distosia bahu

International

International

• Definition and Incidence • Significance • Risk Factors • Diagnosis • Management

International

• impaction of anterior shoulder above symphysis • inability to delivery shoulders by usual methods • 1 to 2 per 1000 deliveries • 16 per 1000 deliveries of babies > 4000 g

International

International

Shoulder Dystocia

International

International

• Fetal/neonatal

-

death asphyxia and sequelae fractures - clavicle, humerus brachial plexus palsy

• Maternal

- postpartum hemorrhage - uterine rupture

International

• post-term pregnancy • maternal obesity • fetal macrosomia • previous shoulder dystocia • operative vaginal delivery • prolonged labour  • poorly controlled diabetes

International

International

• head recoils against perineum, ‘turtle’ sign • spontaneous restitution does not occur  • failure to deliver with expulsive effort and usual gentle direction

International

‘Turtle’ sign

International

1. Release anterior shoulder from impaction at symphisis 2. Reduce biacromial diameter  3. Enlarge pelvic capacity

International

Ask for help Lift

- the buttocks - the legs

}

McRobert’s maneuver 

Anterior disimpaction of shoulder  - suprapubic pressure (Massanti) - rotate to oblique (Rubin) Rotation of the posterior shoulder  -Woods’ maneuver  -Rubin+Wood Cockscrew Manual removal of posterior arm (Schwartz) Episiotomy consider  Roll over  onto 2-4 or knee chest (Gaskin)

International

• Panic • Pulling (on the head) • Pushing (on the fundus) • Pivoting (sharply angulating the head, using the coccyx as a fulcrum)

International

• get the mother on your side • partner, coach • nursing • notify physician back up or other  appropriate personnel

International

International

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm34 2007)501–531

International

TheMcRobertsmaneuverdoesnotchangetheactualdimensionofthematernalpelvis. Rather,themaneuverstraightensthesacrumrelaQvetothelumbarspine,allowingcephalic rotaQonofthesymphysispubisslidingoverthefetalshoulder. AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm342007)501–531

International

International

McRoberts'maneuver.A,Bisacromialdiameterpinnedbehindpubicsymphysis.B,Removing thematernallegsfromthesQrrupsandpungthekneesuptothechestfulcrumsthepubic symphysisovertheimpactedanteriorshoulder JohnA.Marx,RobertS.Hockberger,RonM.Walls.JamesG.Adams.Rosen'sEmergencyMedicine:ConceptsandClinicalPracQce,6thed.

International

Lifting the legs and buttocks (McRobert’s maneuver) •flexion of thighs on abdomen •requires assistance • 70% of cases are resolved with this manoeuvre alone

International

•NO fundal pressure • Abdominal approach: suprapubic pressure applied with heel of  clasped hand from the posterior aspect of the anterior shoulder to dislodge it

International

•NO fundal pressure • Abdominal approach: suprapubic pressure Suprapubicpressure.Suprapubic pressureisapplieddirecQngtheanterior applied with heel of  shoulderdownwardandlaterally.If clasped hand from the possible,pressureshouldbedirected posterior aspect of the fromthesideofthefetalspinetoward theface.Pressureshouldbeappliedby anterior shoulder to anassistantwitheitherthepalmorfist. dislodge it AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm342007)501–531

International

International

International

•vaginal approach •adduction of anterior  shoulder by pressure applied to the posterior  aspect of the shoulder (the shoulder is pushed toward the chest) •consider episiotomy •NO fundal pressure

International

Rubin Maneuver 

International

Rubin Maneuver 

Rubin'smaneuver decreasesthe bisacromial diameter.AP, anteroposterior.

JohnA.Marx,RobertS.Hockberger,RonM.Walls.JamesG.Adams.Rosen'sEmergencyMedicine:ConceptsandClinicalPracQce,6thed.

International

Rubin Maneuver  Rubin'smaneuverdecreasesthebisacromial diameter.AP,anteroposterior.

TheRubin’smaneuver.Thismaneuverinvolvesapplying pressuretothemostaccessiblepartofthefetalshoulder ie,eithertheanteriororposteriorshoulder)toeffect shoulderadducQonA).B)Curvedarrowsshows rotaQonoffetalshoulders.

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm342007)501–531

International

•pressure on anterior aspect of  posterior shoulder  •may be combined with anterior  disimpaction manoeuvers •NO fundal pressure

International

Wood’s screw maneuver  • can be done simultaneously with anterior  dissimpaction

International

•may be repeated if delivery not accomplished by Steps 1 & 2

International

International

International

TheWoods’corkscrewmaneuver. Thismaneuverinvolvesapplying pressuretotheclavicularsurfaceof theposteriorarm,allowingrotaQon A)suchthattheanteriorshoulder dislodgesB)frombehindthe maternalsymphysis.Curvedarrow showsrotaQon.Straightarrow showsmanualrotaQonofinfant’s bodyincoordinaQonwithrotaQon byhandbelow AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm342007)501–531

International

•flex arm at elbow •(pressure in antecubital fossa to flex arm) •sweep arm over  chest •grasp wrist/forearm or hand •deliver arm

International

Deliveryoftheposteriorarm.Todeliverthe posteriorarm,pressureshouldbeappliedatthe antecubitalfossatoflexthefetalforearm.The forearmorhandissubsequentlygraspedandthe armsweptoutovertheinfant’schestand deliveredovertheperineum.RotaQonofthetrunk tobringtheposteriorarmanteriorlyissomeQmes required.A)First,turnfetalheadtoallowentryof pracQQoner’shandtofacilitatemanipulaQon.B) Second,supportfetalheadwithonehandand sweepsecondhandposteriorly.C)Next,flex infant’sarmatantecubitalfossatoallow pracQQonertograspposteriorforearmorhand. D)Deliverposteriorarm.ThisallowsrotaQonof thefetuswiththegoalofdisimpacQngthe anteriorshoulder.E)Furtherrotatefetusto facilitatedelivery. AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm342007)501–531

International

• may facilitate Wood’s Manoeuver or allow room for  delivery of the posterior arm

International

• = all-fours (Gaskin maneuver) • May allow easier access to posterior shoulder  • Radiographic studies : pelvic diameters increase (10 mm true obstetric conjugate & sagital pelvic outlet)

International

Gaskin maneuver  TheGaskinposiQon.The ‘‘allfours’’posiQonexploits theeffectsofgravityand increasedspaceinthe hollowofthesacrumto facilitatedeliveryofthe posteriorshoulderand arm.

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm342007)501–531

International

Gaskin maneuver 

International

• clavicular fracture • cephalic replacement (Zavenelli manoeuvre) • symphysiotomy

International

Zavenelli manoeuvre

International

Last Resort A,B)Thisfigureshows deliveryoftheposteriorarm withfacilitaQonofdeliveryby hysterotomy.Theintra‐ abdominalhandcanbeused torotatetheanterior shouldertoallowvaginal delivery;oraZavanelli maneuvercanbeperformed subsequently,allowing cesareandelivery.

International

Symphysiotomy

International

• be prepared for PPH • inspect for maternal lacerations and trauma • examine the baby for evidence of  injury • explain the delivery and manoeuvers • chart what was done

Recommendation that a shoulder dystocia intervention form should include the following information

International

•

When and how the dystocia was diagnosed

•

Progress of labor (active phase and second stage)

•

Position and rotation of the infant’s head

• •

Presence of episiotomy Anesthesia required

•

Estimation of force of traction applied

•

Order, duration, and results of maneuvers used

•

Duration of shoulder dystocia

•

Documentation of adequate pelvimetry before initiating labor  induction or augmentation

•

Neonatal and obstetric impressions of the infant after delivery

•

Information given to gravida that shoulder dystocia had occurred

AmyG.Go(lieb,HenryL.Galan.ShoulderDystocia:AnUpdate.ObstetGynecolClinNAm342007)501–531

International

Conclusions

• anticipate and be prepared (most are unpredictable) • remember the mnemonic “ALARMER” • stay calm, don’t panic, pull, push or pivot

International

Ask for help Lift - the buttocks - the legs

}

McRobert’s Maneuver 

Anterior disimpaction - rotate to oblique - suprapubic pressure

Rotate the posterior shoulder - Woods’ maneuver  Manual removal of the posterior arm Episiotomy consider  Roll over 

International

THANK YOU

International

International

Hibbard Manuever 

International

Schwartz Dixon

International

Shoulder Dystocia

International

Shoulder Dystocia

International

Shoulder Dystocia • Management  – Help – obstetrician, pediatrician  – Episiotomy  – Legs – elevate (McRoberts)  – Pressure - suprapubic  – Enter vagina – Rubin’s and Woods’ screw  – Roll or Remove posterior arm  – Zavanelli, clavicular #, symphysiotomy

International

McRoberts Maneuver  • hyperflexion of maternal hips • brings symphysis over anterior shoulder  • straightens sacral promontory

International

Suprapubic Pressure • direct posterior or oblique suprapubic pressure to disimpact anterior shoulder 

International

Rubin’s Maneuver  • adduction of the most accessible shoulder  • moves the fetus into an oblique position and decreases the bisacromial diameter 

International

Woods’ Screw Maneuver  • rotational pressure on the anterior  aspect of the posterior shoulder, moving the fetus 180°

International

Woods’ Screw Maneuver  • the former posterior shoulder is now anterior and past the pubic symphysis

International

All-Fours Maneuver  • changes pelvic dimensions in a similar  way to McRoberts maneuver  • apply downward traction to disimpact the posterior shoulder 

International

Deliver posterior arm • grasp the posterior arm and sweep it across the anterior chest to deliver it

International

Zavanelli Maneuver  • cephalic replacement via reversal of the cardinal movements of labor follow be Cesarean section

International

Clavicular Fracture

• fracture the anterior clavicle by pushing it against the pubic ramus or using a closed pair of scissors • risk of pneumothorax