Shoulder dystocia - kau

Shoulder dystocia - kau

Abdulkareem Fayoumi Definition . Incidence .

Consequences . Risk factors .

Management. A head-to-body delivery time > 60 seconds due to impaction of the shoulder ( anterior )against the symphsis pubis.

Williams Ob Use of any of the obstetric maneuvers to release the shoulder after gentle downward traction has failed. RCOG ,2005

Mean time of N delivery 24 sec. Mean time of delivery with dystocia 79 sec.

0.6 1.4 % ( defenition,population and weight ). An obstetric emergency.

Increased maternal morbidity. Increased fetal morbidity & mortality .

PPH ; 11 % - atony -soft tissue trauma ; 3rd & 4th degree tears 3.8% Symphyseal diathesis ( rare )

Uterine rupture ( rare ) Fetal injury ; - brachial plexus injury 4-16 % . - fractures of clavicle and humerus .

Fetal hypoxia ; - neurological damage . - death . 4-6 % . Due to downward traction on the neck .

Most important fetal effect . Most common cause for litigation in SD . Independent of operator experience . GOOD NEWS >80 % of cases have complete resolution by 6-13 months. Maternal :

previous SD. Obesity. Multiparity. DM. Fetal : Macrosomia

postdate. short stature. IUFD abN pelvic anatomy. Instrumental delivery

NO BUT there is a room for prediction & anticipation. Good glycmic control.

Control weight gain. Identifying risk factors. >50 % of SD cases occur with average weight Babies < 4 kg !!!

so always be ready unpredictable ..unpreventable

Prepare : educate/involve the ptn ahead of delivery. declutter the room . senior person . empty the bladder . STAY CALM !!!

HELPERR Each step 30-60 Sec

For a total Maneuvers) 3- 5 minutes (All No indication that any of these maneuvers

is superior, they represent a valuable tool to help clinicians take effective steps to relieve impacted shoulder ( Category C ) ACOG..October 1997 1. Increase the size of the bony pelvis

2. Decrease bisacromial diameter 3. Change the relation of bisacromial diameter within the bony pelvis .

Prolonged 1st & 2nd stage of labor. Head bobbing ( turtle sign ), then retracting back in the birth canal.

Minimal downward traction does not affect delivery. Do NOT ask the patient to push.

Do NOT apply fundal pressure. ( Grade C ) Do NOT panic !!

RCOG guidelines..December,2005 Call for help SD drill..team work. documentation. Evaluate for Episiotomy

Not for all cases ( Grade B ) Before delivery. Helps when applying the maneuvers RCOG guidelines December,2005 Legs Safe Simple Effective

( McRoberts ) ( used alone resolves 40 % of SD ) Straighten the sacrum. Moves the symphsis pubis toward the maternal head frees the impacted shoulder

Suprapubic Pressure determine the position of the fetal back Initially..continuous Then..in CPR-like rocking motion. Enter=internal Maneuvers : Rubin Woods

Screw Rubin I : rocking the fetus shoulder from side to side. Rubin II : reach for the most easily shoulder &

push it forward decrease the bisacromial diameter . Rotate the posterior shoulder 180 degrees

approach post. Shoulder from front. ant. Shoulder from behind. Reverse woods screw posterior shoulder from behind.

Remove the posterior Arm Never grasp / pull on the hand fractures Roll the patient

Might be disorienting for the unfamiliar doctor Increase the obstetric conjugate by 1.5 cm Gravity?? Movement itself?? Same maneuvers can be applied Deliberate clavicular fracture.

Zavenilli maneuver. Symphysiolotmy.

Cleidotomy. Abdominal surgery + hysterotomy (tocolysis,replace head->CS )

( risk of UT/SP injury ) ( with a dead fetus ) reports,same maneuvers ) ( case

Always be ready and calm while dealing with SD. Know your HELPERR

Always document ( time , manuevers used, duration, involved arm ) Now we will move to practice plz!! Thank you!!

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