Written by Alex Koo, MD and edited by: Kara Purdy, MD

CC:  Induction of Labor

HPI:

31 yo G3P2002 @ 41+2 weeks presenting for IOL for post-dates.

No gush of fluid, no contractions, no VB, no abdominal pain.  +fetal movements.

Pregnancy course thus far uncomplicated and expected pregnancy weight 3500 grams (7lbs 11oz).

Relevant vitals/PMH/meds/allergies, etc:

Maternal VS nml, afebrile.

FHT 156 bpm

Pt in NAD.

PMH: Maternal Obesity, Hashimoto’s hypothyroidism

The Delivery:

Immediately upon fetal head presentation, head was “sucked back in”.  Fetal head, as evidenced in the picture, also failed to restitute and remained occiput posterior.

baby

Key points to the diagnosis, treatment, dispo, etc.

Diagnosis: Shoulder Dystocia

-Occurs in 1% of all births

-Risk Factors: Maternal obesity, high birth weight, postterm pregnancy, maternal diabetes

-Dangerous to fetus due to asphyxia or severe cord compression

-Dx is clinically made by provider due to difficult delivery, fetal presentation, and risk factors.

-“Turtle Sign”: Upon fetal head presentation, head is “sucked” back in as anterior shoulder is trapped behind the pubic bone.

shoulder

Treatment:

  • Immediately call for OB/GYN for suspected shoulder dystocia
  • Provider 1: Attempt normal downward traction on baby’s head to deliver anterior shoulder.  Reach inside vagina to feel baby’s positioning and direct provider 2’s suprapubic pressure.

Provider 2: McRobert’s maneuver and suprapubic pressure can be applied simultaneously.
*McRobert’s: Hyperflexing both hips to open up the AP diameter of the pelvis for passage.

McRoberts ManeuverR

*Suprapubic pressure: Downward pressure just above the pubic bone on baby’s shoulder to push baby’s shoulder anteriorly and fit under the pubic bone

Provider 3: Hyperflexing other leg

Provider 4: Obtaining supplies for further management, as well as noting time of suspected dystocia:

-Foley balloon

-Scissors for episiotomy

  • Continue above, but if no success with downward traction, perform the Wood’s Corkscrew Maneuver—the posterior shoulder is rotated 180 degrees to become anterior
    • Or posterior shoulder delivery: Reach inside the vagina, adduct fetus arm and sweep arm upwards

cork-2

babe

  • If above maneuver’s unsuccessful, other adjuncts and more aggressive approaches:
    • Adjuncts:
      • Foley to drain bladder
      • Hands and knees position (Gaskin all-fours).  Remember to reverse your traction direction as you should now be pulling baby’s head upward.
    • Aggressive approaches:
      • Mediolateral Episiotomy
      • Breaking the clavicle: hook baby’s anterior clavicle and pull to break clavicle in middle to decrease biacromial distance
      • Symphysiotomy: Performed by OB

Complications:

  • Infant complications: Transient brachial plexus injuries (rarely permanent), clavicle fractures, humeral fractures, hypoxic encephalopathy
  • Maternal complications: postpartum hemorrhage, fourth degree lacerations

Case Outcome: Baby delivered with McRobert’s and suprapubic pressure, along with Wood’s corkscrew maneuver.  Baby final weight: 4549 grams (10lbs 0.1 oz.)

What you learned from the case:

  • Recognition of shoulder dystocia
  • Maneuvers to relieve shoulder dystocia

References and other useful links:

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th Edition https://www.emrap.org/episode/snakebitesand/nationallecture
Core EM: Shoulder dystocia http://coreem.net/core/shoulder-dystocia/
AAFP: Shoulder Dystocia http://www.aafp.org/afp/2004/0401/p1707.html http://www.emcurious.com/blog-1/2015/3/28/shoulder-dystocia

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