Shoulder Dystocia

Ans. is D. i.e. Lateral cutaneous nerve of thigh

• McRobert’s maneuver is a technique to deliver babies with shoulder dystocia.
• The technique is performed by flexing the mother’s thigh towards her shoulder while she is lying on her back.
• The McRoberts maneuver does not change the actual dimension of the maternal pelvis. Rather it relieves shoulder dystocia via marked cephalad rotation of the symphysis pubis and by flattening the sacrum.

“Occasionally the mother’s symphyseal joint may become separated or the lateral femoral cutaneous nerve, damaged, most likely as a result of the overaggressive hyperflexion of the maternal legs during attempts at resolving the shoulder dystocia “.

Fundal pressure 1Ref Dutta &hie p. 407; Fernando Arias 3rdie p. 288, 287, 289]

Shoulder dystocia

• The first step in the anticipation of shoulder dystocia is the recognition of paient at risk for this condition.
• The word DOPE is a reminder of the most important risk factors associated with shoulder dystocia.

D is for diabetes

0 is for obesity

P is for postern (also prior large baby)

E is for excessive weight gain during pregnancy

• If the patient in labour is DOPE the obstetrician should mentally rehearse the following steps to manage the complication.

Step 1 (Preparation)

A Have the time noted when the problem is recognized and have minutes counted off by a designated individual.

B call anaesthesia and alert the operating room

C call for somebody to help during the delivery

D do not pull the baby’s head.

E do not apply fundal pressure

Step 2 (diagnosis)

A) Enlarge the episiotomy

B) Explore manually behind the baby’s head and find out whether the posterior shoulder of the baby is in the hollow of the sacrum.

If the posterior shoulder is not in the hollow of the sacrum the diagnosis is bilateral shoulder dystocia (both the shoulders are above the pelvic inlet) and the best thing to do is restitute the baby’s head inside the vagina and perform a cesarean delivery.

lf the posterior shoulder is in the hollow of sacrum, the problem is unilateral shoulder dystocia (only the anterior shoulder is above the inlet) and the chances of correcting the problem is good then the obstetrician should perform the McRoberts Maneuver.

Step 3 (McRoberts maneuver)

A) Remove the mother’s legs from strirrups

B) Abduct her legs and sharply flex them against her abdomen this causes a cephalad rotation of the symphysis and often frees an impacted anterior shoulder without manipulation of the fetus.

C) Someone applies firm suprapubic (not_,fundal) pressure directed laterally inferiorly. This will help force the anterior shoulder under the pubic arch.

D) The operator should apply constant, moderate traction on the fetal head for a count of 30. Avoid intermettent pulling.

• If the McRobert’s maneuver and suprapubic pressure fail to solve the shoulder dystocia, attempts should be made to rotate the anterior shoulder into the oblique diameter of the pelvis.

Step 4 (Oblique diameter)

A) Attempt to rotate the shoulder by applying pressure on the posterior aspect of the impacted anterior shoulder to move it from the anterioposterior to the oblique diameter of the inlet. Suprapubic pressure in the same direction should be applied simultaneously. If there is not enough room under the symphysis to perform the maneuver or if it fails, try the corkscrew maneuver.

B) Apply pressure on the posterior aspect of the posterior shoulder attempting to rotate it anteriorly under the symphysis (crokscrew maneuver of woods). Suprapubic pressure in the opposite direction should be applied simultaneously.

• If the prior steps have been unsuccessful in resoloving the shoulder dystocia, the next thing to do is extract the posterior arm.
• If the extraction of the posterior arm is unseccessful proceed to step 6.

Step 5 (Zavanelli restitution)

• To restitute the baby’s head it is necessary to do the following.

A) Turn the baby’s head to the original position at the time of delivery (usually occipitoanterior).

B) Flex the baby’s head and apply upward pressure the fetal head should move easily upto into the birthe canal.

C) Move the patient to the operative room and perform cesarean section.

• The step by step application of different maneuvers to solve a shoulder dystocia should not take more than 5 minutes.
• The most serious risk to the fetus during those 5 minutes is that of trauma.
• If the problempersists unsolved, the next major potential risk is neurological damage.
• The probability of serious fetal damage is minimized by this protocol because one of the first steps is the recognition of the most dangerous type of dystocia.

Ans. is D. i.e. Mauriceau–Smellie–Veit maneuver

• It is used to assist in the delivery of the fetal head manually.
• While the other three maneuvers (McRoberts’ maneuver, Woods corkscrew maneuver, and suprapubic maneuver) are used in shoulder dystocia.

Mnemonic “HELPERR” as a guide for treating shoulder dystocia:

• “H” stands for help    
• “E” stands for evaluating for an episiotomy.
• “L” stands for legs(pull your legs toward your stomach McRoberts maneuver)
• “P” stands for suprapubic pressure
• “E” stands for entering maneuvers(internal rotation of baby’s shoulders)
• “R” stands for remove the posterior arm from the birth canal.
• “R” stands for roll the patient. 

McRoberts maneuver:

• Abduct the maternal thighs and sharply hyperflex them onto her abdomen.
• This straightens the lumbosacral angle, rotates the maternal pelvis upward and increases the anterior-posterior diameter of the pelvis.
• Suprapubic pressure may be used together. 
• Involves Lateral cutaneous nerve of thigh 

Wood’s maneuver:

• Under GA
• The posterior shoulder is rotated to an anterior position (180°) by a corkscrew movement by inserting two fingers in the posterior vagina.
• Simultaneous suprapubic pressure is applied.
• This helps easy entry of the bisacromial diameter into the pelvic inlet.

Shoulder dystocia

Ans. is A i.e. Fundal pressure

The term shoulder dystocia is used to define a wide range of difficulties encountered in the delivery of the shoulders.

Risk factors

• D = Maternal Diabetes
• O = Maternal Obesity/Fetal Obesity (Macrosomia)
• P = Post-term pregnancy
• A = Anencephaly

Mnemonic “HELPERR” as a guide for treating shoulder dystocia:

• “H” stands for help    
• “E” stands for evaluating for the episiotomy.
• “L” stands for legs(pull your legs toward your stomach McRoberts maneuver)
• “P” stands for suprapubic pressure
• “E” stands for entering maneuvers(internal rotation of baby’s shoulders)
• “R” stands for remove the posterior arm from the birth canal.
• “R” stands for roll the patient. 

Ans. is d i.e. None

Complications

Fetal:

• Asphyxia
• Brachial plexus injury (plexopathy) due to stretch
• Erb & Klumpke palsy
• Humerus fracture
• The clavicle or sternomastoid hematoma during delivery.
• Perinatal morbidity and mortality are high

Maternal:

• PPH (11%)
• Cervical laceration,
• Vaginal tear, perineal tear (3rd and 4th degree)
• Rupture of uterus, bladder
• Sacroiliac joint dislocation
• Morbidity.

Shoulder dystocia poses a greater threat to the fetus than the mother. Risk of recurrent shoulder 

Ans. is B. i.e. Shoulder dystocia

• Shoulder dystocia is a difficulty in the delivery of the shoulder after the head is born.
• Macrosomia can lead to shoulder dystocia.
• Shoulder dystocia occurs when either the anterior or the posterior (rare) fetal shoulder impacts the maternal symphysis or on the sacral promontory respectively.

Risk factors

• D = Maternal Diabetes
• O = Maternal Obesity/Fetal Obesity (Macrosomia)
• P = Post term pregnancy
• A = Anencephaly

Ans. is c i.e. Anencephaly

The term shoulder dystocia is used to define a wide range of difficulties encountered in the delivery of the shoulders.

Risk factors : It occurs in all those conditions where fetus is too big or in cases of mismanaged labour viz.

• Fetal macrosomia                              • Maternal diabetes                                           • Maternal obesity
• Post term pregnancy                          • Anencephaly                                                  • Fetal ascites
• H/o previous macrosomia                   • Midpelvic instrument delivery.