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Shoulder dystocia (Post delivery (active management of the 3rd stage of…
Shoulder dystocia
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Management
Immediately
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Avoid downwards traction on the fetal head (increases risk of brachial plexus injury) – only use “routine” axial traction (i.e. keep the head in line with the baby’s spine), and do not apply fundal pressure (increases the risk of uterine rupture)
First line manouveres
McRoberts manoeuvre: hyperflex maternal hips (knees to chest position) and tell the patient to stop pushing. This widens the pelvic outlet by flattening the sacral promontory and increasing the lumbosacral angle. This single manoeuvre has a success rate of about 90% and is even higher when combined with ‘suprapubic pressure’, (see below).
Suprapubic pressure: applied in either a sustained or rocking fashion to apply pressure behind the anterior shoulder to disimpact it from underneath the maternal symphysis.
Second line manouvres
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Internal rotation (“corkscrew manoeuvre”): apply pressure simultaneously in front of one shoulder and behind the other to move baby 180 degrees or into an oblique position.
If the above manoeuvres fail then roll patient onto all fours and repeat (this may widen the pelvic outlet as the legs are abducted and flexed).
Further manouvres (used very rarely, only when all else fails)
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Clinical Features
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Turtle neck sign: foetal head retracts slightly int the pelvis so that the neck is no longer visible
Risk factors
Pre-labour
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Diabetes: risk x2 (likely secondary to macrosomia, weight distribution disproportionate with increased wiehgt in trunk)
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Complications
Maternal – 3rd or 4th degree tears (3-4%), post-partum haemorrhage (11%)
Fetal – humerus or clavicle fracture, brachial plexus injury (2-16%) [caused by applying traction of foetal head], hypoxic brain injury [proportional to time delay]
Pathophysiology
Normal labour: fetal head is delivered via extension out of the pelvic outlet. This is followed by restitution of the fetal head, so it lies in a neutral position in relation to its spine. This means the fetal shoulders now lie in an anterior-posterior position.
Definition: The anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory after delivery of the head with a delay in delivery of the head during the next contraction after using normal traction
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