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Shoulder Dystocia
Head to body delivery time >60 seconds
Need to employ maneuvers to deliver the
shoulders other than traction
Incidence - 0.9 %
Etiology
o Greater shoulder to head & chest to
head disproportion
Risk factors
o Obesity, multiparity, Diabetes Mellitus,
postmaturity McRoberts Maneuver
Consequencies:
Maternal
o Post partum hemorrhage from uterine
atony & cervical & vaginal lacerations
Fetal
o Fractured clavicle & humerus brachial
plexus injury
DELIVERY OF THE POSTERIOR SHOULDER
Management
Other Techniques to free impacted anterior
shoulder:
1. Rubins maneuver
2. Hibbard maneuver
3. Zavanelli maneuver
4. fracture the clavicle
5. Cleidotomy & Symphysiotomy
Rubins maneuver
Fetal shoulders rocked from side to side by
applying force to the maternal abdomen. Contracted Inlet
If not successful: Shortest AP diameter: < 10 cm. ( obsterical plane)
Pelvic hand reaches the most accessible fetal Greatest transverse diameter: < 11.5 cm.
shoulder, is then pushed toward anterior chest Face & shoulder presentation: 3x more frequent
to reduce shoulder to shoulder diameter Cord prolapse: 4-6x more frequent
(adduction) displacement of the anterior EROM more likely
shoulder from behind the symphysis pubis Slow or absent progress in cervical dilatation
Frequently causes transverse arrest of the head
Hibbard
Prognosis & Management
Pressure applied to fetal jaw and neck in the
AP diameter slightly <10cm vaginal delivery
direction of the maternal rectum, with strong
maybe successful
fundal pressure applied by the assistant
AP diameter < 9cm vaginal delivery nearly
hopeless
Zavanelli
Cephalic replacement into the pelvis followed Management
by CS Trial of labor should be carefully managed
Conduction anesthesia & Oxytocin with caution
Cleidotomy Cesarian section for arrest of cervical dilatation
Cutting the clavicle of the fetus
usually in FDU cases Maternal Effects
1. Uterine rupture
Symphysiotomy 2. Fistula formation
Cutting the symphysis punis of the mother
3. Intrapartum infection
Rare
Fetal Effects
1. Caput succedaneum
Fetal Developmental Abnormalities
2. Fetal head moulding
1. Fetal macrosomia
3. Umbilical cord prolapse
2. Hydrocephalus
3. Large fetal abdomen
4. Conjoined twins
Midpelvic Contraction Pelvic fractures
Likely contracted X-ray
Interischial spinous diameter and posterior Rare pelvic contractions
1. Tuberculosis
sagittal diameter: < 13.5 cm
2. Poliomyelitis
Suspect contraction 3. Kyphoscoliosis
Bispinous diameter is < 10cm 4. Rickets
Definitely contracted
Bispinous diameter is < 8cm Soft Tissue Dystocia
Suggestive of contraction Uterine abnormalities, prolapsed uterus,
Prominent ischial spines uterine torsion diffuse balooning of the uterine
Side walls convergent wall
Flat sacrum Cervical stenosis, coaglutination of the cervix
Narrow intertuberous diameter Vaginal septum
Pelvic masses, myomas, ovarian tumor
Prognosis
Frequently a cause of transverse arrest that can
potentially lead to difficult mid forceps
extraction or cesarean delivery
Management
Natural forces should be allowed to push the
]]biparietal diameter beyond the potential
interspinous obstruction forceps extraction
Fundal pressure not done above obstruction
Cesarian section
Prognosis
Usually associated with midpelvic contraction
Midpelvic contracts, outlet also contracts
If alone, not cause severe dystocia but may
predispose to production of perineal tears