Transcription
Shoulder DystociaMargo Kaplan Gill, MD2011
Objective(s) To review the technical maneuvers forrelieving a shoulder dystociaTo review documentation needsTo review when assistance fromObstetricians should be considered
Contents Call for HelpManeuvers McRobertsSuprapubic PressureRubin’s I and IIWood’s Screw and Reverse Wood’s ScrewPosterior ArmGaskinOtherDocumentationObstetrician support
Help Call for Additional Nursing Support Immediately Need for extra nursing imperative Know who is/ask who is OB on callDocumentationTiming (imperative to know time on perineum)Supplies and medicationsIV access NICU maybe needed for initial assessment ofneonateIf support not forthcoming then may need to callCode White
Maneuvers Communicating with the patient needs tooccur to optimize maneuver successOrder does not matter Each maneuver should be given 30-60 seconds to relieve the dystocia before the next maneuver attemptedSomebody keeping time Clocks are behind us
First things First Restitution of the HeadUse fingers to quickly identify chest andrestitute head appropriately to avoid rotation 90 degrees
Not a ManeuverPulling Harder If you are applying more force then usual STOP Start actual dystocia maneuversOtherwise you go from 49 Newtons, to 69Newtons, and quickly to 100 Newtons Increase risk of fetal injury
External Maneuvers McRobertsSuprapubic PressureGaskinRubin I
McRoberts Flexing Maternal Hips thighs onto abdomenIncreases inlet diameterDecreases thelumbrosacral lordosisRelieves 40% ofshoulder dystocias
Suprapubic Pressure Pressure to the anteriorshoulder from theposterior directionRequires direction fromthe delivering physicianIn conjunction w/McRoberts relieves50% of dystocias
Gaskin Rolling to “All Fours”SAFE, RAPID, EFFECTIVEMay get a full extra 10-20 mm of the pelvicoutletAnterior shoulder dislodges Could still release Posterior shoulder first if that is“free”
Rubin I Rock the fetus’ shouldersfrom side to side once ortwice by pushing on themother’s lower abdomen
Internal Maneuvers Rubin I and IIWoods’ Screw and Reverse Woods’ ScrewRemoval of Posterior Arm “Pringle Maneuver” with the hand
Rubin II Inserting fingers of ONEhand behind mostaccessible fetal shoulderPushing shoulder towardthe fetus’ chestCollapse of shoulder girdle
Wood Screw Approach the posteriorshoulder from the frontof the fetus and rotatetoward symphysisCombine in samedirection as Rubin II 2 fingers behindanterior shoulder and 2fingers in front ofposterior shoulder
Reverse Wood Screw 2 fingers on posterior aspect of posteriorshoulderIdentical to Rubin II on posterior shoulderRotates into an oblique plane
Removal Posterior Arm Decreases bisacromialdiameterAnterior shouldercollapse and fetusdrops into pelvis **flex the elbow*** to deliver forearmavoids humeral fracture(should see hand 1st)
Other Clavicule Fracture
Getting Help If you have attempted any 2 maneuvers withoutsuccess call for second Attending Physician/Chief You are now 1-2 minutes into dystociaConcise Communication relaying what maneuvershave been attempted for how longCall Anesthesia and NICUUse Code White if no rapid response from anyneeded discipline
Fetal Morbidity More maneuvers increases the chance of successMore maneuvers increases the risk of fetal injury Brachial plexusClavicle fractureHead:Body delivery time 5 minutes no significant increase risk of fetal acidosis orhypoxic ischemic encephalopathy (HIE) 5 minutes and risk of acidosis increases 5.9% and risk ofHIE increases to 23.9%
When All Else Fails . Zavanelli Abdominal Surgery and Hysterotomy Administer terbutiline SQ or nitroglycerin IVCephalic replacement of headCesarean DeliveryFacilitates vaginal delivery in severe casesSurgeon rotates fetus through hysterotomy incisionSymphysiotomyMuscle RelaxationTocolysis
Documentation Keeping Time is Imperative Note time of delivery of head Time kept for each maneuver of 30-60 seconds Total time to delivery and mode of deliveryWho is in the room when new providers are called/activated and enter the roomIs FH still obtainable and what it isNurses can’t document if you don’t tell them what you are doingor needUse all information for your written documentation after delivery,including discussion with patient about what occurred
Objective(s) To review the technical maneuvers for relieving a shoulder dystocia To review documentation needs To review when assistance from
