Shoulder Dystocia Making the Best of a Bad
Shoulder Dystocia “Making the Best of a Bad Situation” HOSSAM ELDIN SHAWKI M. D. OBST. & GYN. DEPARTEMENT EL-MINIA UNIVERSITY HOSPITAL 2005 Hossam Shawki MD
Grading – Evidence Based Recommendations A recommendation I evidence B C D recommendation n III evidence IV evidence - at least nonfrom expert I a- meta- one. II acontrolled experimental committee descriptive reports or analysis of study without randomisation studies, such opinions and/or RCTs clinical II b - at least as comparative studies, experience of trials, one other type correlation respected of quasistudies and authorities I b- at least experimental case control study one RCT. studies • GPP Good practice point : The view of the Guideline Development Group Hossam Shawki MD
Definition and Diagnosis “Shoulder dystocia is an obstetric emergency- andlife threatening condition in which there is Difficulty encountered in the delivery of the fetal shoulders after delivery of the head. ” Due to impaction of the fetal shoulder behind the symphysis pubis with the bisacromial diameter (breadth of the shoulders) in the antero-posterior diameter of the pelvic inlet. . Hossam Shawki MD
Definition Shoulder dystocia is the inability to deliver the fetal shoulders after delivery of the head, without the aid of specific maneuvers (ie. other than gentle downward traction on the head). Spong et al. 1995; Beal et al 1998 ; Bruner 1998 Hossam Shawki MD
Definition Objective definition : Mean head-to-body delivery time > 60 seconds ; Bruner 1998 1995; Beal et al 1998 Spong et al. Hossam Shawki MD
Hossam Shawki MD
Hossam Shawki MD
Incidence Varies widely based on criteria used for diagnosis. Gross et al, Toronto General Hospital - 1987 0. 9 % based on coding 0. 2 % based on use of maneuvers Acker et al 1986 2 % based on assessment of operator Incidence appears to be increasing as birth weights increase. Hossam Shawki MD
Incidence Subjective: 0. 6 -1. 6% Objective: Much lower ACOG Bulletin, 22, Novamber 2000 Hossam Shawki MD
The overall incidence is 2 -3% of deliveries • With 48% of cases occurring in normal weight infants • 0. 3% in infants weighing 25004000 grams • 5 -7% in infants weighing 4000 Hossam Shawki MD 4500 grams (RCOG, 2005)
Pathophysiology Shoulder dystocia results from a size discrepancy between the fetal shoulders and the pelvic inlet when: ® The bisacromial diameter is large relative to the biparietal diameter ® Pelvic prim is flat rather than gynecoid Hossam Shawki MD
Types of shoulder Dystocia Bilateral shoulder dystocia (complete ) Unilateral shoulder dystocia (incomplete) Hossam Shawki MD
Bilateral Shoulder Dystocia A bilateral shoulder dystocia. ® The posterior shoulder is not in the hollow of the pelvis. This presentation oftern requires a cephalic replacement. ® (C. Pauerstein [ed. ], Clinical Obstetrics, Churchill Livingstone, New York, 1987. ) Hossam Shawki MD
Unilateral Shoulder Dystocia ® Unilateral shoulder dystocia is usually easily dealt with by standard techniques. ® (B. Harris, Shoulder dystocia. Clinical Obstetrics and Gynecology, 1984 l 27: 106) Hossam Shawki MD
Hossam Shawki MD
Risk factors: • Previous shoulder dystocia • Previous baby >4. 5 kg • Obesity • Maternal Diabetes Mellitus/Gestational diabetes • Big or macrosomic baby (>4. 5 kg) • Abnormal pelvis (congenital malformation or Road Traffic Accident) • Prolonged first stage of labour Oxytocic augmentation of labour Hossam Shawki MD
Fetal Complications Injuries are a common outcome associated with shoulder dystocia and may occur despite use of proper standard obstetric manoeuvers ACOG practice 1997 (B: II-2) Hossam Shawki MD
Fetal Complications Traction combined with fundal pressure has been associated with a high rate of brachial plexus injuries and fractures ACOG practice 1997 (B: II-2) Hossam Shawki MD
Fetal Complications Fewer than 10% of deliveries complicated by shoulder dystocia will result in brachial plexus injury. ACOG practice 1997 (B: II-2) Hossam Shawki MD
Fetal Complications 1 -Fetal Fractures In 18 to 25% of cases 2 -Erb’s Palsy - Although 80% will resolve by 18 months 3 -Perinatal Asphyxia - Uncommon 4 -Neonatal Death – Rare ACOG practice 1997 (A: II-2) Hossam Shawki MD
Fetal Complications Erb’s Palsy Although 80% -90%will resolve by 18 months 10% will have permanent damage Hossam Shawki MD
Fetal Complications Head –shoulder interval > 7 min. Brain injury (sensitivity & specificity : 70 %) With hypoxic fetus it is much shorter Quzounian et al Am J Obstet Gynecol 178; S 76, 1998 Hossam Shawki MD
Maternal Complications 1 -Postpartum Hemorrhage 11% 2 -Vaginal Lacerations 19% 3 -Cervical Lacerations 2% 4 -Puerperal Infection 5 -Perineal tears(2 nd – 3 rd degree 4% he largest study (285 cases) Gherman et al Am J Obstet Gynecol 176: 656, 1997 Hossam Shawki MD
Diagnosis of shoulder dystocia CAN shoulder dystocia be predicted ? Hossam Shawki MD
Diagnosis of shoulder dystocia PRECONCEPTIONAL: Maternal birth weight Prior shoulder dystocia 12% Prior macrosomia Pre-existing diabetes Obesity Multiparity Prior gestational diabetes Advanced maternal age O'Leary &, Leonetti; 1990 Hossam Shawki MD
Diagnosis of shoulder dystocia Antenatal: Excessive maternal weight gain Macrosomia G. diabetes Short stature Post term O'Leary &, Leonetti; 1990 Hossam Shawki MD
Diagnosis of shoulder dystocia Intrapartum: Protracted or arrested active phase 2. Protracted or failure of descent of head 3. Need for midpelvic assisted delivery 1. Hopwood, 1982 ; Baskett &, Allen, 1995 Hossam Shawki MD
Diagnosis of shoulder dystocia MACROSOMIA is the most important risk factor BUT 50 -60 % of Shoulder Dystocia are of < 4 Kg !! Acker et al, Obst. Gynecol 66: 762, 1985 Baskett &Allen Obstet Gynecol 86: 14, 1995 Hossam Shawki MD
Management of Shoulder Dystocia 1)-PREDICTION………. Of what? MACROSOMIA 2)PREVENTION…OF WHAT…MACROSOMIA A-Prophlactic induction of labor B-Elective CS. 3)-ACTIVE MANAGEMENT Hossam Shawki MD
Active Management Know the Drill! CALL FOR HELP REMAIN CALM Hossam Shawki MD
ACOG Issues Guidelines Recommendation 1991 Hossam Shawki MD
Active Management Individuals who MUST be present in the room if shoulder dystocia is anticipated or encountered Attending physician Anesthesiologist Pediatrician Nursing Staff “Extra Hands” Hossam Shawki MD
Who’s the Boss? ® It is important that the conduct of any shoulder dystocia be managed by the most experienced person in the room. ® This individual ( generally the attending physician) must have the ability to intervene at any time and should be the only one giving orders. Hossam Shawki MD
Active Management WITHEN 7 MINUTES Hossam Shawki MD
Six Key Principles for Delivery of Shoulder Dystocia (1)Relieve the bony obstruction, (2) Apply appropriate downward traction, (3) Move the shoulders to an oblique position, (4) Decrease the bisacromial diameter of the shoulders, (5) Increase the effective pelvic dimensions, and (6) Deliver either shoulder. Hossam Shawki MD
Active Management 1)-Initial gentle attempt of traction. 2)-Generous episiotomy. 3)-Suprapubic pressure. 4)-Mc. Roberts Maneuver 5)-Suprapubic Pressure 6)-Woods’ Corkscrew Maneuver 7)-Delivery of the Posterior Arm Hossam Shawki MD
Generous episiotomy Older medical literature calls for episiotomy; however, because shoulder dystocia is a bony dystocia, an episiotomy by itself generally does not help delivery. Episiotomy actually may delay other more helpful maneuvers. But common sense need making a room for the birth attendants' hand to help any rotational maneuvers so, episiotomy allow the birth attendant to insert his or her hand past the wrist into the posterior vagina or hollow of the sacrum, where most of the maneuvering room is available. (1999) Hossam Shawki Bennett MD
Gentle Traction Gentle pressure on the fetal ® vertex in a dorsal direction will move the posterior fetal shoulder deeper into the maternal pelvic hollow, usually resulting in easy delivery of the anterior shoulder. Excessive angulations (>45 ® degrees) is to be avoided. (Gabbe, et al. , Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986) Hossam Shawki MD
Suprapubic Pressure *Moderate suprapubic pressure is often the only additional maneuver necessary to disimpact the anterior fetal shoulder. Stronger pressure can only be exerted by an assistant. (resolve about 40% of shoulder dystocias) TYPS: (1)Mazzanti maneuver pushing the shoulder down posteriorly (2) Rubins' first maneuver into a more oblique plane (1997) Peleg et al Hossam Shawki MD
Hossam Shawki MD
Hossam Shawki MD
Mc. Robert’s Maneuver Exaggerated hyper flexion of the thighs upon the abdomen. *Decreases the angle of pelvic inclination ** Cephalic rotation of the pelvis frees the anterior shoulder highly successful 42% to 79% Peleg et al (1997) Hossam Shawki MD
Exaggerated hyper flexion of the thighs upon the abdomen. + Suprapubic Pressure Hossam Shawki MD (Gabbe, et al. , 1986)
Hossam Shawki MD
Mc. Roberts manoeuvre : X ray pelvimetry study 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 Hossam Shawki MD
Mc Roberts manoeuvre IU pressure by 97% (P<0. 0001) U. contraction amplitude by 25% (P<0. 001) Applied additional 31 Newtons pushing force Buhimschi et al Lancet 358: 470 , 2001 Hossam Shawki MD
Woods’ Corkscrew Maneuver The shoulders must be rotated utilizing pressure on the scapula and clavicle. ® The head is never rotated. (B. Harris, Shoulder dystocia, Clinical Obstetrics and Gynecology, 1984; 27: 106. ) ® (B. Harris, Shoulder dystocia, Clinical Obstetrics and Gynecology, 1984; 27: 106. ) Hossam Shawki MD
Woods’ Corkscrew Maneuver ® Delivery may be facilitated by counterclockwise rotation of the anterior shoulder to the more favorable oblique pelvic diameter, or clockwise rotation of the posterior shoulder. ® During these maneuvers, expulsive efforts should be stopped and the head is never grasped !! Hossam Shawki MD
• The hand is placed behind the posterior shoulder of the fetus if this failed the shoulder is rotated progressively 180 d in a corkscrew manner so that the impacted anterior shoulder is released. Hossam Shawki MD
Hossam Shawki MD
Delivery of the Posterior Arm To bring the fetal wrist within reach, exert pressure with the index finger at the antecubital junction. (E. Sandberg. American Journal of. Hossam Obstetrics and Gynecology, 1985; 152: 481. ) Shawki MD
Delivery of the Posterior Arm Sweep the fetal forearm down over the front of the chest. Hossam Shawki MD
Delivery of the Posterior Arm ® If less invasive maneuvers fail to affect this impaction, delivery should be facilitated by manipulative delivery of the posterior arm by inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder with delivery over the perineum. Hossam Shawki MD
When All Else Fails. . . 1. 2. 3. 4. 5. 6. 7. The Rubin Maneuver The Chavis Maneuver The Hibbard Maneuver Fracture of the Clavicle / Cleidotomy The Zavanelli Maneuver All four Maneuver Symphysiotomy Hossam Shawki MD
The Rubin Maneuver 1 st described by Rubin In 1964 Step 1: The fetal shoulders are rocked from side to side by applying force to the maternal abdomen. Step 2: If step one is not successful, push the presenting fetal shoulder toward the chest. This will often cause addution of both shoulders and create a smaller shoulder to shoulder diameter. ( also called Rubins' second maneuver). Hossam Shawki MD
Hossam Shawki MD
The Chavis Maneuver Described in 1979. A “shoulder horn” consisting of a concave blade with a narrow handle is slipped between the symphysis and the impacted anterior shoulder. This used like a shoe-horn as a lever where the symphysis is the fulcrum. Hossam Shawki MD
The Hibbard Maneuver Release of the anerior shoulder is initiated by firm pressure against the infant's jaw and neck in a posterior and upward direction. An assistant is poised, ready to apply fundal pressure after proper suprapublic pressure ® As the anterior shoulder slips free, fundal pressure is applied, and pressure against the neck is shifted slightly toward the rectum. Proper suprapubic pressure is Hossam Shawki MD continued. ®
The Hibbard Maneuver ® Continued fundal and suprapublic pressure results in an upward-inward rotation of the newly freed anterior shoulder and a further descent in a position beneath the pubic symphysis. Hossam Shawki MD
The Hibbard Maneuver ® As a result of the previous maneuvers, the transverse diameter of the shoulders is reduced. ® Lateral (upward) flexion of the head releases the posterior shoulder into the hollow of the sacrum. Hossam Shawki MD
Fracture of the Clavicle ® The anterior clavicle is pressed against the ramis of the pubis. ® Care should be taken to avoid puncturing the lung by angling the fracture anteriorly. ® Theoretically, a fracture of the clavicle is less serious than a brachial nerve injury and often heals rapidly. Hossam Shawki MD
The Zavanelli Maneuver First described in 1988 Consists of cephalic replacement and then cesarean delivery. Hossam Shawki MD
The Zavanelli Maneuver 1. The head first manually rotated to the occipito anterior (Pre-restitution) position Hossam Shawki MD
The Zavanelli Maneuver 2. Flexion of the head, Returning it to the vagina with upward constant firm pressure, followed by CS Hossam Shawki MD
The Zavanelli Maneuver • It would usually only be applicable in those rare cases of bilateral Sh. D. • It involves an emergency procedure that is not without risks of its own. • It has minimal applicability as it needs Immediate CS Hossam Shawki MD
The Zavanelli Maneuver In an analysis of 92 cases of shoulder dystocia managed by Zavanelli Maneuver: Success rate : 92 % Stillbirth: 7% Neonatal death : 9%. Brain damage : 11% Maternal complication: Rupture uterus , vaginal rupture , severe infection, Sanberg; Obstet Gynecol. ; 93: 312. 1999 Hossam Shawki MD
All- Fours Manoeuver The all-fours (Gaskin) maneuver was first introduced into the United States in 1976 by Ina May Gaskin, a midwife. More widely accepted by midwives and family physicians, recently appeared in the obstetric literature. It consists of moving (or "rolling") the laboring patient to her hands and knees. Generally, once in this position, the posterior shoulder is delivered by downward traction. Hossam Shawki MD
All- Fours Manoeuver It consists of placing the patient into her hands and knees noninvasive, requiring only a change in maternal position. Movement from the dorsal lithotomy position to the all-fours position Hossam Shawki MD
All- Fours Manoeuver It allows rotational movement of the sacroiliac joints resulting in a l-cm to 2 cm increase in the sagittal diameter of the pelvic outlet. • It dis-impact the shoulders, and allowing it to slide over the sacral promontory. • Effective also for bilateral Sh. D. • Hossam Shawki MD
All- Fours Manoeuver In an analysis of 82 cases of shoulder dystocia managed by all-four manoeuver : • Success rate : 83% • Maternal complications 1. 2% • Neonatal complications : 4. 9%, • Time for complete delivery : 2 to 3 Ms. Drummond et al. J Reprod Med. ; 43: 439; 1998. Hossam Shawki MD
. . . Don’t Even Think About It. . . ® Symphysiotomy is a dangerous procedure with substantial risk to maternal health and well being. ® It is difficult to justify this procedure for shoulder dystocia in modern medicine. Hossam Shawki MD
Complications Associated with Symphysiotomy ® Vesicovaginal Fistula ® Osteitis Pubis ® Retropubic Abscess ® Stress Incontinence ® Long Term Walking Disability / Pain Hossam Shawki MD
Conclusions ® Although shoulder dystocia represents a catastrophic event in obstetrics, a wellreasoned plan of action with adequate support and skilled personnel can reduce fetal morbidity. ® Proper patient selection and awareness of risk factors for shoulder dystocia can also reduce morbidity. Hossam Shawki MD
ACOG Issues Guidelines 1997 There is no evidence that any one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury. Hossam Shawki MD (B: II-2).
ACOG Issues Guidelines 1997 However, the Mc Roberts maneuver is easily facilitated and has a high success rate without an associated increased risk of injury to the newborn (B: II-2). Hossam Shawki MD
Addendum to Lecture Hossam Shawki MD
Although half of shoulder dystocias occur in infants weighing less than 4000 gms…. The incidence of shoulder dystocia is directly related to fetal size. Hossam Shawki MD
Q: Can Cesarean Sections for Suspected Macrosomia Reduce the Rates of Shoulder Dystocia? ® Sensitivity of clinical estimates of BW > 4500 gms is only 20% ® USG is not very accurate at extremes of EFW ® Most cases of shoulder dystocia occur in infants of average weight ® The incidence of birth trauma in large infants is not trivial ® (2. 5% with BW > 4500 gms) A: NO Hossam Shawki MD
Top Reasons for Successful Claims Against Obstetricians in Cases of Shoulder Dystocia 1. 2. 3. 4. 5. Inappropriate obstetrical delivery notes Absence of delivery notes Failure to document the dystocia Failure to document use of Mc. Robert’s maneuver Lack of prenatal documentation or follow-up of ® Abnormal or borderline GTT ® Unexpected large maternal weight gain. Harvard Risk Management Foundation (1994) Hossam Shawki MD www. rmf. org
Things To Do After Dystocia Occurs 6 -Check for and treat reproductive tract injuries 7 -Pediatric neurology and neonatology consultation 8 -Document a detailed delivery note, including maneuvers used 9 -Explain the occurrence of dystocia to the parents of the infant 10 -Do not finger-point 11 -Be truthful, but avoid discrepancies in notes by doctors, midwives and nurses. Harvard Risk Management Foundation (1994) Hossam Shawki MD www. rmf. org
Hossam Shawki MD
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