How We Do What We Do: Shoulder Dystocia Delivery

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Dystocia

Shoulder Dystocia is a complication of delivery that occurs with an incidence of 1/300 live births. As an Emergency Physician, you are required to 1) Identify the problem early, and 2) Perform the necessary maneuvers to deliver the baby.

Etiology

Shoulder Dystocia is a problem of the Pelvis or the Passenger. During the fetal head’s cardinal movements of descent, flexion, and internal rotation within the bony pelvis, the shoulders descend to reach the pelvic inlet. If either the fetal shoulder dimensions are too large or the maternal pelvis is too narrow to permit shoulder rotation to the oblique pelvic diameter, or both, persistent anterior-posterior orientation of the fetal shoulders may result in the anterior shoulder being obstructed behind the symphysis pubis. If the sacral promontory also obstructs the posterior shoulder, bilateral shoulder dystocia occurs.

Complications

• While injury can occur at any time interval, there has been shown to be a spike in injuries after a dystocia exceeds 5 minutes, underscoring the importance of being aware of time.. There is increased risk of neonatal depression, acidosis, asphyxia, central nervous system damage, or even death.
• Fetal Complications include Brachial plexus palsy, clavicle fracture, death, humerus fracture contribute to a complication rate of 20%.
• Maternal complications include postpartum hemorrhage, vaginal perineal and anal sphincter tears as well as urinary incontinence. Rectovaginal fistula, symphyseal separation, 3rd or 4th degree laceration, uterine rupture.

Steps for Overcoming Shoulder Dystocia

• Identify that Shoulder Dystocia has complicated this delivery. It should be considered when there is a turtle sign or lack of progression following delivery of the head. Verbalize it to the rest of the team and assign roles. Remember that the clock started as soon as labor stopped progressing and time is tissue.
• Bring the patient down to the bottom of the stretcher, or break down the bed to make the following maneuvers easier.
• Call for Help! The presence of a trained OB will more likely result in a successful delivery with fewer complications. Also, have members of the ED team hold the patient’s legs and keep time.
• Stop applying traction on the head as it will unlikely dislodge the shoulder. It will more likely increase the bisacromial diameter and worsen the dystocia as well cause for fetal and maternal injury.
• Perform McRoberts maneuver – Flex and abduct the maternal hips, positioning the maternal thighs up onto the maternal abdomen. The position flattens the sacral promontory and results in cephalad rotation of the pubic symphysis. (Successful 40% of the time).
• If the anterior shoulder doesn’t deliver, apply suprapubic pressure over the anterior shoulder with a downward and lateral motion on the posterior aspect of the shoulder. The provider who is performing suprapubic pressure should be standing on a CPR stool giving them the appropriate angle.
• These maneuvers are considered ineffective once they have been tried in quick succession without delivery of the baby.
• The Woodscrew maneuver may be considered next by applying the right hand to the back of the posterior shoulder and placing the L hand to the front of the anterior shoulder and rotating the child to face the rectum.
• If these maneuvers paired are ineffective, delivery of the posterior arm is considered next. The elbow should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest. Grasping and pulling directly on the fetal arm may fracture the humerus. An episiotomy should strongly , be considered togive the provider enough room to deliver the posterior arm.If this fails, consider rolling the patient. The change in position to all fours, known as the Gaskin maneuver, will often dislodge the child during the act of turning.
• If all else fails in the delivery of the baby, consider fracturing the fetal clavicle by applying firm and direct upward pressure to the mid portion of the fetal clavicle. This will effectively reduce the shoulder-to-shoulder distance.
• Other considerations include the Zavanelli maneuver in which the head is replaced into the uterus. This is achieved by rotating the fetal head into a direct occiput anterior position (face down), and then flexing and pushing the vertex back into the birth canal. Continuous upward pressure is required until C-section delivery is accomplished. THESE ARE LAST RESORT!!!!!

OF NOTE:
Language is important in this situation:
– NEVER use words like stuck, pull, or trapped.
– Explain to the mother that the baby’s shoulder is behind her pelvic bone and that you will perform some maneuvers to move that shoulder so that the baby can be delivered.

References
1. Allen RH. On the mechanical aspects of shoulder dystocia and birth injury. Clin Obstet Gynecol. Sep 2007;50(3):607-23.
2. Gurewitsch ED, Allen RH. Epidemiology of shoulder dystocia and its associated neonatal complications. In: E Sheiner. Textbook of perinatal epidemiology. Hauppauge, NY: Nova Scientific Publishers; 2010.
3. Sokol RJ, Blackwell SC, for the American College of Obstetricians and Gynecologists. Committee on Practice Bulletins–Gynecology. ACOG practice bulletin no. 40: shoulder dystocia. November 2002 (replaces practice pattern no. 7, October 1997). Int J Gynaecol Obstet. 2003;80:87–92.
4. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol. 1998;179:476–80.
5. Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia. Obstet Gynecol. 1985;66:762–8.
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8. Gross SJ, Shime J, Farine D. Shoulder dystocia: predictors and outcome. A five-year review. Am J Obstet Gynecol. Feb 1987;156(2):334-6.
9. Poggi SH, Allen RH, Patel CR, Ghidini A, Pezzullo JC, Spong CY. Randomized trial of McRoberts versus lithotomy positioning to decrease the force that is applied to the fetus during delivery. Am J Obstet Gynecol. Sep 2004;191(3):874-8.
10. Mollberg M, Wennergren M, Bager B, Ladfors L, Hagberg H. Obstetric brachial plexus palsy: a prospective study on risk factors related to manual assistance during the second stage of labor. Acta Obstet Gynecol Scand. 2007;86(2):198-204.
11. Gurewitsch ED, Allen RH. Reducing the risk of shoulder dystocia and associated brachial plexus injury.Obstet Gynecol Clin North Am. Jun 2011;38(2):247-69, x.
12. Rubin A. Management of shoulder dystocia. JAMA. Sep 14 1964;189:835-7.
13. Bruner JP, Drummond SB, Meenan AL, Gaskin IM. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med. May 1998;43(5):439-43.
14. Spong CY, Beall M, Rodrigues D, Ross MG. An objective definition of shoulder dystocia: prolonged head-to-body delivery intervals and/or the use of ancillary obstetric maneuvers. Obstet Gynecol. Sep 1995;86(3):433-6.
15. American College of Obstetricians and Gynecologists. Shoulder Dystocia. In: Practice Bulletin No 40. 100. 2002:1045-50.
16. Bonnaire C, Bue E. Influence of the position on the shape and dimensions of the pelvis. Annales de Gynecologie et d’Obstetrique. 1899;52:296-310.
17. Gobbo R, Baxley EG. Shoulder dystocia. In: ALSO: advanced life support in obstetrics provider course syllabus. Leawood, Kan.: American Academy of Family Physicians, 2000.

This contribution from:
Danielle Weinman, MD

Thanks to edits from:
Michael Meguerdichian MD, Cara Taubman MD and Komal Bajaj MD

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