shoulder dystocia or, the head’s out; what next? ahmad alkathiri md

Shoulder DystociaShoulder Dystocia

Or,Or,

The head’s out; what next?The head’s out; what next?

Ahmad Alkathiri Ahmad Alkathiri

MDMD

ObjectivesObjectives

At the completion of this presentation, At the completion of this presentation, the participant should be able to:the participant should be able to:– Define shoulder dystocia (MK)Define shoulder dystocia (MK)– Name three risk factors for shoulder Name three risk factors for shoulder

dystocia (MK, PC)dystocia (MK, PC)– List potential complications, both maternal List potential complications, both maternal

and fetal, of shoulder dystocia (MK)and fetal, of shoulder dystocia (MK)– Describe the maneuvers used to relieve a Describe the maneuvers used to relieve a

shoulder dystocia (MK, ICS)shoulder dystocia (MK, ICS)

DefinitionDefinition

“…“…a delivery that requires a delivery that requires additional obstetric maneuvers additional obstetric maneuvers following failure of gentle following failure of gentle downward traction on the fetal downward traction on the fetal head to effect delivery of the head to effect delivery of the shoulders.”shoulders.”

ACOG, Practice Bulletin 40 (November ACOG, Practice Bulletin 40 (November 2002)2002)

DefinitionDefinition

““Prolonged head-to-body expulsion Prolonged head-to-body expulsion time”time”

Objectively defined as 60 secondsObjectively defined as 60 seconds Deliveries with head-to-body interval Deliveries with head-to-body interval

of > 60 seconds more commonly of > 60 seconds more commonly have higher birth weight, shoulder have higher birth weight, shoulder dystocia, and low 1 minute Apgar dystocia, and low 1 minute Apgar scoresscores

– Beall et al 1998; Spong et al 1995Beall et al 1998; Spong et al 1995

Functional DefinitionFunctional Definition

A delivery in which the shoulders do A delivery in which the shoulders do not follow the head as usual, but not follow the head as usual, but rather are delayed in delivering or rather are delayed in delivering or require the use of ancillary obstetric require the use of ancillary obstetric maneuvers to effect delivery.maneuvers to effect delivery.

The anterior shoulder may be The anterior shoulder may be impacted behind the symphysis pubis, impacted behind the symphysis pubis, or (less commonly) the posterior or (less commonly) the posterior shoulder behind the sacral promontoryshoulder behind the sacral promontory

IncidenceIncidence

Reported to occur in 0.2-2% of Reported to occur in 0.2-2% of birthsbirths

May recur with a higher frequency, May recur with a higher frequency, but this is really unknownbut this is really unknown– Many women and clinicians will opt for Many women and clinicians will opt for

cesarean in the future, especially if cesarean in the future, especially if there has been a fetal injurythere has been a fetal injury

– Recurrence rates reported 1-17%Recurrence rates reported 1-17%

Risk FactorsRisk Factors

Maternal diabetes mellitusMaternal diabetes mellitus Fetal macrosomiaFetal macrosomia MultiparityMultiparity Post-term pregnancyPost-term pregnancy Previous macrosomic infantPrevious macrosomic infant Previous shoulder dystociaPrevious shoulder dystocia

MacrosomiaMacrosomia

Birth weight in excess of a specific Birth weight in excess of a specific weight, usually defined as either weight, usually defined as either 4500 grams (1.5% of births) or 4500 grams (1.5% of births) or 4000 grams (10% of births)4000 grams (10% of births)– Birth weight > 4500 grams – rate of Birth weight > 4500 grams – rate of

shoulder dystocia is 10-25%shoulder dystocia is 10-25%– Birth weight > 4500 grams AND Birth weight > 4500 grams AND

maternal diabetes – rate of shoulder maternal diabetes – rate of shoulder dystocia is 20-50%dystocia is 20-50%

Large for gestational Large for gestational ageage Birth weight that exceeds the 90Birth weight that exceeds the 90thth

centile of a standard growth centile of a standard growth curve, regardless of gestational curve, regardless of gestational age.age.

A baby may be LGA without being A baby may be LGA without being macrosomicmacrosomic

PathophysiologyPathophysiology

A “mismatch” between fetal size and A “mismatch” between fetal size and maternal pelvic capacitymaternal pelvic capacity

Positional variations – vertical rather Positional variations – vertical rather than oblique orientation of shouldersthan oblique orientation of shoulders

Increased diameter of shoulder girdleIncreased diameter of shoulder girdle– Subcutaneous fat deposition may be Subcutaneous fat deposition may be

increased in infant of diabetic mother – increased in infant of diabetic mother – especially with sub-optimal glucose especially with sub-optimal glucose controlcontrol

Anatomy of the Brachial Anatomy of the Brachial PlexusPlexus

Nerve roots from C5-C8 and T1Nerve roots from C5-C8 and T1 Merge into three trunksMerge into three trunks

– Superior (C5, C6)Superior (C5, C6)– Middle (C7)Middle (C7)– Inferior (C8, T1)Inferior (C8, T1)

Each splits into anterior and Each splits into anterior and posterior divisionsposterior divisions


The six divisions regroup into The six divisions regroup into three cordsthree cords– Posterior – all 3 posterior trunk Posterior – all 3 posterior trunk

divisions (C5-T1)divisions (C5-T1)– Lateral – anterior divisions of upper Lateral – anterior divisions of upper

and middle trunks (C5-C7)and middle trunks (C5-C7)– Medial – continuation of lower trunk Medial – continuation of lower trunk

(C8, T1)(C8, T1)

Brachial Plexus Brachial Plexus InjuriesInjuries Strain or stretchStrain or stretch Partial disruptionPartial disruption Complete avulsionComplete avulsion

Brachial Plexus Brachial Plexus InjuriesInjuries Injury primarily to lateral trunk Injury primarily to lateral trunk

(C5,6, 7) leads to Erb’s palsy – (C5,6, 7) leads to Erb’s palsy – adducted shoulder, extended elbow, adducted shoulder, extended elbow, and flexed wrist (“waiter’s tip”)and flexed wrist (“waiter’s tip”)

Injury primarily to the medial trunk Injury primarily to the medial trunk (C8, T1) leads to Klumpke’s palsy – (C8, T1) leads to Klumpke’s palsy – paralyzed hand with good shoulder paralyzed hand with good shoulder and elbow functionand elbow function

Maternal Maternal ComplicationsComplications Post-partum hemorrhage occurs Post-partum hemorrhage occurs

in 11%in 11% 44thth degree laceration occurs in 3- degree laceration occurs in 3-

4%4%

Into the Delivery Into the Delivery Room…Room…

Clinical ManagementClinical Management

Step One: Recognize the Step One: Recognize the presence of a shoulder dystociapresence of a shoulder dystocia

Step Two: Be sure enough help is Step Two: Be sure enough help is presentpresent– NursingNursing– ObstetricsObstetrics– PediatricsPediatrics– AnesthesiologyAnesthesiology


Step Three: Apply primary Step Three: Apply primary maneuversmaneuvers– Mc Roberts maneuverMc Roberts maneuver– Oblique suprapubic pressureOblique suprapubic pressure

Step Four: Apply secondary Step Four: Apply secondary maneuvers; no prescribed ordermaneuvers; no prescribed order– Rubin; Woods screw; Posterior arm; Rubin; Woods screw; Posterior arm;

All-fours; Clavicular fractureAll-fours; Clavicular fracture


Step Five (concurrent):Step Five (concurrent):– Repeat steps three and four Repeat steps three and four

(different operator?)(different operator?)– Consider if an episiotomy is needed Consider if an episiotomy is needed

(intentional 4(intentional 4thth degree?) degree?) Step Six: Apply final (heroic) Step Six: Apply final (heroic)

maneuversmaneuvers– Zavanelli; symphysiotomyZavanelli; symphysiotomy

Steps One and TwoSteps One and Two

The operator determines a The operator determines a shoulder dystocia is presentshoulder dystocia is present

Personnel needed:Personnel needed:– NursingNursing

At least two to assist with maneuversAt least two to assist with maneuvers One to serve as “recorder”, as in a code One to serve as “recorder”, as in a code

12 situation12 situation

– Pediatrics – full resuscitation Pediatrics – full resuscitation readinessreadiness

Steps One and TwoSteps One and Two

Personnel (continued)Personnel (continued)– AnesthesiologyAnesthesiology– ObstetricsObstetrics

Attending to supervise and step in as Attending to supervise and step in as neededneeded

2 residents at minimum2 residents at minimum– Ideally 2 at perineumIdeally 2 at perineum– One to assist with maneuvers (suprapubic One to assist with maneuvers (suprapubic

pressure) away from perineumpressure) away from perineum

Step Three – Primary Step Three – Primary ManeuversManeuvers

McRoberts maneuverMcRoberts maneuver– Patient positioned with hips at edge of Patient positioned with hips at edge of

the broken-down birthing bedthe broken-down birthing bed– Both hips are sharply flexed with knees Both hips are sharply flexed with knees

remaining flexed (“knees to shoulders”)remaining flexed (“knees to shoulders”)– Ideally performed by staff, not family, to Ideally performed by staff, not family, to

assure it is adequately performedassure it is adequately performed– No benefit to “prophylactic” McRobertsNo benefit to “prophylactic” McRoberts

McRoberts ManeuverMcRoberts Maneuver


This maneuver assists delivery by:This maneuver assists delivery by:– Straightening maternal lumbar lordosisStraightening maternal lumbar lordosis– Rotates symphysis superiorly and Rotates symphysis superiorly and

anteriorlyanteriorly– Improving angle between pelvic inlet Improving angle between pelvic inlet

and direction of maximal expulsive forceand direction of maximal expulsive force– Elevates anterior shoulder allowing Elevates anterior shoulder allowing

posterior shoulder to descendposterior shoulder to descend

Oblique suprapubic Oblique suprapubic pressurepressure

Usually applied in concert with Usually applied in concert with McRoberts maneuverMcRoberts maneuver

Directed downward and laterally Directed downward and laterally in order to effect rotation of the in order to effect rotation of the fetal anterior shoulder under the fetal anterior shoulder under the symphysissymphysis

Should be applied from the fetal Should be applied from the fetal posteriorposterior

Oblique suprapubic Oblique suprapubic pressurepressure

Step Four – Secondary Step Four – Secondary ManeuversManeuvers

There is no conclusive evidence that There is no conclusive evidence that one maneuver is superior to anotherone maneuver is superior to another

In each patient, the operator must In each patient, the operator must decide which maneuver will be most decide which maneuver will be most effectiveeffective

This is a good time to decide about an This is a good time to decide about an episiotomy – is there room to get your episiotomy – is there room to get your hand in?hand in?

Time to initiate perinatal code (4-2012)Time to initiate perinatal code (4-2012)

Woods screw Woods screw maneuvermaneuver Apply pressure on the clavicle to effect Apply pressure on the clavicle to effect

rotation of the shoulders out of the rotation of the shoulders out of the vertical orientationvertical orientation

As fetus rotates, anterior shoulder As fetus rotates, anterior shoulder should pass under symphysisshould pass under symphysis

May be a good choice for a right-May be a good choice for a right-handed operator when the fetal handed operator when the fetal occiput is oriented to the maternal occiput is oriented to the maternal rightright

Woods screw Woods screw maneuvermaneuver

Woods screw Woods screw maneuvermaneuver Potential complication:Potential complication:

– Fetal clavicular fracture IN Fetal clavicular fracture IN DIRECTION OF APEX OF LUNGDIRECTION OF APEX OF LUNG

Rubin’s maneuverRubin’s maneuver

Apply pressure to the fetal scapula Apply pressure to the fetal scapula to effect rotation of the shoulders to effect rotation of the shoulders out of the vertical orientationout of the vertical orientation

As fetus rotates, anterior shoulder As fetus rotates, anterior shoulder should pass under symphysisshould pass under symphysis

May be a good first choice for a May be a good first choice for a right-handed operator when the right-handed operator when the fetal occiput is directed to the fetal occiput is directed to the maternal leftmaternal left

Rubin’s maneuverRubin’s maneuver

May result in need for less May result in need for less traction and less brachial plexus traction and less brachial plexus strain than McRoberts maneuverstrain than McRoberts maneuver

– Gurewitsch, 2005Gurewitsch, 2005

Delivery of Posterior Delivery of Posterior ArmArm The operator inserts a hand into The operator inserts a hand into

the vagina and locates the the vagina and locates the posterior arm.posterior arm.

The operator applies pressure in The operator applies pressure in the antecubital fossa to flex the the antecubital fossa to flex the elbow across the chestelbow across the chest

The operator grasps the forearm or The operator grasps the forearm or hand and pulls it out of the vaginahand and pulls it out of the vagina

Delivery of Posterior Delivery of Posterior ArmArm The anterior shoulder should pass The anterior shoulder should pass

under the symphysisunder the symphysis Rotation maneuvers (Woods or Rotation maneuvers (Woods or

Rubin’s) can be applied if neededRubin’s) can be applied if needed This maneuver will tend to be This maneuver will tend to be

more difficult with one’s non-more difficult with one’s non-dominant handdominant hand

Delivery of Posterior Delivery of Posterior ArmArm

Delivery of Posterior Delivery of Posterior ArmArm Potential complicationsPotential complications

– Fracture of humerusFracture of humerus– Fracture of clavicleFracture of clavicle

Gaskin All Fours Gaskin All Fours ManeuverManeuver

Attributed to midwife Ina May Attributed to midwife Ina May GaskinGaskin

An option for a patient without An option for a patient without anesthesiaanesthesia

Traction is applied in the opposite Traction is applied in the opposite direction (still toward the floor, direction (still toward the floor, but now directed towards delivery but now directed towards delivery of the posterior shoulder first)of the posterior shoulder first)

Intentional clavicular Intentional clavicular fracturefracture

Apply pressure over mid-clavicle Apply pressure over mid-clavicle in a vector AWAY from the lungin a vector AWAY from the lung

May be difficult to performMay be difficult to perform If successful, may reduce the If successful, may reduce the

diameter of the shoulder girdlediameter of the shoulder girdle Potential complication:Potential complication:

– Lung injuryLung injury

Still not out?!Still not out?!

What now???What now???

Step Five – Regroup and Step Five – Regroup and RepeatRepeat

Considerations:Considerations: Time passed so far?Time passed so far? Episiotomy?Episiotomy? Different operator?Different operator? Make OR preparations!Make OR preparations!

Step Six – Final StepsStep Six – Final Steps

Zavanelli maneuver (cephalic Zavanelli maneuver (cephalic replacement)replacement)– Relax uterus with terbutalineRelax uterus with terbutaline– Rotate head back to OA (“reverse Rotate head back to OA (“reverse

restitution”)restitution”)– Flex neckFlex neck– Upward pressureUpward pressure– To OR To OR

Step Six – Final StepsStep Six – Final Steps

SymphysiotomySymphysiotomy– Not commonly done when cesarean Not commonly done when cesarean

is availableis available– Last ditch effortLast ditch effort

Insert Foley catheterInsert Foley catheter Use vaginal hand to laterally displace Use vaginal hand to laterally displace

urethra to avoid injuryurethra to avoid injury Incise symphysis through mons pubisIncise symphysis through mons pubis

Do not:Do not:

PanicPanic Apply any more lateral traction than Apply any more lateral traction than

would be applied in an uncomplicated would be applied in an uncomplicated deliverydelivery

Apply fundal pressure – may worsen Apply fundal pressure – may worsen the shoulder impaction or even rupture the shoulder impaction or even rupture the uterusthe uterus

Cut a nuchal cord until after the Cut a nuchal cord until after the shoulders are releasedshoulders are released

Do:Do:

Remain calmRemain calm Communicate wellCommunicate well

– Mark time of head deliveryMark time of head delivery– Consider calling out time in one Consider calling out time in one

minute incrementsminute increments Call for helpCall for help Document clearly and legiblyDocument clearly and legibly

Do:Do:

Be sure to “debrief” as a team after Be sure to “debrief” as a team after the delivery is completedthe delivery is completed– Opportunity to analyze situation and Opportunity to analyze situation and

critique team performancecritique team performance– Opportunity to be sure documentation Opportunity to be sure documentation

is consistentis consistent– Who did what becomes very importantWho did what becomes very important

Send cord gasesSend cord gases

Do:Do:

Review with the family exactly Review with the family exactly what happened and answer what happened and answer questions – soon after delivery, questions – soon after delivery, but probably not immediatelybut probably not immediately

Follow the baby’s course in the Follow the baby’s course in the nurserynursery

Notify Risk ManagementNotify Risk Management

ReferencesReferences

Shoulder Dystocia (Practice Bulletin 40). American College of Shoulder Dystocia (Practice Bulletin 40). American College of Obstetricians and Gynecologists. November 2002.Obstetricians and Gynecologists. November 2002.

Rodis, JF. Management of fetal macrosomia and shoulder Rodis, JF. Management of fetal macrosomia and shoulder dystocia. Up to date, v 14.1; last updated October 12, 2005.dystocia. Up to date, v 14.1; last updated October 12, 2005.

Brachial Plexus. Wikipedia, the online encyclopedia. Brachial Plexus. Wikipedia, the online encyclopedia. http://en.wikipedia.org/wiki/Brachial_plexus Accessed March Accessed March 21, 2006.21, 2006.

Beall, MH, et al. Objective definition of shoulder dystocia: a Beall, MH, et al. Objective definition of shoulder dystocia: a prospective evaluation. Am J Obstet Gynecol 1998;179:934.prospective evaluation. Am J Obstet Gynecol 1998;179:934.

Spong CY, et al. An objective definition of shoulder dystocia: Spong CY, et al. An objective definition of shoulder dystocia: prolonged head-to-body interval and/or the use of ancillary prolonged head-to-body interval and/or the use of ancillary obstetric maneuvers. Obstet Gynecol 1995;86:433obstetric maneuvers. Obstet Gynecol 1995;86:433

Gurewitsch ED et al. Comparing McRoberts’ and Rubin’s Gurewitsch ED et al. Comparing McRoberts’ and Rubin’s maneuvers for initial management of shoulder dystocia: an maneuvers for initial management of shoulder dystocia: an objective evaluation. Am J Obstet Gynecol 2005;192:153.objective evaluation. Am J Obstet Gynecol 2005;192:153.

shoulder dystocia or, the head’s out; what next? ahmad alkathiri md

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