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Definition

SHOULDER DYSTOCIA: DIAGNOSIS AND MANAGEMENT

Dystocia Pronunciation: distOshuh Function: noun Slow or difficult labor or delivery

Joseph G. Ouzounian, MD, FACOG

Associate Professor Director, MaternalFetal Medicine Fellowship Program Department of Obstetrics and Gynecology

Keck School of Medicine at USC

Incidence Shoulder Dystocia: Definition

Difficulty with delivery of the shoulders Maneuvers in addition to gentle downward

Author Lurie Benedetti Smith Gherman Langer Lewis Ouzounian Time frame 1/86 12/91 6/74 3/75 1980 1985 1/91 12/94 1970 1985 1/83 12/92 1/91 6/01 # SD 52 33 203 250 456 747 1,686 % 0.19 0.37 0.58 0.57 0.60 2.0 0.60

traction on the fetal head. 1

Prolonged headtobody delivery time (> 60

seconds) and/or use of obstetric maneuvers. 2

1. Benedetti TJ. Contemp Obstet Gynecol 1989;33:150161. 2. Spong CY. Obstet Gynecol 1995;86:4336.

Pathophysiology

Pathophysiology

Persistent AP location of shoulders @ pelvic brim: increased resistance between fetal skin &

vaginal walls

large fetal chest relative to BPD precipitous labor (absence of truncal

rotation)

Anterior shoulder impacts with symphysis pubis: "turtle sign"

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Historic risk factors

Intrapartum Risk Factors

First stage: protraction disorders prolonged deceleration phase Prolonged 2nd stage* nullip: 3 hr. w/ reg. anesthesia or 2 hr. w/o multip: 2 hr. w/ reg. anesthesia or 1 hr. w/o Midpelvic operative delivery

*American College of OB/Gyn Practice Bulletin #17; June 2000.

Diabetes Macrosomia Prolonged second stage Midpelvic operative delivery Midpel ic operati e deli er Oxytocin use Maternal obesity Postterm pregnancy Prior shoulder dystocia

Shoulder Dystocia: Erroneous Assumptions

Risk factors can always be identified prior to labor The presence of risk factors is highly predictive of

Shoulder Dystocia: Erroneous Assumptions (con't)

shoulder dystocia

Costs associated with planned cesareans to avoid shoulder dystocia are less than the costs associated with shoulderdystociarelated injuries

American College of OB/Gyn Practice Patterns

Is Shoulder dystocia predictable?

Ouzounian et al 1686 cases of SD over 10yr period Oxytocin + Induction + BW > 4500 gm had OR 23.5

Is Shoulder Dystocia Predictable?

Factor Wt. Gain > 12 kg Prev. baby > 4000g Multiparous > 1 of above > 2 of above >3 of above BW > 4000 g Sens. 40.9% 27.3% 89.4% 93.9% 53.0% 10.6% 87.9% Spec. 74.1% 90.2% 43.4% 31.0% 79.5% 97.3% 83.2% PPV 1% 1.8% 1% 0.9% 1.6% 2.5% 3.3%

for occurrence of SD

BUT, Sensitivity and PPV were 12% and 3%, respectively

Ouzounian, et al. Am J Obstet Gynecol 2005:192;1933.

Geary M. Eur J Obstet Gynecol & Reprod Biol 1995;62:1518.

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Shoulder Dystocia & Fetal Macrosomia

35 30 25 20 15 10 5 0 4000-4250 4251-4500 4501-4750 >4750 No DM Instr, no DM DM Instr, DM

Recurrent Shoulder Dystocia

Prior studies show 316% risk for recurrent

shoulder dystocia in subsequent delivery

Largest study to date Ouzounian et al.

1,686 Shoulder dystocia cases 263 underwent additional vaginal birth Recurrence 3.7% OR 7.4

Ouzounian JG et al. Am J Obstet Gynecol 2002

Nesbitt TS. Am J Obstet Gynecol 1998;179:47680.

Risk factors vs. "Predictors"

Presence of one or more risk factors

Heightened awareness for potential shoulder dystocia Review personal paradigm i l di Mobilize staff

Maternal Complications

Postpartum hemorrhage (11%) 4th degree laceration (3.8%) Cervical tears (2%) Bladder atony Uterine rupture

Current risk factors are not reliable predictors

Gherman RB and Ouzounian JG. Am J Obstet Gynecol 1997;176:65661.

Accoucheur Complications

Tachycardia, sweating & terror Physical trauma LITIGATION!! Norway (198897): 11% of claims (n=370) f l i Brachial plexus palsy: 75.6% Cerebral palsy: 17.1% Perinatal death: 7.3%

*Skolbekken JA. Acta Obstet Gynecol Scand 2000;79:75056.

Neonatal Complications

Author Gherman McFarland Beall Bofill B fill Baskett Stallings Kees Keller Nocon # SD 285 276 99 21 254 134 56 120 185 Death 0.35 0 0 0 0 10 1.8 NM 0 Clav. fx 9.5 8.5 0 4.8 8 5.1 3 3.6 1.7 7.5 Trans. BPP 16.8 8.5 1 9.5 13 12.7 21.4 3.3 15.1 Perm. BPP 1.4 NM NM 0 NM NM NM 0.83 0.54

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Brachial Plexus Palsy

ACOG ­ PROLOG

"27 y/o G2P1 comes to your office at 9 wks.

ACOG ­ PROLOG

A. Size of the baby B. Her development of gestational

Her prior pregnancy ended with vaginal delivery, 3750 gm male with Erb's palsy. When discussing the likely outcome of her h d h lk l fh current pregnancy, you tell her that the most probable reason for the recurrence of Erb's palsy as a result of shoulder dystocia is:"

diabetes

C. Operative vaginal delivery D. Forces of labor E. Induction of labor

ACOG ­ PROLOG

A. Size of the baby B. Her development of gestational

SD and BPP

BPP often occurs in presence of SD Same factors that predispose to SD also predispose

diabetes C. Operative vaginal delivery D. Forces of labor E. Induction of labor

to BPP

Association should not be equated with an

absolute or causative link!

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Brachial Plexus Palsy

Birth Weight >4500 41% Diabetes 11% >2 hr Second Stage 14% Operative Vaginal Delivery 21% Shoulder Dystocia 94%

Ouzounian, Korst, and Phelan, 1998.

Shoulder Dystocia and Neonatal Brain Injury

Injury No. of cases Head/should. Head/should Birthweight 15 10.6 + 3.0 10 6 + 3 0 4562 + 157 No injury 24 4.3 + 0.7 4 3 + 0 7 4709 + 145 p 0.03 0 03 0.49

A head/shoulder interval of > 7 minutes had a sensitivity of 67% for predicting brain injury Ouzounian JG. Am J Obstet Gynecol 1998;178: S76.

Management Shoulder Dystocia Drill

No sequence or combination of maneuvers

Management

McRobert's manuever Suprapubic pressure Proctoepisiotomy?

Clinician's best judgement

proven definitively "superior"* McRobert's maneuver reasonable firstline maneuver. Wellorganized and rehearsed sequence is most important. Summon help, remain calm, initiate maneuvers.

*ACOG Practice Bulletin, 2002

Wood's/Rubin's corkscrew Posterior arm extraction Zavanelli Other maneuvers

McRoberts Maneuver: Benefits

Straightens maternal sacrum relative to lumbar

spine

Cephalic rotation of symphysis pubis Enhances passage of posterior shoulder over

sacrum

Gherman RB. Obstet Gynecol 2000;95:437

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Xray Analysis of the McRoberts Maneuver

Inclination Angle Symphysis to sacral promontory Around L5 Around symphysis L5 & upper sacrum Lithotomy 38.1 + 1.96 27.1 + 5.26 56.7 + 1.75 133.7 + 2.25 McRoberts 51.5 + 2.03 25.6 + 5.85 38.7 + 2.2 140.1 + 2.12 p < .001 0 .85 0.001 0.04

McRoberts Maneuver: Benefits

Opens pelvic inlet to maximal dimension Pelvic inlet brought perpendicular to maximum

expulsive forces p

Reduces shoulder extraction forces and brachial

plexus stretching

Gonik B. Obstet Gynecol 1989;74:447

Gherman RB. Obstet Gynecol 2000;95:437

McRoberts Maneuver

McRoberts' alone: 41.5% successful McRoberts + SPP and/or proctoepisiotomy: 54.2%

Need for Additional Maneuvers

McRoberts (n=98) Mat age (yr) Mat wt. (lb) EGA (wk) Birth wt (gm) Epidural Active (min) 2nd stage (min) Op. del Oxytocin 27.1 + 6.4 167.3 + 30.4 39 39.7 + 1.8 4024.5 + 458.7 14 (14.3%) 206.8 + 199.1 46.4 + 44.2 7 (7.1%) 38 (38.7%) McRoberts + (n=138) 28.3 + 5.9 174.5 + 32.5 39 9 39.9 + 1.8 4194.9 + 495.9 30 (21.7%) 281.4 + 210.2 84.7 + 75.4 17 (12.3%) 70 (50.7%) p 0.11 0.06 0.55 55 0.008 0.23 0.007 <0.0001 0.28 0.17

successful

Gherman, Ouzounian et al. Am J Obstet Gynecol 1997;176:65661.

Gherman RB, Ouzounian JG et al. Am J Obstet Gynecol 1997;176:65661.

McRobert's maneuver

Should we do it on every delivery? Complications can occur

McRoberts Maneuver: Complications

Case #1:

5 minute 2nd stage Prophylactic McRoberts 4314 gram infant No shoulder dystocia 5 cm symphyseal separation Inferior displacement of pubic rami Transient femoral neuropathy

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McRoberts Maneuver: Complications

Case #2:

2 hr, 11 min second stage Prophylactic McRoberts 3598 gram infant no shoulder dystocia 5 cm symphyseal separation sacroiliac joint dislocation transient lat. fem. cutaneous neuropathy ORIF & symphysis pubis fixation

Suprapubic Pressure

Suprapubic Pressure

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Woods Maneuver

Woods Maneuver

Rubin's Maneuver

Posterior Arm Extraction

Zavanelli Maneuver

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Delivery note

"...head delivered over intact perineum. Turtle sign

Zavanelli Maneuver

Sandberg (1999): 92 reported cases Zavanelli successful in 78 cases (85%) Severe maternal complications: uterine infection vaginal rupture lower uterine segment laceration uterine rupture

Sandberg EC. Obstet Gynecol 1999;93:3127.

and shoulder dystocia encountered. Head replaced within uterus and patient taken for CSection ­ see dictated operative report for details of surgery. dictated operative report for details of surgery "

What next?

All maneuvers used thus far unsuccessful Take a deep breath! Repeat maneuvers Still unsuccessful?

Gaskin Maneuver

Gaskin Maneuver

Initially described in 1976 Bruner (1998): 83% success rate (82 cases) maternal morbidity : 1 2% (1 case PPH) maternal morbidity : 1.2% (1 case PPH) neonatal morbidity: 4.9%

Gaskin Maneuver (cont.)

Mechanism of action:

downward force of gravity favorable change in pelvic diameter g p

Bruner JP. J Reprod Med 1998;43:43943.

one infant with fx'd humerus three neonates with low Apgar scores no cases of BPP average time to delivery: 23 mins

Bruner JP. J Reprod Med 1998;43:43943.

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Symphysiotomy

Emergency Symphysiotomy

Birthwt 4075g EGA 39 Mins 12 Complications a) 4 u PRBCs b) bladder neck & proximal urethra laceration c) urinary leakage @ 4 months a) neonatal death on DOL #4 ) l d h DOL # b) 4 u PRBCs c) superficial serosal bladder laceration d) persistent postpartum urinary incontinence neonatal death on DOL #15

3780g 8

37

13

4820g

41

23

Goodwin TM. Am J Obstet Gynecol 1997;177:4634.

What about fundal pressure?

Case Control study (59 pairs): Cases: infants with permanent Erb's palsy & birth was complicated by SD p y Controls: consecutive cases of SD in which infants had no BPP Higher incidence of fundal pressure for cases:

What about fundal pressure?

Fundal pressure may further aggravate anterior

shoulder impaction.

Our work does not support the use of fundal

pressure in the management of shoulder dystocia.

19/59 (32%) vs. 1/59 (2%) OR = 27.5 (95% CI 4.01163.4), p < 0.001

Phelan JP, Ouzounian et al. Am J Obstet Gynecol 1997;176:S138.

Shoulder Dystocia: Summary

An unpredictable, lifethreatening condition A true obstetric emergency Maneuvers designed to ALLEVIATE shoulder

dystocia y

Maneuvers designed to SAVE LIFE OF FETUS Summon help, initiate drill, work briskly using

your own best clinical judgement/experience

Consider welldesigned training drills Document care thoroughly

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