SHOULDER DYSTOCIA

A patient presents to the emergency department in labor.  You check and as you look, she pushes the head out which you catch just in time with some counter-pressure to control delivery. But now things stop and the shoulder won’t deliver. You run your finger between the neck and shoulder – no nuchal cord. What do you do next?

 

The goal is to get the baby out as soon as possible and prevent hypoxic ischemic encephalopathy and brachial plexopathy (Gurewitsch Clin Ob Gyn 2007). You have about 6-8 minutes of “head-to-body” time until brain injury can occur (time the head is sitting on the perineum). Try a maneuver for shoulder dystocia, but if it does not lead to easy delivery then it did not work and quickly go to the next one.  This is the right kind of haste.  The wrong kind of haste is to jerk the child out, which risks brachial plexopathy.  Finesse is needed, not force.

 

Most of the risk of brachial plexopathy is from lateral traction on the neck.  Axial traction is much safer.  If one finds that lateral traction would be needed, it usually means positioning of the fetus is not yet ideal.

 

In recent years, suprapubic pressure (intended to push the obstructed shoulder posteriorly) and McRoberts maneuver (hyperflexion of the hips) are emphasized.  These maternal maneuvers do work 25-40% of the time. Additionally, McRoberts can help open up passage of the fetus deeper into the pelvis and improve the transit. However, a few generations ago in the 1940s fetal manipulation was used predominantly, and rates of brachial plexopathy were actually lower. (Gurewitsch 2007)

 

Rotational manipulation of the fetus is safe and effective, and should be turned to quickly in cases of dystocia, long before lateral traction is considered.

 

You try suprapubic pressure and the child’s shoulder moves slightly.  You then rotate the infant and the delivery follows spontaneously.

 

Take home points:

-For shoulder dystocia, fetal manipulation can be more effective than maternal manipulation

-if one maneuver does not fully solve the problem, go to the next maneuver

-Lateral traction of the neck is to be avoided

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