Understanding Shoulder Dystocia

Navigating Obstetric Emergency Scenarios Effectively

Slide 1: Defining the Challenge

Introduction to Shoulder Dystocia

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  • What Is It?: Shoulder dystocia occurs when the fetal anterior shoulder impacts the maternal symphysis after head delivery, preventing spontaneous body delivery. Early identification is key.
  • Why It Matters: A significant obstetric emergency that can lead to fetal hypoxia, nerve damage, and maternal morbidity if not managed promptly and effectively.
  • Incidence Rates: The incidence varies, typically occurring in 0.2-3.0% of vaginal deliveries. Understanding risk factors can help in preparation and prevention strategies.
  • Initial Response: Stay calm and call for help immediately. Clear communication with the team ensures coordinated actions and better outcomes for both mother and baby.
  • Video Overview: A visual introduction to the mechanisms and initial management steps for shoulder dystocia, providing a foundation for further learning.

Slide 2: Risk Factor Identification

Antenatal and Intrapartum Clues

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  • Macrosomia Alert: Suspected fetal macrosomia (birth weight >4000g) is a key antenatal risk. Ultrasound estimations and clinical assessments are crucial for planning.
  • Maternal Diabetes: Gestational or pre-existing diabetes increases the risk significantly. Strict glycemic control and vigilant monitoring are essential during pregnancy.
  • Prior Dystocia History: A previous shoulder dystocia incident elevates the risk in subsequent pregnancies. Careful planning and discussion are vital.
  • Prolonged Labor: Protracted labor, especially in the second stage, can indicate potential dystocia. Active management strategies should be considered.
  • Operative Vaginal Delivery: Forceps or vacuum-assisted deliveries increase the likelihood of shoulder dystocia. Skillful application and awareness are paramount.

Slide 3: Immediate Recognition Signs

Spotting the Turtle Sign

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  • Turtle Sign: The hallmark sign is the retraction of the delivered head against the maternal perineum, resembling a turtle withdrawing into its shell.
  • Failure of Restitution: The head fails to rotate externally after delivery, indicating impaction of the shoulders within the birth canal.
  • Red Face: The baby's face appears red and congested due to the pressure from the shoulder being impacted against the pelvis. Be watchful.
  • No Spontaneous Delivery: Despite gentle traction and maternal pushing, the anterior shoulder remains stuck, preventing the completion of delivery.
  • Time Is Critical: Recognize these signs promptly. Time is of the essence to prevent fetal hypoxia and associated complications. Act swiftly and decisively.

Slide 4: The HELPERR Algorithm

Structured Approach to Resolution

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  • H: Call for Help: Summon experienced colleagues, anesthesia, and neonatal teams immediately. A coordinated approach enhances chances of success.
  • E: Evaluate for Episiotomy: Perform a generous episiotomy to provide additional space, although it doesn't directly relieve the shoulder impaction.
  • L: Legs - McRoberts Maneuver: Hyperflex the mother's legs towards her abdomen to flatten the sacrum and rotate the pelvis, often the first and most effective maneuver.
  • P: Suprapubic Pressure: Apply steady, downward pressure above the pubic bone to dislodge the anterior shoulder. Coordinate with maternal pushing efforts.
  • E: Enter - Internal Rotational Maneuvers: Insert a hand into the vagina to rotate the posterior shoulder anteriorly (Wood's screw maneuver) or deliver the posterior arm.

Slide 5: More HELPERR Steps

Completing the Algorithm

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  • R: Remove the Posterior Arm: Sweep the posterior arm across the chest and deliver it, reducing the bisacromial diameter and facilitating delivery of the anterior shoulder.
  • R: Roll Over - Gaskin Maneuver: If other maneuvers fail, have the mother roll onto her hands and knees. Gravity can help dislodge the impacted shoulder.
  • Document Everything: Meticulous documentation of maneuvers performed, timing, and fetal heart rate changes is crucial for legal and audit purposes.
  • Communication Remains Key: Keep the mother informed about the steps being taken and provide reassurance throughout the process. Her cooperation is essential.
  • After Delivery: After the delivery, carefully examine the baby for injuries and the mother for any tears. Be gentle and vigilant.

Slide 6: McRoberts Maneuver Focus

First-Line Intervention

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  • Technique: Two assistants hyperflex the mother's legs sharply towards her abdomen, straightening the lumbosacral angle and rotating the symphysis pubis.
  • Mechanism: This maneuver flattens the sacrum and rotates the pelvis cephalad, freeing the impacted anterior shoulder. Simple, yet effective.
  • Effectiveness: Often successful as a first-line intervention, particularly when combined with suprapubic pressure. Quick and non-invasive.
  • Coordination: Coordinate McRoberts with maternal pushing efforts to maximize its effectiveness. Clear communication is crucial.
  • Limitations: May not be effective in all cases, especially with severe impaction or large fetal size. Proceed to other maneuvers if unsuccessful.

Slide 7: Suprapubic Pressure Details

Applying External Force Effectively

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  • Hand Placement: Apply firm, steady pressure with a closed fist or open palm just above the pubic bone, directing force downwards and laterally.
  • Direction Matters: Apply the pressure at an angle to dislodge the anterior shoulder from behind the symphysis pubis. Maintain steady, consistent force.
  • Coordination Crucial: Coordinate suprapubic pressure with McRoberts maneuver and maternal pushing. A team effort maximizes effectiveness.
  • Avoid Excessive Force: Apply firm, steady pressure, but avoid excessive force that could cause maternal injury. Gentle and controlled movements are ideal.
  • Potential Complications: Rarely, excessive pressure can cause maternal discomfort or injury. Monitor the mother's response and adjust accordingly.

Slide 8: Internal Rotation Maneuvers

Navigating Within

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  • Wood's Screw Maneuver: Insert hand vaginally and apply pressure on the anterior aspect of the posterior shoulder to rotate the baby, freeing the anterior shoulder.
  • Reverse Wood's Screw: Apply pressure to the posterior aspect of the anterior shoulder to rotate the baby in the opposite direction, aiding in disimpaction.
  • Delivery of Posterior Arm: Sweep the posterior arm across the fetal chest and deliver it, reducing shoulder diameter and facilitating anterior shoulder release.
  • Considerations: These maneuvers require experience and careful technique to avoid fetal injury. Gentle and deliberate movements are essential.
  • Increased Risk: Internal maneuvers carry a higher risk of fetal fracture or nerve injury. Weigh the risks and benefits carefully before proceeding.

Slide 9: Gaskin Maneuver

The All-Fours Approach

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  • Positioning: Have the mother move onto her hands and knees (all-fours position). This can widen the pelvic outlet and facilitate shoulder dislodgement.
  • Gravity's Role: Gravity assists in dislodging the impacted shoulder. This position may also improve access for internal maneuvers if needed.
  • Advantages: Non-invasive and can be easily implemented. May be particularly useful when other maneuvers have been unsuccessful. Be gentle.
  • Limitations: May be difficult for women with epidurals or mobility issues. Ensure adequate support and assistance during the maneuver.
  • Communication: Explain the maneuver to the mother and ensure she is comfortable and able to maintain the position safely. Be patient and reassuring.

Slide 10: Last Resort Options

When Standard Maneuvers Fail

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  • Clavicle Fracture: Intentionally fracturing the fetal clavicle can reduce the shoulder diameter, but carries risk. Only attempt as a last resort.
  • Zavanelli Maneuver: Replacing the fetal head back into the vagina and performing a cesarean section is a rare but potentially life-saving option.
  • Symphysiotomy: Surgical division of the symphysis pubis to widen the pelvic outlet, rarely performed in modern obstetrics due to significant risks.
  • Informed Consent: Discuss the risks and benefits of these procedures with the team and the mother, if time allows. Document the decision-making process.
  • Ethical Considerations: Prioritize fetal and maternal well-being. Consult with experienced colleagues and consider ethical implications before proceeding.

Slide 11: Post-Dystocia Management

Immediate Newborn Care

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  • Newborn Assessment: Immediately assess the newborn for signs of trauma such as brachial plexus injury (Erb's palsy), clavicle fracture, and hypoxia. Be vigilant.
  • Resuscitation: Be prepared for neonatal resuscitation. Shoulder dystocia increases the risk of hypoxia and acidosis. Assemble a team.
  • Maternal Assessment: Assess the mother for postpartum hemorrhage, vaginal lacerations, and uterine rupture. Prompt intervention prevents complications.
  • Debriefing: Conduct a thorough debriefing with the team to review the management and identify areas for improvement. Open communication matters.
  • Parental Support: Provide emotional support to the parents. Explain what happened, address their concerns, and offer reassurance. Show empathy.

Slide 12: Brachial Plexus Injury

Understanding Erb's Palsy

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  • Mechanism: Damage to the brachial plexus nerves during delivery, resulting in weakness or paralysis of the arm. It can occur with or without shoulder dystocia.
  • Diagnosis: Assess for asymmetric Moro reflex, limited arm movement, and characteristic positioning (waiter's tip deformity). Early diagnosis aids the treatment.
  • Management: Physical therapy, occupational therapy, and, in some cases, surgery. Early intervention improves long-term outcomes.
  • Prognosis: Most infants recover with therapy, but some may have residual weakness. Provide ongoing support and monitoring.
  • Parental Counseling: Educate parents about the condition, treatment options, and expected outcomes. Offer emotional support and resources. Be informative.

Slide 13: Documentation Essentials

Legal and Clinical Imperatives

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  • Detailed Record: Document the time of head delivery, recognition of shoulder dystocia, all maneuvers performed, and the time of body delivery.
  • Fetal Heart Rate: Record continuous fetal heart rate monitoring throughout the event. Note any decelerations or changes in variability.
  • Team Members: Document all team members present and their roles. Clear documentation supports accountability and coordination.
  • Communication Log: Record communication with the mother, including explanations of procedures and her consent. Transparency is very important.
  • Complications Noted: Document any maternal or fetal complications, such as lacerations, fractures, or nerve injuries. Detailed reports assist in the treatment.

Slide 14: Prevention Strategies

Reducing Dystocia Risk

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  • Gestational Diabetes Management: Strict glycemic control during pregnancy can reduce the risk of fetal macrosomia and subsequent shoulder dystocia. Education is key.
  • Accurate Weight Estimation: Use clinical and ultrasound assessments to estimate fetal weight accurately. Alert when macrosomia is suspected. Be mindful.
  • Labor Management: Avoid prolonged labor and consider elective cesarean delivery for suspected macrosomia or previous shoulder dystocia history. Evaluate.
  • Simulation Training: Regular drills and simulations can improve team preparedness and response to shoulder dystocia emergencies. Training makes perfect.
  • Patient Education: Educate pregnant women about the risk factors for shoulder dystocia and the importance of early identification and management. Empower knowledge.

Slide 15: Thank You

Acknowledging Your Participation

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  • Gratitude: Thank you for your attention and participation in this presentation. Your dedication to improving obstetric outcomes is commendable.
  • Further Learning: Continue to expand your knowledge and skills in managing shoulder dystocia through ongoing education and training. Knowledge is powerful.
  • Teamwork Matters: Remember that effective teamwork and clear communication are essential in managing obstetric emergencies. Teamwork makes dreams work.
  • Patient-Centered Care: Always prioritize the well-being of both mother and baby in your clinical practice. A happy mother makes a happy baby.
  • Commitment to Excellence: Strive for excellence in your obstetric practice to provide the best possible care for your patients. Excellence defines a professional.