Shoulder Dystocia

The reverse corkscrew involves the

applying pressure to the posterior aspect of the posterior shoulder.

Shoulder Dystocia occurs when

the anterior shoulder becomes trapped behind the symphysis pubis after delivery of the fetal head. The posterior shoulder maybe in the hollow of the sacrum or high above the sacral promontory. The impaction is at the pelvic inlet and the force of gravity will keep the fetus against the mothers uterus and pelvis.

What is the Zavanelli manoeuvre

the mechanism of reversing delivery by flexing the fetal head and returning it to the vagina. .

Abduct

to draw away from a position near or parallel to the median axis of the body

Maternal complications

-3 or 4th degree tears -Lacerations and or haematoma -Uterine rupture -Postpartum haemorrhage -Psychological trauma

Fetal injuries

-Brachial plexus injuries -Hypoxia ischemic encephalopathy -broken clavicle

Warning signs of shoulder dystocia are

-Difficulty with delivery of the face and chin -'Turtle neck' head retraction after the head is born against the perineum -No restitution of the head -Gentle traction does not effect delivery

Erbs

-Lateral trunk -C5 C6 C7 -Adducted shoulder -extended elbow -flexed wrist

Klumpkes Palsy leads to

-Medial trunk -C8 and T1 -Paralysed claw hand with good shoulder and elbow function

Factors that may indicate shoulder dystocia

A high head at term Prolonged first or second stage Ocytocic Augmentation Failure of head to descend Assisted births.

How long should manoeuvres be attempted for

A max of 30secs each Note time of each manoeuvre

Shoulder dystocia is diagnosed when

Additional manoeuvres are required to deliver the fetal shoulders after normal downward traction has failed

Shoulder dystocia is defined as

An impaction of the anterior shoulder against the maternal symphysis pubis after the fetal head has been birthed.

H

Call for Help

How is the posterior arm delivered

Carried out by inserting a hand into the vagina and following the posterior shoulder down the length of the humerus to the anticubal fossa. If the elbow is flexed the forearm or hand can be grasped and swept across the chest. If the elbow isn't flexed pressure can be applied in the anticubal fossa to flex the forearm. However because of impaction this is often unsuccessful and it is a matter of reaching further in so that the forearm can be grasped and brought across the chest and delivered in a sweeping motion (cat lick). Traction to the humerus should be avoided as this can cause a fracture. Once the posterior arm is delivered there will be more space for the anterior shoulder to enter the pelvis.

After traumatic event

Counsel woman and provide support. Clarify any questions the woman may have and listen if the woman wants to talk about it. Assess support systems and coping. Organise community supports if needed. Team debrief.

2nd E

Enter the vagina to perform the corkscrew (Rubins II)

Rubins II (corkscrew) is performed by

Entering the vagina posteriorly follow fetal back towards the symphysis pubis until the posterior aspect of the anterior fetal shoulder is located. Pressure is applied from behind the shoulder towards the fetal chest.

1st E

Episiotomy assess for

Steps in managing shoulder dystocia

H = Help (call for additional assistance) E = Evaluate for episiotomy L = Legs (McRoberts Manoeuver) P = Pressure (suprapubic) Rubin 1 E = Enter the vagina Rubin 11 R = Roll the patient (to hand and knees) R = Remove the posterior arm

L

Legs- Think Mc Roberts Maneuver- Knees to nipple

P

Pressure Suprapubic Rubins I

Risk factors

Prior shoulder dystocia Gestational diabetes Postdates pregnancy Macrosomia Maternal short stature High Pregnancy weight and high pregnancy weight gain Abnormal pelvic anatomy Induction of labour or sometimes unexpected

2nd R

Remove the posterior arm

1st R

Roll the patient (to hand and knees)

How does Rubins I work to dislodge shoulders.

Simultaneous suprapubic pressure can shorten the bisacromial diameter, displace the impacted shoulder into the oblique diameter and effect delivery

Adduct

To draw inward toward the median axis of the body or toward an adjacent part or limb