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| Shoulder dystocia Classification and external resources |
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| ICD-10 | O66.0 |
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| ICD-9 | 660.4 |
| DiseasesDB | 12036 |
Shoulder dystocia is a specific case of dystocia whereby after the delivery of the head, the anterior shoulder of the infant cannot pass below the pubic symphysis, or requires significant manipulation to pass below the pubic symphysis. It is diagnosed when the shoulders fail to deliver shortly after the fetal head. In shoulder dystocia, it is the chin that presses against the walls of the perineum1
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Signs
One often described feature is the turtle sign, which involves the appearance and retraction of the foetal head (analogous to a turtle withdrawing into its shell), and the erythematous, red puffy face indicative of facial flushing. This occurs when the baby's shoulder is obstructed the maternal pelvis.2
Procedures
A number of obstetrical maneuvers are sequentially performed in attempt to facilitate delivery at this point, including :
- suprapubic pressure (or Rubin I)5
- Rubin II or posterior pressure on the anterior shoulder, which would bring the fetus in an oblique position with head somewhat towards the vagina6
- Woods' screw maneuver which leads to turning the anterior shoulder to the posterior and vice versa (somewhat the opposite of Rubin II maneuver)7
- Jacquemier's maneuver (also called Barnum's maneuver), or delivery of the posterior shoulder first, in which the forearm and hand are identified in the birth canal, and gently pulled.
- Gaskin maneuver, named after Certified Professional Midwife, Ina May Gaskin, involves moving the mother to an all fours position with the back arched, widening the pelvic outlet.citation needed
More drastic maneuvers include
- Zavanelli's maneuver, which involves pushing the fetal head back in with performing a cesarean section.8 or internal cephalic replacement followed by Cesarean section
- intentional clavicular fracture, which reduces the diameter of the shoulder girdle that requires to pass through the birth canal.
- symphisiotomy, which makes the opening of the birth canal laxer by breaking the connective tissue between the two pubes bones facilitating the passage of the shoulders.
- abdominal rescue, described by O'Shaughnessy, where a hysterotomy facilitates vaginal delivery of the impacted shoulder9
Management
Management of shoulder dystocia has become a focus point for many obstetrical nursing units in North America. Courses such as the Canadian More-OB program encourage nursing units to do routine drills to prevent delays in delivery which adversely affect both mother and fetus. A common treatment algorithm is ALARMER
- A sk for help. This involves requesting the help of an obstetrician, anesthesia and pediatrics for subsequent resuscitation of the infant.
- L eg hyperflexion (McRobert's maneuver)
- A nterior shoulder disimpaction (suprapubic pressure)
- R ubin maneuver
- M anual delivery of posterior arm
- E pisiotomy
- R oll over on all fours
The advantage of proceeding in the order of ALARMER is that it goes from least to most invasive, thereby reducing harm to the mother in the event that the infant delivers with one of the earlier maneuvers. In the event that these maneuvers are unsuccessful, a skilled obstetrician may attempt some of the additional procedures listed below. Intentional clavicular fracture is a final attempt at nonoperative vaginal delivery prior to Zavanelli's maneuver or symphisiotomy, both of which are considered extraordinary treatment measured.
Risk factors
Although the definition is imprecise, it occurs in approximately 1% of vaginal births. There are well-recognised risk factors, such as diabetes,10 fetal macrosomia, and maternal obesity, but it is often difficult to predict11. Despite appropriate obstetric management, fetal injury (such as brachial plexus injury) or even fetal death can be a complication of this obstetric emergency.
Recurrence rates are relatively high and low most of the short time.12
Complications
The major concern of shoulder dystocia is damage to the upper brachial plexus nerves. These supply the sensory and motor components of the shoulder, arm and hands.2 The aetiology of injury to the foetus is debated, but a probable mechanism is manual stretching of the nerves, which in itself can cause injury. Furthermore, excess tension may physically tear the nerve roots out from the neonatal spinal column, resulting in total dysfunction. The dorsal roots (motor pathway) are most prone to injury, as they are in the plane of greatest tension (anterior, sensory nerves are somewhat protected due to the usual inward movement of the shoulder).
- Klumpke paralysis
- Erb's Palsy
- Foetal hypoxia
- Foetal death
- Cerebral palsy
- Maternal post partum haemorrhage
References
- ^ Kish, Karen; Joseph V. Collea (2003). "Malpresentation & Cord Prolapse (Chapter 21)", in Alan H. DeCherney: Current Obstetric & Gynecologic Diagnosis & Treatment, Lauren Nathan, Ninth Edition, Lange/McGraw-Hill, 381-382. ISBN 0-07-118207-1.
- ^ a b "Can shoulder dystocia be resolved without fetal injury when it does occur?". Retrieved on 2008-11-19.
- ^ Stallard TC, Burns B (2003). "Emergency delivery and perimortem C-section". Emerg. Med. Clin. North Am. 21 (3): 679–93. doi:. PMID 12962353.
- ^ Kish, Karen; Joseph V. Collea (2003). "Malpresentation & Cord Prolaps (Chapter 21)", in Alan H. DeCherney: Current Obstetric & Gynecologic Diagnosis & Treatment, Lauren Nathan, Ninth Edition, Lange/McGraw-Hill, 382. ISBN 0-07-118207-1.
- ^ "Shoulder Dystocia Management". Retrieved on 2007-11-28.
- ^ "Shoulder Dystocia - April 1, 2004 - American Family Physician". Retrieved on 2007-11-28.
- ^ "Fetal Dystocia: Abnormalities and Complications of Labor and Delivery: Merck Manual Professional". Retrieved on 2007-11-28.
- ^ Fernandez H, Papiernik E (1990). "[The Zavanelli maneuver: use during breech retention of the head in the birth canal. Apropos of a case]" (in French). J Gynecol Obstet Biol Reprod (Paris) 19 (4): 483–5. PMID 2380511.
- ^ O'Shaughnessy MJ (1998). "Hysterotomy facilitation of the vaginal delivery of the posterior arm in a case of severe shoulder dystocia". Obstet Gynecol 92 (4 Pt 2): 693–5. doi:. PMID 9764668.
- ^ Jouatte F, Aitken B, Dufour P, et al (1999). "[Diabetes before pregnancy, apropos of 143 cases]" (in French). Contracept Fertil Sex 27 (12): 845–52. PMID 10676041.
- ^ Breeze AC, Lees CC (2004). Managing shoulder dystocia. Lancet 364, 2160-1[1]
- ^ Gurewitsch ED, Johnson TL, Allen RH (2007). "After shoulder dystocia: managing the subsequent pregnancy and delivery". Semin. Perinatol. 31 (3): 185–95. doi:. PMID 17531900.
External links
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