00:02
Now as part of abnormal labor,
let's discuss Shoulder Dystocia.
00:07
So here's a clinical pearl.
00:09
Shoulder dystocias are
unpredictable so you should
always be prepared.
00:14
There are some signs that you
can look for such as prolonged
second stage of labor.
00:18
But any delivery has
the potential to become
a shoulder dystocia.
00:22
Any delivery requiring more
than one routine maneuver to
accomplish the delivery is
considered a dystocia.
00:29
In a shoulder dystocia
the anterior shoulder of the infant
gets impacted behind
the maternal pubic symphysis.
00:38
While shoulder dystocias can
happen in any delivery
there are some risk factors.
00:42
First, fetal macrosomia.
00:44
Next, maternal obesity.
00:47
Next a long second stage of
labor in moms that are diabetic
or have gestational diabetes.
00:53
There's an increased risk
of shoulder dystocia.
00:55
And if a mom have a history of
shoulder dystocia in a previous
pregnancy, she's increased
risk during that pregnancy.
01:04
So this is an ominous sign.
01:06
It's called the Turtle Sign.
01:08
And you can see here the chin
is retracted against the maternal
perineum and that's because
the anterior shoulder is stuck
behind the pubic symphysis.
01:16
This causes the head to
recoil after delivery.
01:21
So what do we do when we
see a shoulder dystocia.
01:23
Where's here is a
mnemonic to help you.
01:25
It's called HELPERR.
01:26
First you want to call for help.
01:30
So when you are doing that
delivery and you see that
the anterior shoulder is not
delivering, or you see
the turtle sign that we discussed,
you have a shoulder dystocia
and you should call for Help.
01:39
Help means calling other nurses
in the room.
01:42
Calling for an additional
obstetrician and possibly
contacting your
anesthesiologist.
01:47
The next thing to do
is consider an Episiotomy.
01:52
Now I say consider an episiotomy
because we have to remember
that a shoulder dystocia is
not a skin dystocia.
01:58
However, depending on the size
of the infant and depending on
the hands of the physician,
you may need to consider
cutting an episiotomy to be
able to fit the hands in
and do those additional maneuvers
that we are going to discuss.
02:12
Next is lower the head
of the bed and elevate
the legs.
02:15
So what that means you lower
the head of the bed
so that mom's back is flat.
02:21
Elevate the legs means
that you flex the knees
towards the chest.
02:25
We're doing this, this is
called McRoberts maneuver.
02:27
This opens up the pelvis,
flattens out the sacrum
and gives us more room in
the posterior column
so that you can put that
anterior shoulder down to
relieve that shoulder dystocia.
02:39
Next is provide
suprapubic pressure.
02:42
Now this maneuver is performed
not by the physician
during the delivery
but an assistant.
02:47
Whether that assistant be
an obstetrician or a nurse,
it's performed by someone
else in the room.
02:52
As you can see here in this
picture, what the assistant is
doing is placing her hands in
the CPR maneuver finding that
anterior shoulder behind
the pubic symphysis
and rotating the shoulder forward.
03:05
That will relieve the shoulder's
dystocia hopefully
and get that anterior shoulders
from behind the pubic symphysis.
03:14
Now, if our suprapubic
and McRobert's maneuver
have not worked,
we want to start moving
towards other maneuvers.
03:20
These maneuvers you can remember
by saying, enter the vagina
for internal rotation.
03:26
Now there's two internal
rotations that we want
to talk about here.
03:30
Woodscrew and Rubin maneuver.
03:32
So with the Woods' screw maneuver,
you have two fingers
behind the posterior shoulder.
03:37
Two fingers front of the
anterior shoulder of the baby
and you're rotating the baby to
try to change the angle
of the shoulder to relieve
that shoulder dystocia.
03:47
Rubin maneuver is a
little bit different.
03:50
You place two fingers behind
the posterior shoulder
to rotate the shoulder in.
03:55
You kind of folding the
shoulders in like a taco
decreasing the diameters between
the shoulders to relieve
that shoulder dystocia.
04:05
The next maneuver to consider
is relieve the posterior arm.
04:08
Now, there is no literature to
support which internal maneuver
should be done first.
04:13
Meaning Woodscrew versus
Rubin versus delivery
of the posterior arm.
04:18
However, many practitioners
to start with the delivery
of posterior arm.
04:23
When you do that, this causes
an increased space
in the hollow of the sacrum
allowing that anterior shoulder
to be delivered downward.
04:31
Care must be taken however
with this maneuver.
04:33
As there is an increased risk
of fracture of the clavicle
and the head of the humerus.
04:38
Fracture of the head
of the humerus is particularly
dangerous and that it can
disrupt the blood flow
to the humerus and cause
necrosis of the joint.
04:47
And then one other maneuver we
can try is rotate the patient
to hands and knees.
04:53
This is known as Gaskin Maneuver.
04:55
And it's aim for a famous
mid-wife Ina Gaskin.
04:58
What you do is you place your
patient on hands/knees position.
05:01
So basically on our pores.
05:02
This rotates and changes
the angle of the pelvis
so that the baby can
be delivered
and that shoulder dystocia
can be relieved.
05:10
Now the downside of this
maneuver is that the patient has
physically be able to roll over.
05:15
Remember the patient previously
is on her back and now she needs
to rotate hands and knees.
05:20
So this is not an option for our
patients that have an epidural.
05:26
Now when you've done those other
maneuvers and they haven't
worked, we do have some
additional maneuvers.
05:30
However, before you proceed
to these additional maneuvers,
you do want to try the maneuvers
that we discussed a couple of
times to see if you change
the angle of the pelvis
and that anterior shoulder
enough that you can deliver
that shoulder dystocia.
05:44
However, if you have done those
a couple of times
and you're still unable to relieve
the shoulder dystocia.
05:48
Here's some additional more risky
maneuvers that we can try.
05:52
First is breaking the clavicles.
05:54
So to break the clavicles of
the fetus, you want to place
your finger underneath
the clavicle and pull out.
05:59
It's very important to
pull out and not push in.
06:03
If you push in you can break
the clavicle and clavicle
can then puncture the lung.
06:07
You can break one clavicle
or you can break two clavicles.
06:10
You can imagine that once
the clavicles are broken,
now your shoulder diameter is
much shorter and you can deliver
that shoulder dystocia--relieve
that shoulder dystocia.
06:20
The next maneuver is
Zavanelli maneuver.
06:22
This one is very tricky.
06:24
You basically have to take
the infant and go through
the cardinal movements of labor
in reverse and push the baby
into the uterus to then go
perform a cesarean section.
06:32
This maneuver is very difficult
to perform and should only be
considered if you've done your
other maneuvers
and they have not been successful.
06:41
The next maneuver
consider is a symphysiotomy.
06:43
With this maneuver you take
a scalpel
and you cut the cartilage that's
in between the pubic symphysis.
06:50
Once you've done that, the
shoulder will no longer be stuck
behind the pubic symphysis.
06:54
Again this is a very risky
maneuver and should only be done
in a life or death situation
when your other maneuvers
have not been successful.
07:03
So the common complications
of shoulder dystocia
that we also need to discuss.
07:07
The first is brachial
plexus injury.
07:09
Next clavicular fracture.
07:12
Then humerus fracture.
07:14
Asphyxia.
07:15
And then contusions
and lacerations.
07:18
So let's talk about brachial
plexus injury in some detail.
07:23
So with the brachial plexus
injury, you can have either
an Erb's palsy or you can
have a Klumpe's palsy.
07:29
With Erb's palsy this is going
to be injury to the C5
and C6 nerves.
07:35
And this comes from continuous
downward traction on that neck
when you have an anterior
shoulder that is stuck
and you're continually pulling down.
07:44
When you stretch those nerves,
you can get an Erb's palsy.
07:47
Now these are often reversible
with physical therapy
sometimes surgery.
07:52
And with Erb's palsy that
accounts for 75%
of brachial plexus injuries.
08:00
Klumpke's comes from the injury
to C8 and T1,
again from that stretching of
those nerves is not as common.
08:07
This only accounts for about
2% of lower nerve injury
from brachial plexus.
08:12
And again this can be reversible
with surgical intervention.
08:17
So let's take a case.
08:19
A 41 year old Gravida 2 Para 2
female just delivered
a 5010 gram female infant.
08:26
The delivery was complicated
by a shoulder dystocia
requiring 4 maneuvers to deliver
the shoulder dystocia.
08:33
You are called to the infant's
bedside because the infant
is not moving the left arm
as much as the right arm.
08:40
What is the most common nerve
injury responsible
for this palsy?
It is A. C5 and C6.
08:48
B. C6 and C7.
08:50
C. C7 and C8
or is it D. C8 and C9.
08:56
The answer is A.
08:57
C5 and C6.
08:59
Remember this is our Erb's palsy
and this accounts for 75%
of brachial plexus injuries.