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Shoulder Dystocia

Shoulder Dystocia. Objectives Definition and Incidence Significance Risk Factors Diagnosis Management. Definition impaction of anterior shoulder above symphysis inability to delivery shoulders by usual methods Incidence 1 to 2 per 1000 deliveries

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Shoulder Dystocia

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  1. Shoulder Dystocia

  2. Objectives Definition and Incidence Significance Risk Factors Diagnosis Management

  3. Definition impaction of anterior shoulder above symphysis inability to delivery shoulders by usual methods Incidence 1 to 2 per 1000 deliveries 16 per 1000 deliveries of babies > 4000 g

  4. Complications of Shoulder Dystocia Fetal/neonatal death asphyxia and sequelae fractures - clavicle, humerus brachial plexus palsy Maternal postpartum hemorrhage uterine rupture

  5. Risk Factors post-term pregnancy maternal obesity fetal macrosomia previous shoulder dystocia operative vaginal delivery prolonged labour poorly controlled diabetes

  6. Risk factors are present in < 50% of cases

  7. Diagnosis head recoils against perineum, ‘turtle’ sign spontaneous restitution does not occur failure to deliver with expulsive effort and usual gentle direction

  8. Ask for help Lift - the buttocks - the legs Anterior disimpaction of shoulder - rotate to oblique - suprapubic pressure Rotationof the posterior shoulder - Woods’ manoeuver Manual removal of posterior arm } McRobert’s manoeuver

  9. Avoid the P’s Panic Pulling (on the head) Pushing (on the fundus) Pivoting (sharply angulating the head, using the coccyx as a fulcrum)

  10. Ask for HELP get the mother on your side partner, coach nursing notify physician back up or other appropriate personnel

  11. Lift - McRobert’s Manoeuver

  12. Lifting the legs and buttocks • McRobert’s manoeuver • flexion of thighs on abdomen • requires assistance • 70% of cases are resolved with this manoeuvre alone

  13. Anterior Disimpaction - 1) Suprapubic Pressure (Massanti Manoeuvre) NO fundal pressure Abdominal approach: suprapubic pressure applied with heel of clasped hand from the posterior aspect of the anterior shoulder to dislodge it

  14. Anterior Disimpaction - • 2) Rubin Manoeuver • vaginal approach • adduction of anterior shoulder by pressure applied to the posterior aspect of the shoulder (the shoulder is pushed toward the chest) • consider episiotomy • NO fundal pressure

  15. Rotation of Posterior Shoulder - Step 1 • pressure on anterior aspect of posterior shoulder • may be combined with anterior disimpaction manoeuvers • NO fundal pressure

  16. Rotation of Posterior Shoulder - Step 2 • Wood’s screw manoeuvre • can be done simultaneously with anterior dissimpaction

  17. Rotation of Posterior Shoulder - Step 3 • may be repeated if delivery not • accomplished by Steps 1 & 2

  18. Rotation of Posterior Shoulder - Step 4

  19. Manual removal of posterior arm flex arm at elbow (pressure in antecubital fossa to flex arm) sweep arm over chest grasp wrist/forearm or hand deliver arm

  20. Manual removal of the posterior arm

  21. Episiotomy may facilitate Wood’s Manoeuver or allow room for delivery of the posterior arm roll over to knee chest: May allow easier access to posterior shoulder

  22. As a last resort clavicular fracture cephalic replacement (Zavenelli manoeuvre) symphysiotomy

  23. Afterwards be prepared for PPH inspect for maternal lacerations and trauma examine the baby for evidence of injury explain the delivery and manoeuvers chart what was done

  24. Conclusions • anticipate and be prepared (most are unpredictable) • remember the mnemonic “ALARMER” • stay calm, don’t panic, pull, push or pivot

  25. Ask for help Lift - the buttocks - the legs Anterior disimpaction - rotate to oblique - suprapubic pressure Rotate the posterior shoulder - Woods’ manoeuver Manual removal of the posterior arm Episiotomy - consider Roll over } McRobert’s Manoeuver

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