posterior arm E pisiotomy R oll over on all fours The advantage of proceeding in the order of ALARMER is that it goes from least to most invasive, thereby reducing harm to the mother in the event that the infant delivers with one of the earlier maneuvers. In the event that these maneuvers are unsuccessful, a skilled obstetrician may attempt some of the additional procedures listed above. Intentional clavicular fracture is a final attempt at nonoperative vaginal delivery prior to  Zavanelli's maneuver  or  symphysiotomy , both of which are considered extraordinary treatment measures.

15. Contd…..

16. Contd………. Head and neck should be grasped and taken posteriorly while suprapubic pressure is applied by an assistant slightly towards the side of fetal chest. This will reduce the bisacromial diameter and rotate the anterior shoulder towards the oblique diameter. This maneuver is simple as well as effective It needs only one assistant Mc Roberts maneuver : Abduct the maternal thighs and sharply flex them onto her abdomen. There is rotation of symphysis pubis upwards

17. Contd……………………… and decrease in angle of pelvic inclination. This does not increase pelvic dimensions but straightens the sacrum relative to lumbar vertebrae. It needs two assistants.

18. Contd………… WOOD’S Maneuver: General anesthesia is administered. The posterior shoulder is rotated to anterior position(180 degree) by a corkscrew movement. This is done by inserting two fingers in the posterior vagina. Suprapubic pressure is applied. This pushes the bisacromial diameter from the antero-posterior diameter to an oblique diameter. This helps easy entry of the bisacromial diameter into the pelvic inlet.

19. Contd……………..

20. Contd……… EXTRACTION OF THE POSTERIOR ARM:- The operators hand is introduced into the vagina along the fetal posterior humerus. The arm is then swept across the chest and thereafter delivered by gentle traction. This procedure may cause fracture clavicle or humerus or both.

21. Contd…………. Other techniques may be used when all the above maneuvers have failed. CLEIDOTOMY:- One or both clavicles may be cot with scissors to reduce the shoulder girth. This is applicable to a living anencephalic baby as a first choice or in a dead fetus.

22. ZAVANELLI MANEUVER:- (pushing the fetus back to the uterus and delivering by cesarean section) or symphysiotomy are done rarely.

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