Shoulder Dystocia

Risk Factor Shoulder Dystocia:

· Fetal factors: ~ Estimated big baby more than 4 kg ~ Previous history of shoulder dystocia ~ Previous history of big baby ~ Anencephaly ~ Post term pregnancy · Maternal factors: ~ Diabetic mother ~ High maternal birth weight ~ Maternal obesity more than 80kg ~ High maternal weight gain ~ Advance maternal age · Abnormality of labour: ~ Prolonged late active phase ~ Prolonged second stage ~ Excessive moulding ~ Delayed in descent leading to mid pelvic instrumental delivery ~ Turtle neck sign during second stage of labour

5 consistently associated with SD and permanent brachial plexus injury (BPI)

-History of previous SD -Macrosomia -GDM -Small maternal stature -use of forceps of vacuum for delivery

Common features of SD

-There is an arrest of spontaneous delivery due to impaction of shoulder against symphysis pubis -A prolonged "head to body delivery>60 seconds is noted -Additional obstetric manoeuvers need to be effected -Degree of difficulty varies from being slight to severe -commonly in macrosomia -Brachial palsy (Erb's commonest) seen in 4-16% of SD

Others

-Zaveneil manoeuver -Cleidotomy -symhysiotomy

Prevention

Caesarean section -diabetic women with a fetal weight estimated to be above 4.0 kg -non diabetic women with an estimated fetal weight above 4.5 kg and slow progress of labour

H-help

Call for help, senior staff must be called in -inform mother to stop pushing -do not apply fundal pressure -mother is lie flat and buttock are drawn at edge of bed

E- Enter vagina for internal manoeuvers

Enter vagina for internal manoeuvers Rubin II- 2 fingers applied to posterior aspect of anterior shoulder and forward pressure is applied to adduct the shoulder so as to move it to oblique position Wood's screw-If above fails, 2 finger of opposite hand is used to press on anterior aspect of posterior shoulder Reverse Wood's: If unsuccessful, place 2 fingers on posterior shoulder to rotate to opposite direction

E-episotomy

Evaluate and perform episiotomy to facilitate obstetric manoeuver

MANAGEMENT

HELPERR -Help -Episiotomy -L (McRobert's position) -P (Suprapubic pressure) -E (Enter vagina for internal manoeuvers) -R (Removal of posterior arm) -R (Roll woman onto FOURS)

Complication of dystocia

Maternal -Postpartum hemorrhage -Genital tract trauma -Bladder atony -Femoral neuropathy -Psychological trauma Fetal -Brachial plexus injury -Clavicle and humerus fractures -spinal cord injury -Asphyxia -Stillbirth

L -McRobert's position

McRobert's position (flex and abduct hips) ~ Abduct hips, rotated outwards and flexed with the thighs touching the abdomen and the two assistants holding a leg each ~ Encourage maternal pushing ~ Lateral neck traction / downward axial traction on the fetus -straighten lumbosacral angle -increase A-P diameter of pelvis

P-Suprapubic pressure

Pressure by assistant with the flat hand of the hand laterally in the direction the baby is facing and posteriorly -Suprapubic pressure is applied continuous 30 s followed by rocking pressure for 30 s as effort to delivery -To reduce bis-acromial diameter -Dislodge impacted shoulder -Facilitate movement to oblique position

R-remove of posterior arm

Remove of posterior arm -fingers introduced to fetal axilla to bring the shoulder down and deliver the posterior arm

R-roll

Roll the woman into FOURS (Gaskin maneuver) if required

What is shoulder dystocia?

Shoulder dystocia is defined as a vaginal cephalic delivery that requires additional obstetric maneuvers to release the shoulder after the head has delivered and gentle traction has failed