Shoulder dystocia

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Background

  • Occurs in 0.2-3% of all births[1]
  • Anterior shoulder becomes impacted in pubic symphysis

Risk Factors

  • Pre-labor
    • Previous shoulder dystocia
    • Macrosomia
    • DM
    • Maternal BMI > 30
    • Induction of labor
  • Intrapartum
    • Prolonged first or second stage
    • Oxytocin augmentation
    • Assisted vaginal delivery

Clinical Features

  • Routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder or additional obstetric maneuvers are required for delivery of anterior shoulder.
  • "Turtle sign" - fetal head retracts against perineum after it appears (rare)

Differential Diagnosis

Emergent delivery and related complications

Diagnosis

  • Clinical diagnosis

Treatment

No consensus on best treatment/maneuver or order of their application.

HELPERR mnemonic - all maneuvers able to be performed by Emergency Physician, generally from least to most invasive

  • H call for help
  • E Evaluate for possible episiotomy (or episioproctotomy) to increase the anteroposterior diameter of passage
  • L Legs flex (McRoberts maneuver) - best first option - hyperflexion of legs with mild abduction and external rotation (successful in 40% of cases[1])
  • P Pressure (suprapubic pressure, aka Rubin I maneuver) - apply pressure just proximal to pubic symphysis, either continuously or in rocking motion (in conjunction with McRoberts, increases success rate to 54%[1]
  • E Entry maneuvers - Wood’s corkscrew maneuver by pushing the most accessible shoulder toward the chest to corkscrew the shoulders through, while maintaining rocking suprapubic pressure at the same time
  • R Remove posterior arm by sweeping it across the chest and bring fetal hand to the chin, grasp and pull out of the birth canal and across the face
  • R Roll on all fours

Complications

  • Transient brachial plexus palsy (3.0 to 16.8 percent)
  • Clavicular fracture (1.7 to 9.5 percent)
  • Humerus fracture (0.1 to 4.2 percent)
  • Permanent brachial plexus palsy (0.5 to 1.6 percent)
  • Hypoxic-ischemic encephalopathy (0.3 percent)
  • Death (0 to 0.35 percent)

See Also

References

  1. ↑ 1.0 1.1 1.2 Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.
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