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SHOULDER DYSTOCIA

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  1. Definition, Incidence and Complications impaction of anterior shoulder of fetus against symphysis pubis after fetal head has been delivered (life threatening emergency)
  2. occurs when breadth of shoulders is greater than biparietal diameter of the head
  3. incidence is 0.15-1.4% of deliveries
  4. watch for ”turtle sign” (head advances during contraction but returns to previous position  at end of contraction) 
  5. chest compression by vagina or cord compression by pelvis can lead to hypoxia
  6. danger of brachial plexus injury (Erb palsy)
  7. fetal fracture (clavicle, humerus, cervical spine)
  8. maternal perineal injury, may result in PPH
.

Associated Conditions maternal
  1. maternal
    • obesity
    • diabetes
    • multiparity
  2. fetal
    • prolonged gestation
    • macrosomia
  3. labour

    • prolonged 1st and 2nd stages
    • prolonged deceleration phase (8-10 cm)
    • instrumental midpelvic delivery
.

Management

  1. goal: to displace anterior shoulder from behind symphysis pubis
  2. initial gentle traction with maternal pushing
  3. adequate analgesia
  4. apply suprapubic pressure (to dislodge shoulder) with downward traction
  5. ask for help
  6. legs into hyperflexion on maternal abdomen (McRobert maneuver)
  7. anterior shoulder disimpaction
  8. release posterior shoulder (deliver posterior arm and shoulder)
  9. maneuver of Woodís corkscrew (insert hand beyond occiput into vagina and push anterior shoulder forward to the oblique or push the posterior shoulder through a 180 degree arc to reduce the biacromial diameter presented to the pelvic inlet)
  10. episiotomy (midline)
  11. cleidotomy: deliberate fracture of the clavicle (last resort)
  12. Zavanelli maneuver (involves flexion of the fetal head,replacement of the fetus within the uterine cavity and emergent ,C-section; reported success in a small series)
SHOULDER DYSTOCIA SHOULDER DYSTOCIA Reviewed by Radiology Madeeasy on January 17, 2011 Rating: 5
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