Shoulder dystocia

T/F: Suspected fetal macrosomia is not a contraindication to a trial of labor after cesarean (TOLAC).

True

T/F: The duration of the shoulder dystocia alone is not an accurate predictor of neonatal asphyxia or death.

True

T/F: The forces of labor, fetal position, and maternal pushing may be sufficient to cause excessive traction on the brachial plexus and fetal bones

True

T/F: There is no evidence that any one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury.

True

T/F: in a shoulder dystocia delivery measuring clinician traction during the delivery, delivery of the posterior arm resolved the shoulder dystocia with half the force used during an earlier unsuccessful attempt using McRoberts maneuver?

True

T/F: shoulder dystocia is initially managed with shoulder rotation, Woods maneuver, or delivery of the posterior arm, the injury rate is significantly lower than when initially managed with McRoberts maneuver and traction?

True

T/F: the greatest risk with the delivery of the posterior arm is fracture of the humerus?

True

T/F: the single greatest risk factor for permanent neonatal brachial plexus injury is clinician-applied lateral traction during antecedent shoulder dystocia?

True

True or false: the Barnum maneuver (Jacquemier's maneuver) is when you bring out the fetus' posterior arm?

True

T/F A study found that cutting an episiotomy to prevent brachial plexus injury when a shoulder dystocia is encountered, held no real benefits

True (slide 91)

Sign suggestive of shoulder dystocia

Turtle sign (when the fetal head retracts into the perineum after expulsion d/t reverse traction from the shoulders being impacted in the pelvic inlet)

Why using shoulder dystocia maneuvers that minimize or eliminate direct application of traction to the fetal head important?

a. Because it reduces the risk of neonatal brachial plexus injury

Describe how you would deliver the arm(s) behind the back after long arc rotation.

a. Bring the arm that is behind the back around to the chest b. Deliver the posterior arm

When do we do a modified Woods Screw Maneuver?

a. If the previous Woods Screw Maneuver does not effect release of the shoulders and birth.

What will you do if this technique does not deliver the posterior arm?

a. If this does not effect delivery, the body is rotated ½ circle to bring the posterior, and the maneuver is repeated to deliver the other arm.

When should you reserve posterior auxiliary sling retraction?

a. It should reserve for cases of severe shoulder dystocia in which all other methods have failed

When can we do a modified Menticoglou maneuver to deliver the posterior arm in severe shoulder dystocia?

a. Multiparous with type II DM b. First pregnancy resulted: AVD (midpelvic vacuum), and SD (McRoberts) c. Index pregnancy with poor glucose control resulted in: induction at 37 weeks; AVD (vacuum); failed: McRoberts' suprapubic pressure, Rubin's and Wood's Screw.

Describe the Letellier Maneuver AKA posterior shoulder above sacral promontory?

a. One uses the hand corresponding to the fetal back (right hand for the left shoulder, left hand for the right shoulder). b. One reaches upward and tries to hook the index finger into the posterior part of the axilla and the thumb in the anterior part of the axilla c. Instead of trying to pull the posterior shoulder directly downward the posterior shoulder is pushed in the direction of the pubis while simultaneously rotating it along the pelvic brim. d. If one is fortunate, the posterior shoulder can be rotated under the pubis and the arm brought down.

How do we do a modified Woods Screw Maneuver?

a. Reverse the maneuver i. Rotate the newly posterior shoulder back to the anterior ii. Keeping back uppermost

What is another way to deliver the posterior arm?

a. The operator has already inserted a hand into the vagina and delivered the posterior arm by sweeping it across the fetal chest. b. Thus delivered the posterior shoulder as well c. A 13cm bisacromial diameter becomes an 11cm axillo-acromial diameter upon delivery of the arm

Explain: closed loop communication. * check back * team debriefing

closed loop: - call for___ "I called for ___ as requested" check back : "do you mean suprapubic pressure?" team debrief: *what just happened * how did this go * improvements for next time

shoulder dystocia - things to tell the family after

communication is important. (communication is often interpreted as guilt), make sure whole team has a consistent story, if neuro injury present..."wait & see", discuss importance of maneuvers performed, they are "lifesaving" difficult to predict, discuss events more than once

Describe the Posterior axilla sling traction (PAST), (posterior shoulder in sacral concavity) AKA a technique for Intractable shoulder dystocia?

i. A size 14 F suction catheter is looped over the right index finger and inserted transvaginally around the fetus' posterior axilla ii. The catheter loop is passed from the right index fingertip to the left index finger to form a sling around the fetus's axilla iii. The catheter loop is withdrawn from the vagina by the left index finger iv. The catheter position indicating the direction in which traction is applied v. Use of this sling could create a laterally derived traction force that potentially could widen the angle between the neck and upper shoulder further, thereby stretching the brachial plexus.

When do we use the Menticoglou maneuver?

i. For the delivery of the posterior shoulder - if it is not possible to reach the elbow or forearm because the posterior arm is above the pelvic brim ii. A preferred posterior axilla maneuver because it can be accomplished rapidly; requires no equipment, such as a sling catheter; and the provider has good tactile feedback throughout the application of gentle force.

Describe how to do the Barnum maneuver (Jacquemier's maneuver).

i. Introduce hand into the vagina, ii. locate the posterior arm, iii. splint fetal humerus, iv. apply pressure to antecubital fossa, v. flex arm at the elbow. vi. Grasp the forearm or hand and sweep the fetal arm across the chest vii. The fetal hand is grasped and extended along the chest and face viii. The shoulder girdle is then rotated into one of the oblique diameters of the pelvis, and the anterior shoulder can usually be delivered ix. Delivery of the posterior arm.

Describe the "rotational maneuver AKA Woods Screw Maneuver"

i. Place one hand on the clavicle (chest side) of the posterior shoulder ii. Place one hand on the baby's back (scapula of the anterior shoulder) iii. Push the shoulder around ½ circle so it becomes anterior iv. By pressing on the baby's chest side to effect the rotation, the back is kept uppermost to avoid deflexion of arms.

What other maneuvers for shoulder dystocia reported in the literature?

i. Posterior axilla sling traction (PAST), (posterior shoulder in sacral concavity) ii. Letellier Maneuver (posterior shoulder above sacral promontory) iii. Shoulder Shrug maneuver

What do we do if birth does not occur?

i. Stop ii. Regroup iii. Reattempt [posterior arm delivery iv. Reattempt rotational maneuvers v. As that the OR be set up after 3-3.5 minutes vi. Posterior axilla sling traction (PAST) (Posterior shoulder in sacral concavity) vii. Letellier maneuver (Posterior shoulder above sacral promontory) viii. Shoulder Shrug Maneuver

How do we use the Menticoglou maneuver?

i. The right and left 3 rd fingers are locked into the posterior axilla, one finger from the front and one from the back of the fetus. ii. Gentle downward guidance is provided by the fingers to draw the posterior shoulder down and out along the curve of the sacrum, thus releasing the anterior shoulder iii. An assistant gently holds the head up iv. Once the shoulder has been brought down sufficiently, the posterior arm can be grasped and delivered.

symphysiotomy - steps

lidocaine -catheter inserted - urethra displaced laterally - incision made through cartilaginous portion of the symphysis - not recommended unless all other maneuvers have failed and c/s is not possible

primary nurse v secondary nurse roles (for dystocia) (4)

primary: call team secondary: *located at the head of the bed *calls out time in 60 second intervals *record *communicates practitioners requests to the woman

Shoving _____________ saves ____________

scapulas, shoulders

T/F: Axial traction is applied in alignment with the fetal cervico- thoracic spine and has a downward component (without lateral deviation) typically along a vector estimated to be 25-45 degrees below the horizontal plane when the laboring woman is in a lithotomy position.

true

Shoulder Dystocia: Anterior Shoulder Impaction

*Anterior Shoulder Impaction: - anterior shoulder is overriding the superior aspect of the pubic bone in the midline. - is unengaged & lying in an oblique diameter, or - is engaged in an oblique diameter & is unable to descend further or to rotate internally.

Shoulder Dystocia: Posterior Shoulder in Anterior Impaction

*Posterior Shoulder in Anterior Impaction (debate by authors- possible both opinions are correct): 1. bilateral dystocia: - posterior shoulder is held above the level of sacral promontory 2. unilateral dystocia: - posterior shoulder is compacted firmly & tightly in the hollow of the sacrum

Effects of McRoberts

*elevates the anterior shoulder & flexes the fetal spine toward the anterior shoulder. This lifting & flexion push the posterior shoulder over the sacrum & through the inlet. *maternal lordosis is straightened *sacral promontory is removed as an obstruction *weight bearing force is removed from he sacrum *the inlet is opened to its max *the inlet is brought perpendicular to max expulsive force

Role of leader during shoulder dystocia (4)

*identify shoulder dystocia & announce it clearly to the team *designates roles of team members *perform & direct maneuvers *when OB help arrives tell them what has already been done as not to waste time

Who should be called for a shoulder dystocia?

*nursing *obstetric *anesthesia *pediatrics *respiratory therapy

grouping of maneuvers (preparing)

*prepare for full scale neonatal resuscitation , PPH *lower head of bed and position woman with buttocks at edge of bed *drain bladder if distended *evaluate need for episiotomy *r/o other causes of dystocia (compound presentation) *if a nuchal cord & can't correct, clamp and cut *attempt maneuvers between ctx *no more than 30 secs on each maneuver

3 initial steps prior to actively managing shoulder dystocia

*simply wait for the next contraction to allow for normal restitution *if restitution does not occur, assess the location of the shoulders prior to initiating any maneuvers *if the shoulders are in the AP diameter *Rubin 1 - transabdominally rock side to side *Rubin 2- intravaginally adduct & reposition accessible shoulder to oblique

describe suprapubic pressure during shoulder dystocia

*stool in room *assistant applies oblique suprapubic pressure with heel of hand or fist to free the anterior arm (fist and locked elbows) *force should be directed at about a 45 degree angle off the vertical to move the fetal shoulder down & laterally toward the fetal chest

Signs of Shoulder Dystocia

1. "WCO" Won't come out! 2. Neonatal Double Chin 3. Cranial Recoil "turtle sign"

Minor Abnormalities of Carbohydrate Metabolism

1. Abnormal GCT & normal GTT 2. At risk for birthing a macrosomic infant 3. Even those women whose glucose screens are >130 mg/dl with normal GTT's are at higher risk of birthing a macrosomic infant than those with a GCT <130 mg/dl 4. These women birth higher-birthweight infants than women with overt gestational diabetes owing to comparatively less attention paid to diet, weight gain, and overall fetal growth patterns.

Potential Injuries to the Mother with shoulder dystocia

1. Birth canal lacerations - 2-3 fold increase in 3rd & 4th degree lacerations with macrosomia 2. Episiotomy extensions 3. Postpartum hemorrhage 4. Lateral femoral cutaneous neuropathy - From aggressive hyperflexion of the maternal legs 5. Rectovaginal fistula 6. Symphyseal separation 7. Maternal morbidity from "last resort" measures

Potential Fetal Injuries with shoulder dystocia

1. Bruisingn 2. Fracture of the clavicle or humerus 3. Hypoxia 4. Death 5. Injury to the Brachial Plexus (Erb's or Klumpke Palsy) resulting in: - Loss of motor function to the affected arm - Permanent dysfunction - 3%-33% of injuries are permanent

Erb-Klumpke palsy

1. Complete brachial plexus injury 2. Involving C5-T1 3. Characterized by a flail, paralyzed arm without sensation or reflexes.

Reasons for differences in reported rates of shoulder dystocia

1. Differences in definition. 2. Reliance on providers clinical judgement to determine whether ancillary maneuvers are actually necessary. 3. Variability between study population.

What causes brachial plexus injury by exertion extreme amounts of traction & flexion on the infant's neck?

1. Fundal pressure 2. Many cases are not due to shoulder dystocia or excessive force by the provider. 3. The forces of labor, fetal position, and maternal pushing may be sufficient to cause excessive traction on the brachial plexus.

Definition of Macrosomia

1. Growth beyond an absolute birth weigh. 2. Historically 4,000g or 4500g, regardless of gestational age - Most commonly used definition in developed countries: >4500g - Risk of morbidity increases sharply when birth weight is >4500g - Risk of mortality increases significantly when birth weight is >5000g 3. Establishing a universally acceptable definition has been challenging.

Pathophysiology of shoulder dystocia

1. If the fetal shoulders remain in an AP position during descent or descend simultaneously rather than sequentially into the pelvic inlet, then - the anterior shoulder can become impacted behind the symphysis pubis and/or - the posterior shoulder may be obstructed by the sacral promontory - Neither shoulder has a chance to adduct & flex 2. A persistent AP location of the fetal shoulders at the pelvic brim can occur in the following: - Increased resistance between the fetus & vaginal walls (fetal macrosomia). - Large fetal chest relative to the biparietal diameter (fetuses of diabetic mothers). - Truncal rotation does not occur (precipitous labor.

Risk factors of shoulder dystocia

1. In the majority of cases, shoulder dystocia can neither be prevented nor predicted. 2. Many women without any risk factors develop shoulder dystocia - at least 50% of pregnancies complicated by shoulder dystocia have no identifiable risk factors (UpToDate 2019). 3. Principle risk factors include: - Fetal macrosomia *Approximately 50 percent of shoulder dystocias occur in infants with birth weight <4000 g (UpToDate 2019) - Maternal diabetes - History of Shoulder Dystocia in a prior pregnancy

3 ways a persistent AP location of the fetal shoulders at the pelvic brim can occur

1. Increased resistance between the fetus & vaginal walls (fetal macrosomia) 2. Large fetal chest relative to the biparietal diameter (fetuses of diabetic mothers) 3. Truncal rotation does not occur (precipitous labor)

Primary maneuvers of mngmt of shoulder dystocia

1. Mc Roberts Maneuver 2. Suprapubic pressure 3. Position Change: FlipFLOP - Flip woman with Gaskin Maneuver - Lift the Leg for Running Start on Side of Baby's Back - Rotate to the Oblique (Rubin II Maneuver) - Bring out the Posterior Arm OR 4. Barnum Maneuver While in McRoberts: Delivery of Posterior Arm - Menticoglou Maneuver

Can Fundal Height Measurements Predict Fetal Macrosomia ?

1. Measurement of the symphysis-fundal height alone is a poor predictor of fetal macrosomia. 2. Although fundal height measurement has a greater sensitivity for fetuses exceeding 4,500 g, the utility of this measurement alone is questionable.

Is there any benefit to planned cesarean birth for the prevention of the complications of shoulder dystocia in cases of suspected fetal macrosomia?

1. Most fetuses with macrosomia that are delivered vaginally do not experience shoulder dystocia. 2. Elective cesarean delivery should be considered for - women without diabetes who are carrying fetuses with suspected macrosomia with an estimated fetal weight of at least 5,000 g and for - women with diabetes whose fetuses are estimated to weigh at least 4,500 g

3 P's of management of shoulder dystocia

1. No Pulling 2. No Pushing 3. No Pivoting

Phrenic Nerve Injury results in ....

1. Partial paralysis of the diaphragm 2. Ipsilateral Horner's syndrome: - Ptosis and pupillary meiosis (decrease in size) resulting from interruption of nerve fibers in the cervical sympathetic chain

Special Care Scenarios of mngmt of shoulder dystocia

1. Posterior axilla sling traction (PAST) 2. Letellier Maneuver 3. Shoulder Shrug Maneuver 4. Clavicular Fracture 5. Cephalic Replacement (Zavanelli Maneuver) 6. Abdominal Rescue through Hysterotomy 7. Symphysiotomy

Macrosomia: Risk Factors

1. Preexisting maternal diabetes 2. Uncontrolled gestational diabetes 3. Maternal prepregnancy obesity 4. Excessive gestational weight gain 5. Prior macrosomic infant 6. Postterm pregnancy 7. Maternal nonsmoking status

Rotational Maneuvers of mngmt of shoulder dystocia

1. Shoulder Rotation (Rubin I & II) 2. Wood's Screw Maneuver

Platypelloid pelvis and shoulder dystocia

1. Shoulder dystocia 8 to 10 times more frequent 2. Wide subpubic arch 3. Straight or divergent side walls 3. Wide interspinous diameter 4. Flat anterior & posterior segment at the inlet 5. Short AP diameter

Success of mngmt of shoulder dystocia depends on what 3 factors?

1. Size of the infant 2. Position of the fetal arm 3. Space available in the birth canal

Can Ultrasound Be Utilized to Predict Shoulder Dystocia?

1. Studies comparing the accuracy of ultrasonography with that of physical examination for the detection of macrosomia have been inconsistent. 2. None have proven that ultrasonography is superior to physical examination in a clinically meaningful way. 3. Parous women appear to be able to predict the weight of their newborns as well as clinicians who use ultrasound measurements or clinical palpation maneuvers.

Erbs Palsy or Duchenne's Palsy

1. The classic posture is a result of paralysis or weakness in the shoulder muscles, the elbow flexors, and the forearm supinators. 2. The affected arm hangs down and it is internally rotated, extended, and pronated. 3. Oftentimes, the C7 nerve is also involved, causing loss of innervation to the forearm, wrist, and finger extensors. The loss of extension causes the wrist to flex and the fingers to curl up—the "waiter's tip" position. 4. The affected arm is held straight and internally rotated, with the elbow extended and the wrist and fingers flexed. 5. The function of the fingers is usually retained.

Macrosomic infants of diabetic mothers

1. There are differences in the anthropomorphic measurements of infants of diabetic mothers (IDMs) compared to offspring of women without diabetes. 2. Prone to asymmetrical increase in shoulder & truncal fat. 3. The chest-to-head and shoulder-to-head ratios are increased in IDMs, thereby increasing the risk of shoulder dystocia independent of fetal weight.

Klumpke's Palsy

1. Weakness of the triceps, forearm pronators, and wrist flexors leading to a "clawlike" paralyzed hand. 2. Good elbow and shoulder function. 3. only 40% of Klumpke's palsies resolve by 1 year of life

When should C/S be considered with macrosomia?

1. With DM EBW>5000g 2. With DM EBW>4500g

Explain bilateral and unilateral dystocia

1. bilateral dystocia - posterior shoulder is held above the level of sacral promontory unilateral dystocia 2. posterior shoulder is compacted firmly & tightly in the hollow of the sacrum

Factors that may cause fetal-shoulder-maternal pelvis disproportion

1. broad fetal shoulders 2. fetal congenital anomalies and tumors 3. maternal pelvic deformities from trauma or disease 4. short maternal stature (less than 4 feet 10 inches)

Compression of the umbilical cord, reduced ...?... from prolonged increased intrauterine pressure, and ....?....

1. placental intervillous flow 2. secondary fetal bradycardia. Compression of the umbilical cord, reduced placental intervillous flow from prolonged increased intrauterine pressure, and secondary fetal bradycardia.

benefits of the gaskin maneuver

1. the movement may elicit the disimpaction of the shoulders 2. the additional gravity to the forces tending to push the posterior shoulder anteriorly; allowing it to slide over the sacral promontory

How much time does one have to deliver a previously well-oxygenated term infant before an increased risk of asphyxial injury occurs?

5 minutes

Neonatal asphyxia is a significant risk by _________ mins

5 minutes

Risk of morbidity increases sharply when BW is > .... g and mortality increases significantly when BW > .... g

> 4500g > 5000g

Definition of shoulder dystocia

A birth that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders.

Definition of LGA

A birth weight = or > than the 90th percentile for a given gestational age

Is there any benefit to labor induction for the prevention of shoulder dystocia in the setting of suspected macrosomia or diabetes?

At this time, and until the results of additional studies are reported, the ACOG continues to discourage induction of labor solely for suspected macrosomia at any gestational age.

What is the greatest risk of lateral traction?

Brachial plaxus injury

Cause of the brachial plexus injury with shoulder dystocia

Caused by extreme amounts of traction & flexion exerted on the infant's neck

Characteristics associated with recurrent shoulder dystocia

Characteristics associated with recurrent shoulder dystocia include: 1. Maternal prepregnancy weight is higher than in the previously affected pregnancy. 2. Greater maternal weight gain during pregnancy than in the previously affected pregnancy 3. Longer second stage of labor than in the previously affected pregnancy 4. Birth weight higher than birth weight than in the previously affected pregnancy 5. Birth weight greater than 4000grams. *The combination of a prior shoulder dystocia and fetal macrosomia may be particularly concerning.

Once the dystocia clock is started, what is the most important direction to give the woman?

Do not push during attempt to re-position the fetus (aka dont push until i tell you to)

rare complication of McRoberts

Excessive force or prolonged placement of pts leg is a hyper flexed position has led to maternal complication such as *symphyseal separation *sacroiliac joint dislocation *transient lateral memorial cutaneous neuropathy

T/F: checking for the shoulders before managing shoulder dystocia increases the risk of brachial plexus injury?

F, it reduces the risk

T/F Midwife should spend no more than 1 minute on each maneuver

False - 30 seconds

T/F suprapubic pressure during a shoulder dystocia should be done at a 90 degree angle

False - 45 degrees

T/F During Rubin 2 the shoulder is intravaginally adducted by clockwise pressure on the anterior shoulder in LOT position

False - counterclockwise (slide 99)

T/F during a shoulder dystocia all nuchal cord must be clamped & cut. if no nuchal cord, its ok to do delayed clamping

False - if the nuchal cord can be reduced, corrected it should not be clamped/cut

T/F symphysiotomy is widely used in the US

False - it is widely used in developing countries

T/F Clavicular fracture works by reducing the diameter of the fetal chest

False - it reduces the diameter of the shoulders

T/F fundal and suprapubic pressure should be combines with McRoberts

False - never fundal

T/F shoulder dystocia drills revealed that most people knew to insert their *whole* hand into the vagina using the *posterior* approach

False - people made the following mistakes: using anterior approach, using a lateral approach, only using 2 fingers, leaving the thumb outside

T/F the way to avoid subclavian vascular injury with a clavicular fracture is to fracture it by a downward pressure against its mid portion

False - safely = upward pressure against its mid portion

T/F the running start maneuver has the woman lift the leg on the opposite side of the baby back

False - same side as baby back

T/F Dystocia maneuvers should be attempted during ctx so the fundal pressure can help aid in getting the baby free

False - should be attempted between ctx

T/F Shoulder rotation into the oblique diameter of the pelvis and abduction of shoulders is known as Rubin 1

False 1) adduction 2) Rubin 2

T/F the gaskin maneuver is a knee to chest position

False hands and knees

T/F: shoulder dystocia is 3x more likely to occur among mothers who are obese compared to normal weight

False: 2x

T/F: about 50% of shoulder dystocia occur in infants with BW of <3500g

False: < 4000g

T/F: If shoulder dystocia >3-4 minutes severe asphyxia can occur

False: >5-7 minutes severe asphyxia can occur

T/F: Klumpke's palsy is more common than Erb's palsy

False: Erb's palsy is 80% of brachial plexus injuries.

T/F: Goal of management: fast birth, not atraumatic birth

False: Goal of management: atraumatic birth, not speed

T/F: ACOG says induce suspected macrosomia @ any GA

False: They discourage induction of labor solely for suspected macrosomia

T/F: Lower-arm function differentiates Klumpke's palsy from Erb's palsy.

False: Upper-arm function differentiates Klumpke's palsy from Erb's palsy.

T/F: Use minimal & very gentle lateral traction (on the fetal head and neck - not the fetal shoulder).

False: Use minimal & very gentle lateral traction (on the fetal shoulder - not the fetal head & neck).

T/F: If the anterior shoulder gets impacted behind the symphysis and posterior shoulder is obstructed by the sacral promontory than the shoulders don't have the chance to abduct and extend

False: adduct and flex

T/F: Clinical pelvimetry is not useful in predicting shoulder dystocia. So it should not be included in mngmt since it causes so much discomfort.

False: easily performed without increased risk or expense, must be considered an integral part of the evaluation of labor.

T/F: The quantity of the carbohydrates rather than the quality in diet affects insulin sensitivity, glucose response curves, gestational weight gain and BW

False: it's the quality rather than quantity

T/F: Waiting for the next contraction, in deliveries exhibiting a turtle sign, actually increases the incidence of shoulder dystocia.

False: lower the incidence of shoulder dystocia

T/F: Planned C/S may be reasonable for non-diabetics with EFW > 5500g or diabetics > 4000g

False: non-diabetics - >5000g, diabetics - >4500g

T/F: fundal height is a great predictor of fetal macrosomia

False: poor predictor

T/F: Most cases of shoulder dystocia (95%) can be resolved within 3 minutes by the sequential use of (a)McRobert's and suprapubic pressure, (b)rotational maneuvers, and (c)delivery of the posterior arm.

False: within 4 minutes

position change - flip flop

Flip woman with gaskin maneuver, lift the Leg for running start on the side of the baby back * rotate to the Oblique (rubin 2) * bring out the Posterior arm

What are the 4 "maneuvers" used in special care scenarios

Fracture the clavicle Cephalic replacement (Zavanelli maneuver) Abdominal rescue (through hysterotomy) Symphysiotomy

Describe the "running start position."

It is a position that is used when the Gaskin maneuver fails. The mother is on all fours, lifts one leg and plants the sole of the foot down flat. This movement causes the symphysis to "shrug off the fetal shoulder."

Barnum maneuver - also known as --

Jacquemiers maneuver

What is the reasonable initial maneuver for mngmt of shoulder dystocia?

Mc Roberts maneuver

Shoulder Dystocia: PREVENTION (Williams Obstetrics 25th ed. 2018 & ACOG, 2017 (Reaffirmed 2019))

PREVENTION: "...The preponderance of most current evidence is consistent with the view that: 1-Most cases of shoulder dystocia cannot be predicted or prevented because there are no accurate methods to identify which fetuses will develop this complication. 2-Ultrasonic measurements to estimate macrosomia have limited accuracy. 3-Planned cesarean delivery based on suspected macrosomia is not a reasonable strategy. 4-Planned cesarean delivery may be reasonable for the non-diabetic with an estimated fetal weight >5000g or the diabetic whose EFW is >4500g.

Describe Zavanelli maneuver

Reverse the cardinal movements of labor and then replace the fetal head into the pelvis and proceed with c/section. ****hollow of sacrum must be empty (rare) for the babies head to fit back in

Explain Rubin 1 & 2

Rubin 1 - Anterior shoulder is transabdominally disimpacted by rocking it from side to side. Rubin 2 - The most accessible shoulder is adducted intravaginally, reducing the shoulder circumference & transverse diameter

PeriGen Shoulder Screen

Step 1. A simple checklist applied at 36 weeks identifies which expectant mothers are recommended for further testing. Additional mothers may be tested, if desired. Step 2. Clinicians enter seven common items, such as mother's height and weight, gestational age and estimated fetal weight, on their own secure PeriGen Shoulder Screen website. Step 3. A risk assessment is then calculated by the application, which provides graphical and numerical estimates of the mother's risk. Step 4. The website contains specialized consent forms so that a mother can attest to understanding her own risk, the limitations of estimating risk, available delivery options and her preference for delivery method.

Diagnosis of shoulder dystocia

The diagnosis can be made when the routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder.

Sequential use of (McRobert's and suprapubic pressure, rotational maneuvers, and delivery of the posterior arm have the greatest effect with delivery of which arm (posterior or anterior)?

The greatest effect was seen with delivery of the posterior arm, which decreased anterior nerve stretch by 71% (3.9% vs. 13.5%) and showed an 80% decrease in delivery force.

describe the shoulder shrug maneuver

The shoulder shrug technique involves shrugging the posterior shoulder and rotating the head-shoulder unit 180 degrees to resolve the shoulder dystocia. 1.Grasp the posterior shoulder at the axilla using the provider's thumb and index finger in a pincer grip so that the tips of the thumb and index finger come together in the axillary fossa. 2.Pull the axilla out toward the head of the neonate to shrug the shoulder and retract the shoulder toward the vaginal opening. 3.Maintain the pincer grip of the shrugged shoulder and, using the opposite hand, hold the head and retracted shoulder together as a unit 4.Rotate this unit toward the neonate's face 180 degrees (this will allow the impacted anterior shoulder to roll toward neonate's chest as it moves toward the posterior position). If unable to rotate toward the face, the opposite direction may be attempted. 5.As long as the shrugged shoulder remains inferior to the symphysis pubis, it will be deliverable anteriorly. 6.Now proceed with delivery of the remaining shoulder posteriorly. On rotation, the trapped anterior shoulder should be deliverable posteriorly.

Ultrasound Detection of Accelerated Fetal Growth

Those with AC greater than the 75th percentile (ie, with sonographic evidence of accelerated somatic growth compared with overall growth) within 3 weeks of delivery were 4 times as likely to experience shoulder dystocia compared with the general population.

Goal of Management of shoulder dystocia

To safely effect birth of the infant before asphyxia and cortical injury occur from umbilical cord compression and impeded inspiration, and without causing peripheral neurologic injury or other trauma.

T/F Rubin maneuver can be combines with McRoberts

True

T/F Rubin maneuvers resulted in less brachial plexus extension and required less traction force than McRoberts

True

T/F: 34-47% of the injuries are not associated with shoulder dystocia (4% occur after cesarean births)

True

T/F: 67%-97% of brachial plexus injury resolve without permanent disability

True

T/F: According to Retrospective review from 3 data sets, addition of episiotomy conferred no benefit in averting neonatal injury.

True

T/F: According to the current evidence study on the delivery of the posterior shoulder, "delivery of the posterior shoulder should be considered following the Mc Roberts maneuver and suprapubic pressure in the management of the shoulder dystocia?"

True

T/F: Although posterior auxiliary sling retraction may be worth attempting before initiating the Zavanelli maneuver or symphysiotomy, limited conclusions can be drawn at this time concerning the risk of iatrogenic neurologic injuries.

True

T/F: Among women who experience a shoulder dystocia, the severity of the dystocia and likelihood of neonatal injury are greater if the mother is obese

True

T/F: Brachial plaxus injury can happen with no evidence of shoulder dystocia, no evidence of extreme lateral flexion on the head and posterior shoulder involvement

True

T/F: Brachial plexus injury can occur at birth weights less than 4000 gms

True

T/F: Compared with those maneuvers that still use such traction, direct fetal manipulation confers greater mechanical advantage in resolving shoulder dystocia and should be prioritized in management algorithms?

True

T/F: Evidence suggests that lateral and downward traction, and rapidly applied traction are more likely to cause nerve avulsion.

True

T/F: In approximately 2/3 of the posterior arm injuries, there is no association with shoulder dystocia.

True

T/F: Pregnant women with DM are 2 to 6 times more likely to experience shoulder dystocia than women who do not have DM

True

T/F: Suspected fetal macrosomia is not a contraindication to a TOLAC

True