Shoulder Dystocia
What is the turtle sign?
Usually, once the back of the neck impinges the symphysis pubis and the head is born, the head does not retract. But if the bottom part "turtles" back in, that is the turtle sign.
What words should you not use when documenting shoulder dystocia?
We never "pull" babies uptodate suggests not using traction --> use guidance
What is the "running start position?"
When Gaskin fails, the mother on all fours lifts the foot on the side of the baby's back and plants the sole of the foot down flat (sort of like a lunge)
When are complications associated with McRobert's most likely?
With epidural, because mom can't tell you it hurts.
What is Erb's palsy?
a result of paralysis or weakness in the shoulder muscles, the elbow flexors, and the forearm supinators.
Which women should you pay particular attention regarding shoulder dystocia?
abnormal GCT followed by a normal GTT
What is the Gaskin maneuver?
all fours
What is the first Rubin maneuver?
ask nurse to transabdominally rock the shoulders side to side
When is induction to prevent shoulder dystocia somewhat effective?
at 41w rather than at 42w
What is the relationship between risk factors and shoulder dystocia?
at least 50% of pregnancies complicated by shoulder dystocia have no identifiable risk factors
What is the goal of shoulder dystocia management?
atraumatic birth, not speed
What does the running start position accomplish?
causes the symphysis to "shrug off the fetal shoulder"
When can ultrasound help in preventing shoulder dystocia
detecting accelerated fetal growth earlier in the pregnancy --> so nutritional counseling can happen.
How is suprapubic pressure applied?
downward pressure, sweep (to the side), and release. - use heel of the hand or fist - best performed with fist and locked elbows - the force should be directed at about a 45 degree angle off the vertical to move the fetal shoulders down & laterally toward the fetal chest
When is planned cesarean delivery based on suspected macrosomia a reasonable strategy?
for the non-diabetic with an estimated fetal weight >5000g or the diabetic whose EFW is >4500g.
What should you NEVER do in the management of a shoulder dystocia?
fundal pressure
What is gentle downward traction w/r/t dystocia?
it is a DIAGNOSTIC tool, NOT a maneuver. If it doesn't work, STOP and start maneuvers.
What is ponderal index?
measurement of the leanness of a body
Indication for symphysiotomy?
not suggested unless all other maneuvers have failed and cesarean delivery is not possible.
Where should the suprapubic be applied in relation to the baby's body?
on the side of the baby's back (look at which side the baby's facing)
What type of pelvis has an increased incidence of shoulder dystocia?
platypelloid
Where is all vaginal access in these maneuvers?
posterior
What happens in a unilateral posterior shoulder impaction?
posterior shoulder is compacted firmly & tightly in the hollow of the sacrum
What happens in a bilateral posterior shoulder impaction?
posterior shoulder is held above the level of sacral promontory
Why is lithotomy a problem with shoulder dystocia?
restricts posterior movement of the sacrum
Why does a platypelloid pelvis have an increased incidence of shoulder dystocia?
short AP diameter
What should you do with a nuchal cord during dystocia?
should not be cut and clamped if at all possible.
How can you imagine the pressure in Rubin II?
shoulders toward each other anterior shoulder toward the face
Which position closes the inlet and therefore should be avoided during dystocia?
squat
What should you make sure you support during Rubin II?
support the head!
When obstetric help arrives, what should you do?
tell him or her what already has been done so as not to waste time.
What happens to the normal MOL in a shoulder dystocia?
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 adduce t& flex
What is the safest way to fracture the clavicle?
upward pressure against its midportion
How does the Gaskin maneuver work?
weight evenly distributed over all four extremities allows rotational movement around a transverse axis through the sacroiliac joints
There is some evidence to support doing what first instead of McRoberts?
when 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.
When does shoulder dystocia happen (in terms of MOL)?
when there is a large bisacromial diameter in the AP of the pelvis
In what period of time can most cases of dystocia be resolved?
within 4 minutes
What measures can prevent shoulder dystocia?
"...The preponderance of most current evidence is consistent with the view that most cases of shoulder dystocia cannot be predicted or prevented because there are no accurate methods to identify which fetuses will develop this complication.
What sequential management can usually resolve dystocia within 4m?
(a) McRoberts and suprapubic pressure, (b) rotational maneuvers, and (c) delivery of the posterior arm
What are some intrapartum risk factors for shoulder dystocia?
- Abnormal first stage - Molding early on - Prolonged second stage - Protracted descent - Arrest of descent - Failure of descent - Macrosomia - EFW documented? - male fetus
What is Zavanelli?
- Administer IV tocolytic (terbutaline 0.25 mg subcutaneously or Nitroglycerin 50-500 mcg IV) - Place a fetal scalp electrode - If restitution has occurred: manually rotate head to pre- restitution position of full extension and occiput anterior - Manually flex head & replace with gentle upward pressure using the palm of the hand - The other hand may be used to depress the perineum
What is abdominal rescue through hysterectomy?
- As the anterior shoulder is adducted & slightly rotated, the infant descends - Posterior arm is grasped & delivered - Abdominally applied direct downward pressure on the anterior shoulder allows the infant's body to be delivered
What are some of the potential injuries to the mother due to shoulder dystocia?
- Birth canal lacerations - Episiotomy extensions - Postpartum hemorrhage - Rectovaginal fistula - Symphyseal separation - Maternal morbidity from "last resort" measures
What are some of the potential injuries to the fetus due to shoulder dystocia?
- Bruising - Fracture of the clavicle or humerus - Hypoxia - Death - Injury to the Brachial Plexus (Erb's or Klumpke Palsy) resulting in loss of motor function to the affected arm, 10-15% of which are permanent
What is some evidence that might have you suspect cephalo-pelvic-disproportion?
- Cervical edema or swollen anterior lip - The head is coming through the cervix (i.e. caput) - head not well applied to the cervix - Arrested labor - Molding early on - Severe caput - Deflexion - Persistent asynclitism - narrow arch and/or a snug pelvis - early decels EARLY ON - "I can't feel the position" - "a good size baby" - wedging or fixation - shrinking cervix after amniotomy - overrding - premature pushing - reverse mueller (receding head between contractions)
What are the special care scenarios?
- Clavicular Fracture - Cephalic Replacement (Zavanelli Maneuver) - Symphysiotomy - Abdominal rescue through hysterotomy
What else should you consider when you diagnose dystocia?
- Drain bladder is distended - Evaluate need for episiotomy - R/O other causes of dystocia (such as impound presentation)
What are the definitions of macrosomia?
- EFW of birth weight ≥4500 grams Alternative: - EFW of birth weight >90th percentile for gestational age
What is the Flip-Flop maneuver?
- Get into Gaskin - Lift Leg for Running Start on the side of the infant's back - Go into the side of the baby's back, rotate the shoulders into the oblique (Rubin II) - Remove the posterior arm
What are some characteristics associated with recurrent shoulder dystocia
- Maternal prepregnancy weight higher than in index pregnancy - Greater maternal weight gain during pregnancy than in index pregnancy - Longer second stage of labor than in index pregnancy - EFW higher than birth weight in the index pregnancy - EFW greater than 4000 grams.
What are the primary maneuvers?
- Mc Roberts Maneuver - Suprapubic - Position Change: Gaskin Maneuver (all-fours) - Barnum Maneuver: Delivery of Posterior Arm
What is a reasonable first maneuver?
- Mc Roberts maneuver (reasonable initial Maneuver) - high success rate without increase in injury to the neonate
What intrapartum events are most related to shoulder dystocia?
- POSSIBLY precipitous or prolonged second stage - definitely vacuum and forceps
What can phrenic nerve injury result in?
- Partial paralysis of the diaphragm - Ipsilateral Horner's syndrome
How to do Woods Screw Maneuver
- Place one hand on the clavicle (chest side) of the posterior shoulder - Place one hand on the baby's back (scapula of the anterior shoulder) - Push the posterior shoulder around 1/2 circle so it becomes anterior (your hands will cross) - the back is kept uppermost to avoid deflexion of arms
How should you position the woman as soon as you diagnose dystocia?
- Position woman with her buttocks flush with the edge of the bed
What should you prepare for in the event of a shoulder dystocia?
- Prepare for full scale neonatal resuscitation - Prepare for postpartum hemorrhage
What is Horner's syndrome?
- Ptosis and pupillary meiosis (decrease in size) resulting from interruption of nerve fibers in the cervical sympathetic chain - The incidence has decreased with the reduction in forceps use over the last two decades
What are the rotational maneuvers?
- Shoulder Rotation (Rubin I & II) - Wood's Screw Maneuver
What is the relationship between obesity and shoulder dystocia?
- Shoulder dystocia is at least twice as likely to occur among obese mothers compared with normal weight controls, yet most such women experience uncomplicated vaginal births. - In the same manner that it generally impedes normal progress of labor among obese women, excess soft tissue likely adds to the true bony obstruction that begets shoulder dystocia in any woman, thereby increasing the severity of shoulder dystocia if and when it occurs in an obese woman. - Among women who experience a shoulder dystocia, severity of shoulder dystocia and likelihood of neonatal injury are greater if the mother is obese.
What are the first three things you should do when you diagnose shoulder dystocia?
- Stay calm: Simply waiting for the next contraction, even in births exhibiting a turtle sign, lowers the incidence of shoulder dystocia - Initiate dystocia clock: Some providers find it useful for a nurse to verbally note the passage of time in 60 second intervals - Call for help (attending, anesthesia, peds)
What is the classic posture of Erb's palsy?
- The affected arm hangs down and it is internally rotated, extended, and pronated. - 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. - The affected arm is held straight and internally rotated, with the elbow extended and the wrist and fingers flexed. - The function of the fingers is usually retained.
How is symphysiotomy done?
- The skin over the symphysis pubis and fibrocartilaginous area is infiltrated with local anesthetic. - Catheter is inserted. - The urethra is displaced laterally using the index and middle fingers placed against the posterior aspect of the symphysis or with a catheter - An incision made through the cartilaginous portion of the symphysis
What maneuver is superior when it comes to shoulder dystocia?
- There is no evidence that any one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury. - The initial choice and order of progression are at the provider's discretion.
What are the signs of shoulder dystocia?
- WCO (won't come out) - Neonatal Double Chin - Cranial Recoil aka "turtle sign"
What is Klunke's palsy?
- Weakness of the triceps, forearm pronators, and wrist flexors leading to a "clawlike" paralyzed hand. - Good elbow and shoulder function.
What happens in an 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
What are some risk factors for shoulder dystocia?
- baseline maternal obesity - excessive gestational weight gain - maternal diabetes - postdatism - history of shoulder dystocia
What are some factors that may effect maternal-pelvis disproportion?
- broad fetal shoulders - fetal congenital anomalies and tumors - maternal pelvic deformities from trauma or disease - short maternal stature (less than 4 feet 10 inches)
When should delivery of the posterior shoulder be considered?
- following the McRobert's - potentially just go straight to posterior shoulder - potentially do Gaskin then go to posterior
What is the Barnum maneuver?
- introduce the hand into vagina - locate posterior arm, splint fetal humerus - apply pressure to antecubital fossa - flex arm at the elbow - Grasp the forearm or hand & sweep the fetal arm across the chest - The fetal hand is grasped & extended along the chest & over the face
What is the second Rubin maneuver?
- most accessible shoulder is adducted intravaginally by counterclockwise pressure on the anterior shoulder for the fetus in LOT position - The shoulder is rotated into the oblique diameter of the pelvis
What are some benefits of the Gaskin maneuver?
- movement involved in the actual change in position may help disimpact the shoulders - the addition of gravity to the forces tending to push the posterior shoulder anteriorly, allowing it to slide over the sacral promontory
If Woods doesn't work initially, what should you do?
- reverse the maneuver - rotate the newly posterior shoulder back to the anterior - keeping back uppermost
What does McRobert's maneuver achieve regarding the mother's pelvis?
- straightens sacrum relative to lumbar spine (more room for the bisacromial diameter) - rotation of symphisis pubis cephalic and decrease in angle of inclination - moves the sacral promontory (and potentially shrug the posterior shoulder off) - Maternal lordosis is straightened - The sacral promontory is removed as a point of obstruction - The weight-bearing force is removed from the sacrum - The inlet is opened to its maximum - The inlet is brought perpendicular to the maximum expulsive force
When should shoulder dystocia be immediately suspected?
- turtle sign --> when the fetal head retracts into the perineum after expulsion due to reverse traction from the shoulders being impacted in the pelvic inlet
What is the average bisacromial diameter?
12.4 cm.
What is the definition of shoulder dystocia
A birth that requires additional obstetric maneuvers following failure of gentle downward traction (guidance) on the fetal head to effect delivery of the shoulders.
What is the relationship between shoulder dystocia and post-term pregnancies?
A significant proportion of births complicated by shoulder dystocia occur in post-term pregnancies, although the majority of post-term pregnancies are not complicated by shoulder dystocia
What ethnic differences have been reported regarding shoulder dystocia?
African American women and "non-Caucasian" women reported to have increased incidence. But it is unclear -> recent studies also suggest there is no difference, or that hispanic women have decreased incidence.
What is the relationship between EFW and shoulder dystocia?
Approximately 50 percent of shoulder dystocias occur in infants with birth weight <4000 g
Why is persistent asynclitism a problem?
Baby should straighten out and go into the AP diameter as it enters of the midpelvis
What do you need to do if you are trying to perform Barnum and there's a posterior arm?
Bring the arm that's behind the back around the chest.
What location causes Erb's palsy?
C5 and C6 (sometimes C7)
What location causes Klunke's palsy?
C8 and T1
When do you need to catch accelerated growth to make an impact on shoulder dystocia?
Early in the third trimester
What does McRobert's maneuver achieve regarding the fetal body?
Elevates the anterior shoulder and flexes the fetal spine toward the anterior shoulder. This lifting and flexion push the posterior shoulder over the sacrum and through the inlet.
Which type of palsy is 80% of injuries related to shoulder dystocia?
Erb's
What are some complications associated with McRobert's?
Excessive force or prolonged placement of the patient's legs in a hyperflexed position has led to maternal complications such as - symphyseal separation - sacroiliac joint dislocation - transient lateral femoral cutaneous neuropathy
When can you not deliver the posterior shoulder using traditional Barnum?
If there is a posterior arm (from a long arc rotation)
What is McRobert's maneuver?
Legs sharply flexed upon abdomen
Which maneuver is suprapubic pressure often applied with?
McRobert's
Is labor induction for suspected macrosomia effective in decreasing the occurrence of shoulder dystocia?
No
Is planned cesarean delivery based on suspected macrosomia a reasonable strategy to avoid dystocia?
No
Where should you NOT have your hands during a shoulder dystocia?
No pointing fingers toward the neck
What are three P's of shoulder dystocia?
No pushing No pulling No pivoting
When should you attempt maneuvers?
ONLY BETWEEN contractions Instruct the mom not to push
When should episiotomy happen with a shoulder dystocia?
Only if you need room to perform the maneuver. Otherwise episiotomy confers no benefit averting neonatal injury.
What is the relationship between shoulder dystocia and diabetes?
Pregnant women with diabetes are two to six times more likely to experience shoulder dystocia than women who do not have diabetes
What should you tell the women as soon as dystocia is diagnosed?
She should stop pushing
What is a helpful memory device for Rubin II?
Shoving Scapulas Saves Shoulders
What is important to keep in mind about Zavanelli?
The hollow of the sacrum MUST be empty -- check first
What does the Barnum maneuver accomplish?
The shoulder girdle is then rotated into one of the oblique diameters of the pelvis, and the anterior shoulder can usually be delivered
