shoulder dystocia

 Shoulder Dystocia (SD)

1. Definition

2. Risk factors

3. HELPERR

4. BE CALM

5. Complications

6. Prevention

** HELPER, BE CALM

Definition: 

- unanticipated obstetric emergency which requires early recognition and rapid intervention

- refers to a situation where after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory.

RIsk factors:

• maternal
• maternal obesity
• small maternal stature
• GDM
• previous SD 
• IOL
• prolong stage 1 and 2 of labour
• augmentation of delivery
• fetal
• macrosomic
• instrumental delivery

* those underline is the most common risk factors for SD. 

When SD occurs

1st: call for HELPPER!

H: call for HELP!

E: episiotomy

L: Mc robert maneuver

Mc Robert's maneuver: 

hyperflex and abduction of hips, cause cephalad rotation of symphysis pubis

flex mothers leg to abdomen,

 to flatten sacral promontory, straighten lumbosacral angle, increase A-P diameter of pelvis, 

thus free the impacted shoulder

P: suprapubic pressure: 

- help reduce bisacromial diameter, dislodge impacted shoulder, facilate to oblique position to permit delivery with gentle traction

E: Enter hand to deliver : 

- posterior arm delivery: finger introduce to fetal axilla to bring shoulder down and deliver posterior arm across baby chest

- wood screw method

- reverse wood screw

R: Roll on four (GASKIN maneuver)

all fail: for Zavenalli maneuver: atttempt to push back into uterus for Caesarean

Adapt BE CALM

- Breathe and stop pushing

- Elevate legs

- Call for help

- Apply suprapubic pressure

- enLarge vaginal opening: episiotomy

- Manoeuvres

Complications: 

• Fetal:
• Brachial Palsy, Brachial plexus injury, 
• fracture of clavicla and humerus
• cerebral hypoxia- d/t delay of delivery (should deliver within 5minutes once baby head out)
• Ischemic encephalopathy
• Cerebral palsy
• maternal:
• vaginal and perineal laceration
• 3rd and 4th degree tears
• postpartum hemorrhage
• uterine rupture(rare)

Preventions:

- identify risk factors

- early IOL to prevent macrosomia

- Risk assessment: documentation of factors

- Early detection

- Plan of action: caesarean for babies > 4kg (in mothers with GDM), >5kg in mothers without GDM

References:

1. https://www.hopkinsmedicine.org/gynecology_obstetrics/education/training/shoulder-dystocia