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SHOULDER DYSTOCIA

Shoulder Dystocia1

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Incidences:

5-9% if fetal weights of 4000-4500 g

14-21% if fetal weights of 4500-5000 g

American College of Obstetricians and Gynecologists (ACOG) recommends cesarean delivery for 5000 g without diabetes, 4500 g with diabetes. However, diagnosis of macrosomia is imprecise.

Diagnosis:

Turtle sign—Retraction of head against maternal perineum immediately after delivery of the head. Or resistance of delivery of anterior shoulder with usual traction to fetal head.

Risk Factors

Maternal

  • Abnormal pelvic anatomy

  • Gestational or pregestational diabetes

  • Previous shoulder dystocia

  • Short stature (<60 in)

  • Obese (>200 lbs)

  • Previous large infant (>4000 g)

  • Excessive weight gain

Fetal

  • Suspected macrosomia

Labor

  • Operative vaginal delivery

  • Protracted active phase

  • Prolonged second stage

  • Precipitous labor

Be CALM

  • Breathe, do not push

  • Elevate legs, McRoberts position (knee/chest supine)

  • Call for help

  • Apply suprapubic NOT fundal pressure

  • Enlarge vaginal opening with episiotomy

  • Maneuvers to rotate baby to deliver posterior arm

Extraordinary Maneuvers

  • Fracture fetal clavicle

  • Zavenelli maneuver—cephalic replacement for cesarean delivery

  • Symphysiotomy

Complications

Maternal

  • Postpartum hemorrhage

  • Rectovaginal fistula

  • Symphysial separation or diathesis with or without femoral neuropathy

  • Third to fourth degree tear or episiotomy

  • Uterine rupture

Fetal

  • Brachial plexus injury

  • Clavicle or humeral fracture

  • Fetal hypoxia with or without permanent neurological injury

  • Fetal death

UMBILICAL CORD PROLAPSE

Sudden and significant cord compression leads to immediate and sustained fetal bradycardia.

Risk Factors

  • Premature rupture of membrane (PROM), iatrogenic ROM with presenting part not well applied to cervix

  • Vaginal delivery of twins

  • Vaginal delivery of footling breech

Intervention

Manual elevation of fetal head off cervix until emergent cesarean delivery.

UTERINE INVERSION

Uterus turns itself inside out with the fundus passing through the cervix into the vagina leading to severe and sudden postpartum hemorrhage, significant discomfort, and severe nausea and vomiting.

Risk Factors

  • Excess traction on cord applied to facilitate delivery of placenta, or excess fundal pressure on a relaxed uterus

  • About 1 in 2000 to 1 in 6400 vaginal deliveries

  • Fundal implantation of uterus is potential risk

  • Higher risk in primigravida

Treatment

Manually pushing the fundus back through the cervix, which should be done immediately before cervical constriction. Delay delivery of placenta if it still attaches to the uterus to limit ...

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