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TRANSCRIPT
High-Risk Obstetrics for the Family Physician
March 2017
Simulation Training for Shoulder Dystocia
Disclosures - No Financial Conflicts
Deborah Cahill, MD
Physician Facilitator, Gossman Advanced Healthcare Simulation
Mark A Johnson, MD
Swedish Family Medicine
Susan Bryar, ARNP
Program Facilitator, Gossman Advanced Healthcare Simulation
Merllie Flores, RN
Program Facilitator, Gossman Advanced Healthcare Simulation
By the end of this presentation you should be able to –
1. Define shoulder dystocia
2. Have a standardized team approach to this emergency
3. Describe the main maneuvers for managing shoulder dystocia
4. Know the important information to be recorded in the medical record after a shoulder dystocia & ALWAYS use the EMR Dystocia template (or paper equivalent)
ACOG Practice Bulletin 2002 (reaffirmed 2013) “Shoulder Dystocia”
“a delivery that requires additional obstetric maneuvers
following failure of gentle downward traction on the fetal head to effect delivery of the shoulders”
Resnik R. Management of shoulder girdle dystocia.
Clin Obstet Gynecol 1980;23:559-64
Note – time is not in the definition
This is also not the baby who takes a while to deliver but whose shoulder isn’t stuck (avoid calling it body dystocia)
History of Shoulder Dystocia
(>10% recurrence)
Diabetes
Macrosomia history
Maternal obesity, <5 ft tall
Excessive weight gain
DEVELOP IN LABOR
Long 1st stage
Long 2nd stage (espec. multips)
Labor Augmentation
Instrumented delivery
Precipitous delivery
MANY CASES UNANTICIPATED. CONSIDER THOSE IN LABOR -
CAN WE HEIGHTEN AWARENESS OF RISK AND BE BETTER PREPARED?
PLAN AHEAD: “Break” the bed & prophylactic Mc Roberts • Wait for next contraction - then with exam hand ready, use momentum
of next contraction w/mom pushing until shoulder clears symphysis • Don’t stop pushing until shoulder clears – No routine bulb suctioning • Don’t check for a nuchal cord - Can reduce as shoulders deliver or cut
after anterior shoulder clears the symphysis
All internal maneuvers done with your left hand working with fetal left
arm/shoulder and your right hand working with fetal right arm/shoulder
• Deliver posterior arm (84%) - Use hand on side fetus is facing
• Rotational maneuver: Ant/Woods (72%), Post/Rubin (66%)
Episiotomy, if needed to do internal maneuvers
• Suprapubic (62%) - Smooth oblique move/CPR hands
• Gaskin maneuver (hands/knees; to side if epidural)
• Repeat all maneuvers, break clavicle
Zavanelli procedure with C/S - if nothing else works and only if the decision is made
early enough that delivery can be done in enough time to avoid hypoxia
Ref: A Comparison of Obstetric Maneuvers for the Acute Management of Shoulder
Dystocia. Hoffman et al, Obstet & Gynecology; Vol 117: p1272, 6/2011
Do -
Cord gases on all cases
Document fully
Discuss with parents
Newborn exam
Inform “pediatrician”
Documentation debrief
Documentation Needed Duration of dystocia Discouraged pushing
Confirm NO fundal pressure Sequence of maneuvers Which shoulder anterior Names of all staff present
McRoberts Maneuver
Only Effect is Tilting the Pelvis
Posterior Arm Maneuver
Vaginal access with flattened
whole hand
Sweep the wrist up to flex arm,
keep the elbow flexed
Sweep posterior upper arm
across chest which usually
rotates ant. shoulder backward,
then can have mother push
Or arm can be delivered, but
need to be sure that anterior
shoulder is no longer stuck
Anterior Shoulder Rotation
Modified Wood’s Screw Maneuver
MODIFIED WOOD’s: Position
hand behind the anterior
shoulder; apply pressure to
rotate the anterior shoulder away
from the symphysis, in the
direction the baby is facing
ORIGINAL WOOD SCREW - Anterior
approach as above plus: Position
fingers in front (on clavicle) of the
posterior shoulder & apply pressure
Suprapubic Pressure = External Rotation
Smooth Lateral Move in direction baby is facing
“CPR” Hands placed near inguinal
region, above symphysis
Lateral-oblique smooth move
Only if order is given - specify
correct person & direction
Firm, smooth continuous
pressure laterally, in the
direction the fetus is facing
Provider’s exam hand in place,
touching baby’s scapula/back
prior to maneuver to assess
success & do anterior rotation
if needed
Posterior Rotational Maneuver
(Rubin’s Maneuver)
Consider if the Posterior Arm ,
Anterior Rotation or Suprapubic
maneuvers were not successful
Apply pressure w/flat hand on
the back, adjacent to the
posterior shoulder –
Rotate anteriorly using your
shoulder/upper body, wrist fixed
& elbow flexed to effect rotation
– approx 120 degree arc
Need thumb on clavicle to
stabilize hand for rotation
www.shoulderdystociainfo.com
Gaskin Maneuver – All Fours
May consider as 1st maneuver if
no epidural
Weight of maternal abdomen off
stuck shoulder
May be easier access for
posterior maneuvers
If epidural, may roll patient to the
side appropriate for the planned
maneuver
Int J Gynaecol Obstet 2006;
95(2),153-4
What to Avoid What to Do
Avoid the P’s -
• Panic (don’t do it, or at least don’t show it)
• Pulling (on the head/neck)
• Pushing (coach maternal breathing)
• Pivoting (sharply angulating the head)
Do the C’s –
*Calm yourself & Calm the room (anyone can do)
*Controlled Maneuvers (rotations, no force)
*Coordinated teamwork
*Clearly state concerns, make suggestions
“P’s” from McMaster University, Ontario