2. unanticipated, unpredictable nightmare of the
obstetrician
(Langer et al,1991)
INCIDENCE
0.2-2%
Depend on definition & fetal size (1/2: >4Kg)
Increased in the past 2 decades
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3. DEFINITION
Failure of the shoulders to spontaneously traverse
the pelvic brim after delivery of the head
(Benedetti,1989)
Special maneuvers to deliver the shoulders
(Resnik,1980)
Prolonged head to body delivery time > 60 sec
(Spong et al,1995).
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5. 2. Mild= Unilateral:
The posterior shoulder enters the pelvic cavity, while
the anterior shoulder hooked behind the S. pubis.
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6. CAUSE
Not simply increase in F. wt
increase in body size in relation to head size.
increased shoulder/ head circumference
(Baskett,200).
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7. RISK FACTORS
The majority: No risk factors.
S. dystochia cannot be predicted from clinical
characteristics or labor abnormalities
(Basket,200)
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8. A. Antepartum:
DOPE
1. D.M (Tissues of the shoulders are insulin sensitive
& the brain is not & is not affected by D.M.)
2. Obesity: (90 kg before pregnancy or 110 kg at
delivery)
3. Postterm pregnancy.
4. Past history of S. dystocia.
5. Excessive f wt (>4.5 kg) or
maternal wt gain (>20 kg)
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10. The predictive factors
(Dildy & Clark,2000)
1. D.M. with EFW >4250 g
2. Macrosomia & 2nd stage arrest with midpelvic
ventouse or forceps
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11. PREDICTION OF FETAL
MACROSOMIA
A. Clinical
Sensitivity is only 20%
(Park & Ziel,1978)
The diagnosis of f macrosomia is imprecise.
Accuracy of EFW using US is no better than that
obtained with cl palpation (Leopold's maneuver).
ACOG Guidelines, 2000 (Level :A)
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12. B. U/S
1. EFW: 10-15 % error (Hadlock or Shepard)
2. Femur SC tissue
3. Cheek to cheek D.
4. Chest D - BPD > 1.4 cm
5. Chest C. - HC. > 1.6 cm.
6. Shoulder C. - HC > 4.8 cm.
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13. CLINICAL PICTURE
(Rubin, 1969)
Early
1. Slow crowing.
2. It is necessary to press the perineum back to
deliver the face.
3. Fatty cheeks.
4. Turtle sign (head is drawn tight against the
perineum).
5. Restitution is slow or does not occur.
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14. Late
1. Usual down traction of the head does not result in
appearance of the anterior shoulder
2. Vascular congestion of the face.
3. Vaginal ex is difficult
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15. PREVENTION
A. Ante partum
1. Identification of risk factors & proper management.
2. IOL at 38 W:
History of S dystocia
(Kjos et al,1993).
Suspected f macrosomia:
increased CS without improving perinatal outcomes
(ACOG Issues Guideline 2000 (Level B)
(Sanchez-Ramos, Systematic Review, 2002)
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16. DM treated with insulin:
Dec risk of macrosomia
Small dec in s dystocia
No dec in maternal or neonatal morbidity
(Cochrane review).
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17. 3. C.S:
Cumulative risk factors
(Basket, 2001).
Previous history of S dystocia:
Either CS or vaginal delivery is appropriate
The decision should be made by the woman and her
careers
(RCOG, 2005).
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18. EFW:
In DM:
>4250 g in DM
(Dildy & Clark, 2000)
>4,500 g (ACOG, 2003)
Non diabetic
> 5,000 g (ACOG, 2003)
Planned CS on the basis of suspected macrosomia in the general
population is not a reasonable strategy
{1. Number & cost of additional CS required to prevent one
permanent injury is excessive To prevent one Erb,s palsy an
additional 500 CS are done
2. 3% of brachial plexus injury are associated with C.S
.
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19. B. Intrapartum
Management of macrosomic F. during labor
(Louca & Johanson,1998)
1. Manage as far as CS during labor:
NPO, IVF, decrease stomach acidity
2. Close observation of the fetus & mother.
3. Experienced obstetrician, anesthetist &
neonatologist.
4. Prophylactic Mc Roberts maneuver if risk factors.
Position can be maintained by the woman herself.
5. Generous episiotomy
6. Early detection of S. dystocia.
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20. MANAGEMENT
I. Effective plan
1. Call for help
2. Clear infant mouse & nose.
3. Avoid 5 P:
Panic,
pulling,
pushing,
pressure on the fundus {an unacceptably high neonatal
complication rate and may result in uterine rupture}
pivoting
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21. II. Improve pelvic dimensions
1. Episiotomy or extend it.
{facilitate manoeuvres such as delivery of the posterior
arm or internal rotation of the shoulders}.
Episiotomy is not mandatory
(RCOG, 2005).
2. Mc Roberts maneuver
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22. III. Disimpact F. shoulders
1. Suprapupic pressure
2. Rotation of the shoulders:
Wood,s maneuver, Rubin M.
3. All-fours maneuver
4. Delivery of the posterior arm.
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23. IV. If all else fail
3rd -line methods
1. Cleidotomy
(bending the clavicle with a finger or surgical division),
2. Symphysiotomy
(dividing the symphyseal ligament)
3. Zavanelli maneuver.
4. Abdominal rescue
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25. Increase IU pressure by 97%
Increase U. contraction amplitude by 25%
Applied additional 31 Newtons pushing
force (Buhimschi et al, 2001)Aboubakr Elnashar
26. McRoberts manoeuvre: X ray pelvimetry study
(Gherman et al, 2000)
No increase in pelvic dimensions.
Decrease in the angle of pelvic inclination
Straightening of the sacrum
Tends to free the impacted anterior shoulder
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27. Suprapubic pressure:
Mazzanti:
directed posterioly to dislodge the ant shoulder &
push it beneath S.P.
Rubin:
directed laterally, with pressure applied to the
posterior surface of the anterior shoulder.
Apply for 30 seconds.
No difference in efficacy between continuous
pressure or ‘rocking’ movement.
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30. .
The Mc Roberts manoeuvre can
be applied with Suprapubic
pressure to increase success
rate
(ACOG , 1991; RCOG, 2005)
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31. Rotation of the F. shoulders:
Woods screw M.:
Pressure on the anterior surface of the posterior shoulder:
±increase shoulder to shoulder D.
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32. Rubin M.
Pressure on the posterior surface of the posterior
shoulder.: decrease shoulder to shoulder D.
It is preferred by many obstetrician
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33. All-fours M.:
The woman is placed on her hands & knees.
Gravity pushes the posterior shoulder anteriorly.
The flexibility of the sacro-iliac joints increases the
saggital D of the pelvic inlet.
The posterior shoulder is delivered first.
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34. • It allows rotational movement of the sacroiliac
joints: 1-2 cm increase in the sagittal diameter of the
pelvic outlet.
• It disimpacts the shoulders, and allowing it to slide
over the sacral promontory.
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35. •Success rate: 83%
• Maternal complications: 1.2%
•Neonatal complications: 4.9%,
•Time for complete delivery: 2 to 3 ms.
•Effective also for bilateral Sh. D.
(Drummond et al; 1998)
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36. Delivery of the posterior arm:
± difficult to insert the hand in the vagina.
Fracture of the humerus is common.
{No advantage between delivery of the posterior arm
and internal rotation maneuvers}: clinical judgment
and experience can be used to decide their order.
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37. By inserting a hand into
the posterior vagina and
ventrally rotating the arm
at the shoulder
Delivery over the
perineumAboubakr Elnashar
38. Cephalic replacement & C.S.
(Zavanelli) :
Early indicated in bilateral S. dystochia.
If replacement is done within 4 min: good Apgar.
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39. Zavanelli
2.Flexion of the head,
Returning it to the vagina with
upward constant firm
pressure, followed by CS
1.The head first manually
rotated to the occipito
anterior (Pre-restitution)
position
Reversing the mechanism
of delivery of the vertex
under tocolytic
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40. Abdominal rescue:
If cephalic replacement is failed.
C.S
direct disimpaction of the shoulder
vaginal delivery.
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41. •Bilateral Shoulder dystocia
All- Fours Maneuver
Used at all circumstances
except if the patient has received
epidural analgesia,
heavy analgesia or anesthesia
Zavanelli Maneuver
Used if the patient has received epidural analgesia or
heavy analgesia with obstetric facilities for
emergency CS
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42. The HELPERR mnemonic
H Call for help
E Evaluate for episiotomy
L Legs (the McRoberts’ manoeuvre)
P Suprapubic pressure
E Enter maneuvers (internal rotation)
R Remove the posterior arm
R Roll the patient
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44. COMPLICATIONS
A. Fetal
1. Death:
{asphyxia}.
8% of all intrapartum F. death.
(Baskett,2001)
Head –shoulder interval
4-6 min: No permanent hypoxic damage
>7 min: permanent hypoxic damage
With hypoxic fetus it is much shorter
(Quzounian et al, 1998)
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45. 2. Injuries:
Cerebral hge.
Brachial plexus palsy
10%
Determine whether the affected shoulder was
anterior or posterior at the time of delivery
{damage to the plexus of the posterior shoulder is
considered not due to action by the accoucheur}.
Fracture clavicle (the most common) or
humerus.
Traction combined with fundal pressure:
high rate of brachial plexus injuries and
fractures
(ACOG , 1997)
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