The Difficult Delivery: Shoulder Dystocia

A simplified approach to the shoulder dystocia in the emergency department

Case

You are proceeding with the precipitous delivery described in the previous post. You have just delivered the head, but it seems to pull back. No further progress is being made. As you stare down at the head, you swear it reminds you of some kind of animal – oh right, a turtle! This is shoulder dystocia…

 

My approach

Call for help: Obstetrics and pediatrics probably should have already been called for this precipitous delivery, but if they weren’t get them mobilized now.

Equipment: Hopefully the ED delivery kit is already out. Also, make sure a neonatal warmer and all neonatal resuscitation equipment is available.

As soon as shoulder dystocia is recognized, ask mom to stop pushing.

Check for a nuchal cord. If present slide over the head. If you cannot get it over the head, clamp x2 and cut between; deliver the baby ASAP.

If it can be accomplished within 1 min, insert a foley catheter to drain the bladder.

The first step is called McRobert’s maneuver: an assistant is directed to push mom’s thighs as close to her chest as possible. A second assistant then applies suprapubic pressure.

suprapubic-pressure_434 from shoulerdystociainfo

The next option is to slide your hand along superior head and above the superior shoulder to attempt to disimpact the shoulder manually.

If not successful, next use 2 fingers to firmly push on the scapula of the inferior shoulder and turn the baby 180 degrees to make it the superior shoulder (Wood’s corkscrew maneuver).

rotate-posterior from shoulderdystociainfo

Next, attempt to delivery the posterior arm first, by flexing the arms across the baby’s chest. This should allow the easy delivery of the baby. If not, turn the baby and repeat.

If the above steps have been unsuccessful, perform a mediolateral episiotomy by first injecting lidocaine, then making a 2-3cm cut with scissors 45 degrees from the midline.

Finally, if all else fails and obstetrics is not available to perform a c-section (Zavanelli maneuver), fracture the baby’s clavicles using direct pressure over the middle of the clavicle.

Notes

Images are courtesy of Dr. Henry Lerner, who runs the excellent website: ShoulderDystociaInfo.com

The is no evidence based series of maneuvers. What maneuvers are attempted and in what order is dependent on the individual practitioner. The above approach seems to be the most commonly suggested series of steps.

 

Other FOAMed Resources

YouTube video: Steps to overcome shoulder dystocia by the Reproductive Health Library

ShoulderDystociaInfo.com

Shoulder Dystocia by MedEDMasters

 

References

VanRooyen MJ, Scott JA. Chapter 105. Emergency Delivery. In: Tintinalli JE et al eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381574

Pope, Jennifer V. and Tibbles, Carrie D. (2012). The difficult emergency delivery. In: Winters, M.E. (Ed). Emergency Department Resuscitations of the Critically Ill. Dallas, Tx: ACEP.

Baxley E and Gobbo R. Shoulder Dystocia. Am Fam Physician. 2004;69(7):1707-14. http://www.aafp.org/afp/2004/0401/p1707.html

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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