Obstetrics Book

Delivery

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Shoulder Dystocia Management

Aka: Shoulder Dystocia Management, Shoulder Dystocia Maneuvers, McRoberts Position, Suprapubic Pressure on the Fetal Shoulder, McRoberts Maneuver, Wood-Screw maneuver, Freeing the Posterior Arm In Shoulder Dystocia, Rubin Maneuver, Zavanelli Maneuver, Gaskin Maneuver
  1. See Also
    1. Shoulder Dystocia
  2. Definitions
    1. Suprapubic Pressure on the Fetal Shoulder
      1. Apply pressure over Bladder (never over fundus)
        1. Pressure is applied to bring the fetal Shoulder closer to the fetal anterior chest and Sternum
        2. Example: If fetus faces the mother's right side
          1. Pressure is applied from mother's left suprapubic region, down and toward the right
      2. Oblique downward and anterior pressure
        1. Initial attempt: Apply pressure for 30 to 60 sec
        2. Later: Rocking motion similar to CPR
      3. Effect: Decreases fetal Shoulder breadth
    2. McRoberts Position
      1. Efficacy
        1. Resolves >40% of dystocias
        2. Resolves 50% when used with suprapubic pressure
      2. Technique
        1. Flex thighs
        2. Patient pulls knees toward ears
      3. Effect: Expands size of maternal Pelvis
        1. Flattens lumbar lordosis
        2. Symphysis rotates superiorly
    3. Episiotomy
      1. Cut a generous episiotomy
      2. May be delayed until after pressure and McRoberts
      3. Effect
        1. Does not effect Bony Pelvis obstruction
        2. Increases room to work for rotational maneuvers
    4. Rotational Maneuvers
      1. Perform maneuvers while maintaining downward traction
      2. Maneuvers described for left occiput position
      3. Rubin II Maneuver
        1. Two fingers placed behind anterior Shoulder
        2. Apply downward pressure around arc of rotation
        3. Rotate presenting part clockwise for 30-60s
      4. Wood-Screw maneuver
        1. Two fingers placed in front of posterior Shoulder
        2. Apply upward pressure around arc of rotation
        3. Rotate presenting part clockwise for 30-60 sec
      5. Rubin II Maneuver with Wood-Screw maneuver
        1. Maximizes torque for rotation
        2. Difficult due to limited vaginal space for maneuver
      6. Reverse Wood-Screw
        1. Reverse direction of rotation (counter-clockwise)
    5. Posterior arm delivery
      1. Flex elbow and sweep Forearm across chest
      2. Avoid grasping upper arm (Humerus Fracture risk)
    6. Gaskin Maneuver or all-fours position
      1. Patient rolls onto hands and knees
      2. Apply downward traction to deliver posterior Shoulder
      3. Above rotational maneuvers may be repeated if needed
      4. Effect: Increases pelvic diameters (TOC, Sagittal)
    7. Maneuvers of last resort
      1. Deliberate Clavicle Fracture
      2. Zavanelli Maneuver
        1. Cesarean Section with cephalic replacement
      3. Symphysiotomy
      4. Abdominal surgery with hysterotomy
  3. Management: Mnemonic PERSPIRE
    1. Preparation
      1. Delivery Room
      2. Nurses on steps
    2. Episiotomy
    3. (Mc)Roberts Position (See Above)
    4. Suprapubic Pressure
    5. Posterior arm delivery
    6. Internal Rotation
      1. Wood-Screw maneuver (rotate face towards floor)
      2. Try with patient positioned on all 4 extremities
    7. Emergency
      1. Fracture Clavicle
      2. Zavanelli Maneuver (See above)
  4. Management: Mnemonic HELPER (ALSO course)
    1. Help
      1. Call for Help
    2. Episiotomy
    3. Legs
      1. Position with McRoberts Maneuver for 30-60 seconds
      2. See description above
    4. Pressure at suprapubic area
      1. Only apply to suprapubic region (never apply to the uterine fundus)
    5. Enter
      1. Position hands in position
        1. Two fingers by anterior Shoulder
        2. Two fingers by posterior Shoulder
      2. Rubin Maneuver: Rotate counter-clockwise for 30-60s
      3. Wood-Screw maneuver: Rotate clockwise for 30-60 sec
    6. Remove the posterior arm
      1. Repeat the above procedure
    7. Rotate the patient
      1. Roll the patients to hands and knees
    8. Replace fetal head (Zavanelli Maneuver)
      1. Followed by Emergency C-Section
  5. Precautions
    1. Understand Fetal Position (where is the occiput and which direction is the fetus facing)
    2. Avoid harmful maneuvers
      1. Fundal pressure
      2. Excessive traction on fetal head or neck
      3. Twisting or bending neck
  6. References
    1. Warrington (2019) Crit Dec Emerg Med 33(8): 16-7
    2. Gherman (1998) Am J Obstet Gynecol 178:1126-30 [PubMed]
    3. Baxley (2004) Am Fam Physician 69:1707-14 [PubMed]

Maneuvers for delivery in shoulder dystocia (C0404396)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 237008007
English Manoeuvres - del shoulder dyst, Maneuvres for delivery in shoulder dystocia, Maneuvers for delivery in shoulder dystocia, Manoeuvres for delivery in shoulder dystocia, Maneuvers for delivery in shoulder dystocia (procedure)
Spanish maniobras de parto en distocia de hombros (procedimiento), maniobras de parto en distocia de hombros
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Suprapubic pressure on fetal shoulder (C0404397)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 237010009
English Suprapub pressure, fet should, Suprapubic pressure on fetal shoulder, Suprapubic pressure on fetal shoulder (procedure)
Spanish presión suprapúbica sobre hombro fetal (procedimiento), presión suprapúbica sobre hombro fetal
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Freeing the posterior arm (C0404398)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 237012001
English Freeing the posterior arm, Freeing the posterior arm (procedure)
Spanish liberación de brazo posterior (procedimiento), liberación de brazo posterior
Sources
Derived from the NIH UMLS (Unified Medical Language System)


McRoberts maneuver (C0473306)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 237009004
English McRobert's maneuver, McRobert's manoeuvre, McRobert's maneuvre, McRobert's maneuver (procedure), McRoberts maneuver (procedure), McRoberts manoeuvre, McRoberts maneuver, McRobert maneuver
Spanish maniobra de McRobert (procedimiento), maniobra de McRobert
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Wood's screw maneuver (C0473307)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 237011008
English Wood's screw maneuvre, Wood screw manoeuvre, Wood screw maneuver, Wood's screw manoeuvre, Wood's screw maneuver (procedure), Wood's screw maneuver
Spanish maniobra del sacacorchos de Woods (procedimiento), maniobra del sacacorchos de Woods
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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