distocia de hombros eduardo gandara residente1 igss

Distocia de hombros

Describir la historia clínica típica de la paciente y examen físico

apropiado e identificar los principales hallazgos clínicos

anormales

Etiología y Causas y signos clínicos de la distocia de hombros

Técnicas y Maniobras eutosicas para la atención de la distocia de

hombros

Técnicas y Maniobras distosicas para la atención de la distocia

de hombros

Complicaciones y morbi-mortalidad materna y neonatal de la

distocia de hombros

Fuentes

RCOG Guideline

December 2005

Cochrane Library

Medline

Falta de expulsión de la cintura escapular a

pesar de maniobras obstétricas sistémicas

después del nacimiento de la cabeza.

Se presenta en 0.23 a 2.9% de los partos

vaginales.

Dr. Gándara Matheu distocia de hombros clínicas de Norteamérica 2000.

There can be a high perinatal mortality

and morbidity associated with the

condition, even when it is managed

appropriately.

Maternal morbidity is also increased,

particularly postpartum haemorrhage

(11%) and fourth-degree perineal tears

(3.8%).

Background

Nacimiento del hombro posterior, no obstante

hombro anterior se impacta detrás de la

sínfisis del pubis e impedir descenso.


Los factores de riesgo para la

prediccion de distocia de hombros son

insuficientes para permitir la

prevencion en la mayoria de casos

con factores de riesgo.

Grade B

A number of antenatal and intrapartum

characteristics have been reported to be

associated with shoulder dystocia .

There is a relationship between fetal size

and shoulder dystocia but it is not a good

predictor.

Prediction

Evidence level III


Maternos:

Parto precipitado

Dilatación mayor de 5cms/hora en Multíparas

Dilatación mayor de 3cms/hora en Nulíparas

Estructura pélvica diferente a la ginecoide

(antropoide/androide)

Obesidad

Diabetes sacarina

Embarazo prolongado

Pelvis

Ginecoide


Pelvis

Androide

Pelvis

Antrop

oide


Fetal

Macrosomia

peso fetal al nacimiento mayor de 4000 gr

peso fetal estimado mayor de 4500 gr

50 a 90% de las distocias son fetos normales.

1.2 a 1.7% de fetos macrosomicos hacen distocia de

hombros

Conventional risk factors predicted only

16% of shoulder dystocia that resulted in

infant morbidity.

The large majority of cases occur in the

children of women with no risk factors.

Shoulder dystocia is, therefore, a largely

unpredictable and unpreventable event.

Prediction

Evidence level III


Solicitar ayuda!!!!!!

Evitar tracción excesiva y comprensión de

fondo uterino

• Aumento de la impactación de hombro

anterior

• Ruptura uterina por compresión fúndica

desordenada

Fundal pressure

Fundal pressure should not be employed.

Fundal pressure should not be used for the

treatment of shoulder dystocia.

It is associated with an unacceptably high

neonatal complication rate and may result in

uterine rupture.

Evidence level IV

Grade C

An experienced obstetrician, should be available

on the labour ward for the second stage of labour

when shoulder dystocia is anticipated.

However, it is recognized that not all cases can be

anticipated and therefore all birth attendants

should be ready with the techniques required to

facilitate delivery complicated by shoulder

dystocia.

Intrapartum

Evidence level IV

El uso de la maniobra de

McRoberts’comparado con la posicion de

litotomia antes del diagnostico de distocia de

hombros, no reduce la traccion de la cabeza

fetal durante el parto vaginal en multiparas

NO puede ser usada para prevenir la

distocia de hombros

Parto

Evidence level Ib

No increase in pelvic dimensions.

Decrease in the angle of pelvic inclination P=0.001

Straightening of the sacrum P= 0.04%

Tends to free the impacted anterior shoulder

Gherman et al Obstet Gynecol 95:43 ,2000

McRoberts manoeuvre: X ray pelvimetry study

McRoberts’ manoeuvre

The McRoberts’ manoeuvre is the

single most effective intervention,

with reported success rates as high

as 90%.

It has a low rate of complication and

therefore should be employed first.

Grade B

Episiotomy

Episiotomy is not necessary for all cases.

Some authors have advocated that episiotomy is an essential part of the management in all cases but others suggest that it does not affect the outcome of shoulder dystocia.

The authors of one study have concluded that episiotomy does not decrease the risk of brachial plexus injury with shoulder dystocia.

An episiotomy should therefore be considered but

it is not mandatory.

Grade B

Evidence level III

Suprapubic pressure

Suprapubic pressure is useful.

Suprapubic pressure can be employed together with

McRoberts’ manoeuvre to improve success rates.

Suprapubic pressure reduces the bisacromial

diameter and rotates the anterior shoulder into the

oblique pelvic diameter.

The shoulder is then free to slip underneath the

symphysis pubis with the aid of routine traction.

Grade C

Evidence level IV

.

Maniobra de McRoberts y Rubin

combinadas

Maniobra de Gaskin

Advanced manoeuvres should be used if the

McRoberts’ manoeuvre and suprapubic pressure fail.

If these simple measures fail, then there is a

choice to be made between the all-fours-position

and internal manipulation.

Traditionally, internal manipulations are used at

this point but the-all-fours position has been

described, with an 83% success rate in one case

series.

The individual circumstances should guide the

accoucheur.

Evidence level III

No existe ventaja entre:

1. El Nacimiento del hombro posterior (jaquemiere)

2. Maniobras de rotación interna (Maniobra de

Woods ) y

Así que el juicio clínico y la experiencia pueden

decidir el orden de estas maniobras

Maniobras internas

.

Si Mc Roberts falla:

Maniobra de Woods :

•La mano es posicionada

Detras del hombro

Posterior del feto.

•El hombro se rota

Progresivamente 180 grados en forma de sacacorcho,

de manera que el hombro anterior sea liberado.

Insertando la mano

en la parte posterior

de la vagina y

rotando el brazo

hacia el hombro.

Se realiza

el parto

sobre el

periné

Maniobra de Jaquemiere.

Delivery of the posterior arm has a high

complication rate: 12% humeral fractures

in one series.

Some authors favour delivery of the

posterior arm, particularly where the

mother is large.

Delivery of the posterior arm

Evidence level III

Varios metodos de tercera linea han sido descritos para los casos en los que ha resistencia a las medidas simples

Estos incluyen:

1. Cleidotomia (fractura de la clavicula con la mano o tijera quirurgica),

2. Sinfisiotomia (division de las fibras de los huesos pubianos)

3. Maniobra de Zavanelli.

The maternal safety of this procedure is

unknown, however, and this should be borne

in mind, knowing that a high proportion of

fetuses have irreversible hypoxia-acidosis by

this stage.

Zavanelli manoeuvre

Evidence level III

Symphysiotomy

Has been suggested as a potentially useful

procedure, both in the Developing and

developed world.

There is a high incidence of serious maternal

morbidity and poor neonatal outcome.

After delivery, the birth attendants should be

alert to the possibility of postpartum

haemorrhage and third- and fourth-degree

perineal tears.

Evidence level III

Fetales

Parálisis del plexo braquial.

Parálisis de Erb

Parálisis de Kumpke

Acidosis fetal por compresión del cordón

umbilical.

Maternos

Hemorragia post parto

Rasgadura grado 4

Brachial plexus injuries,

Fractures of the humerus, and

Fractures of the clavicle

are the most commonly reported

injuries associated with shoulder

dystocia

ACOG practice 1997 (A: II-2)

Fetal Complications of Sh D

Brachial plexus injuries are one of the most

important fetal complications of shoulder

dystocia, complicating 4–16% of such

deliveries.

This appears to be independent of operator

experience.

Most cases resolve without permanent

disability, with fewer than 10% resulting in

permanent brachial plexus dysfunction.

Brachial plexus injuries

In the UK, the incidence of brachial

plexus injuries is 1/2300 live births.

Neonatal brachial plexus injury is the

single most common cause for

litigation related to shoulder

dystocia.

Brachial plexus injuries

distocia de hombros eduardo gandara residente1 igss

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