Shoulder Dystocia

(T/F) Studies have shown that prepregnancy, antepartum, and intrapartum risk factors have extremely poor predictive value for shoulder dystocia.

True - Be prepared to address it in all deliveries - High suspicion for increased birthweight and maternal diabetes - Prior hx increases risk - Fetal abdominal diameter-biparietal diameter is not clinically useful

(T/F) The presence of brachial plexus injury is not evidence that shoulder dystocia has occurred.

True - Not all brachial plexus injuries are associated with shoulder dystocia. - 50% of brachial plexus injuries are associated with uncomplicated vaginal deliveries

List the neonatal complication associated with shoulder dystocia.

- Brachial plexus injuries (10-20%) and fractures of the clavicle and humerus (most common) - Erb palsy (upper trunk C5-C6) - Klumpke palsy (lower trunk of brachial plexus) - Hypoxic-ischemic encephalopathy (mean time of delivery of 10.75 minutes in 1 study) - Death

Management of shoulder dystocia

- Diagnosis - Communication - Maneuvers: McRoberts, suprapubic pressure, delivery of the posterior arm, Rubin maneuver, Gaskin, Zanevelli, abdominal rescue - These maneuvers relieve shoulder dystocia in 4 minutes 95% of the time. - Routine use of episiotomy is supported by little evidence

Delivery of posterior arm

- High degree of success in accomplish delivery

List the maternal complications associated with shoulder dystocia

- Increased risk of postpartum hemorrhage (11%) - Higher degree perineal lacerations and obstetric anal sphincter injuries (rate of 4th degree laceration 3.8%) - Maternal symphyseal separation and lateral femoral cutaneous neuropathy (hyperflexion of the legs) - Cervico-vaginal lacerations, uterine rupture, urethral injury, and bladder laceration with "heroic" maneuvers such as Zavanelli

McRobert maneuver and suprapubic pressure

- Sharply flex thigh back against abdomen causing cephalad rotation of the symphysis pubis and flattening the lumbar lordosis - Assistant using fist or hand to apply pressure downward and laterally to abduct and rotate the anterior shoulder

What is the incidence of shoulder dystocia?

0.2 - 3% - This reported incidence is so wide because of the variability between study populations and reliance on delivering physician clinical judgement

Complete the sentence: the recurrence rate for shoulder dystocia is _______

1 - 16.7%. At least 10% reported in most studies. - May not be true incidence because of not attempting trial of labor after adverse neonatal outcomes

Role of stimulation training for shoulder dystocia

Effective tool in preparing for shoulder dystocia - After stimulation, frequency of evidence based management has increased. - Decrease in frequency of brachial plexus palsy

What is shoulder dystocia?

Failure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head requiring additional obstetric maneuvers to effect delivery

Documentation after shoulder dystocia

Follow the patient ACOG checklist

Is c-section recommended to prevent recurrent shoulder dystocia?

No - Risk and potential benefit should be discussed - Most subsequent deliveries will not be complicated by shoulder dystocia - Universal elective cesarean delivery is not recommended

Do labor abnormalities predict shoulder dystocia?

No - Some risks factors for prolonged second stage can be associated with increased risk which will help in deciding use of operative vaginal delivery.

Is suspected macrosomia an indication for induction?

No Elective c-section can be recommended for women without diabetes if EFW 5,000 g and with diabetes if EFW 4,500g

Is there any benefit to planned c-section for prevention of the complications of shoulder dystocia in cases of suspected fetal macrosomia?

No, most fetuses with macrosomia that are delivered do not experience shoulder dystocia - A study showed need for 3,695 c-setions to prevent one injury for macrosomia in setting of no maternal diabetes

Gaskin maneuver

Patient is placed on her hands and knees

Rubin maneuver

Placing hand on posterior fetal shoulder and rotate it anteriorly towards fetal face

Wood Screw maneuver

Rotates fetus by exerting pressure on the anterior clavicular surface of the posterior shoulder to turn the fetus until the anterior shoulder emerges from behind the maternal symphysis

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

Studies are inconsistent - With induction, studies shown there is a decrease rate of shoulder dystocia, no change in c-section rate.