Shoulder dystocia

Question 1

What are general measures to take with shoulder dystocia?

Answer 1

• neonate should ideally be delivered in 10 minutes
• call for help: 2 additional RNs, 1 OBGYN, anesthesiologist, pediatrician
• functional IV
• oxygen for mother
• empty bladder and rectum, even though this is a bony problem
• nitroglycerin to relax uterus (50-100 mcg, onset within 30-90 seconds, lasts 2-3 minutes; side effect hypotension)

Question 2

specific measure for shoulder dystocia (in order):

Answer 2

• drain bladder
• suprapubic pressure (no fundal pressure)
• mcroberts maneuver
• delivery the posterior arm
• attempt a rotational maneuvers:
  1) woods screw maneuver
  2) rubin maneuver
• gaskin maneuver - place mother on hands and knees
• intentional humeral/clavicular fracture
• Consider episiotomy: makes space for operator’s hand, but does not improve the outcome of the dystocia and increases the risks of vaginal laceration
• symphysiotomy can be considered
• perform maneuvers x2
• then zavanelli -> CD

no fundal pressure

Question 3

describe rubin’s and wood’s corkscrew manuever

Answer 3

1) rubin maneuver- back of any shoulder; exert pressure on posterior aspect of the scapula; rotate fetus < 180 degrees to disimpact shoulder from symphysis (works by decreasing bisacromial diameter)
2) woods corkscrew maneuver: exert pressure on front of posterior shoulder - shoulder i rotated 180 degrees, rotational descent, increases the bis-acromial demeter

Question 4

how to intentionally fracture clavicle

Answer 4

exert upward pressure (away from lung) on the mid-portion of the clavicle

• should never be performed with scissors (risk of lung puncture and brachial plexus injury)
• if dystocia persists, consider intentional fracture of other clavicle

Question 5

risk of clavicle fracture

Answer 5

pneumothorax, hemothorax, sublcavian vessel injury, brachial plexus injury (erbs, klumpke’s)

Question 6

what is the recurrence rate of shoulder dystocia?

Answer 6

10%, but wide range in literature

Question 7

counseling for history of shoulder dystocia

Answer 7

universal recommendation of c-section not advised. can consider, discussing risks of both.

Question 8

can you induce for macrosomia to reduce risk of shoulder dystocia?

Answer 8

ACOG recommends against induction prior to 39 weeks unless medically indicated.

Question 9

what should be included in documentation?

Answer 9

• time of diagnosis
• management
• time of delivery
• sequelae

Question 10

risk factors for shoulder dystocia?

Answer 10

• prior shoulder dystocia
• prior hx of macrosomic delivery
• post term pregnancy
• high 1 hr normal 3 hr gtt
• gestational diabetes
• macrosomia